In this consecutive study, 40 patients undergoing SAGB were included. Patients’ demographic data is presented in Table 1. All patients were treated according to the routine protocol for our bariatric patients (Table 2). After a consultation with the bariatric surgeon, patients are referred to the bariatric committee (including bariatric surgeon, therapist, nutritionist, and psychologist) for surgery approval. The typical time from referral to operation is 4–5 weeks. In the preoperative phase, patients were urged to stop smoking and to minimize alcohol consumption. A daily 30-min. walk was advised. Preoperative weight loss was evaluated individually.

Premedication included tramadol once a day 100 mg perorally in the evening before surgery. Dexamethasone 8 mg was given in the operation room to prevent postoperative nausea and vomiting (PONV). Furthermore, patients were given intravenous (iv) antibiotics: cefazolin 2 g and metronidazole 0.5 g. Preoperative carbohydrates were not given.

Patients walked to the operating room and placed themselves on the operating room (OR) table for optimal ramping position. In the OR, perioperative noninvasive monitoring was initiated using electrocardiography (ECG), noninvasive blood pressure monitoring, and peripheral oxygen saturation. Preoxygenation was prolonged and given before induction using initial bolus of remifentanil followed by induction with a bolus of propofol. Airway management and oral intubation were achieved using videolaryngoscopy. Suxamethonium was kept at hand, but only as rescue if relaxation was needed for intubation.

Pneumatic pumps (Kendall SCD™ Express Sleeves, CardinalHealth, Leeds, UK) were used to prevent deep venous thrombosis.

Preoperatively, 1000 ml isotonic saline was administered. Anesthesia was maintained with propofol and remifentanil (TIVA). Fentanyl 100 μg was administered 10 min prior to the end of the procedure, with dehydrobenzperidol 0.2 mg iv, ondansetron 4 mg iv, and clemastin 1 mg iv.

Patients were extubated at the end of skin closure and were able to reposition themselves from the OR table to bed within minutes. Urinary catheters were not used.

In the post-anesthesia care unit (PACU), Ringer lactate 1000 ml iv was initiated and, if needed, continued on the ward. Mobilization in the PACU within 30–60 min was stressed.

A Veress needle was placed in the supraumbilical region. The abdominal cavity was insufflated with CO2 to a pressure of up to 15 mm Hg. The first trocar (supraumbilical) was placed with an optical trocar, after which the other optical trocars were placed under visual control. The left liver lobe was lifted with the liver retractor (Nathanson retractor) when needed. About 10–15 cm below the angle of His, on the small curvature side below the second branch of the crow’s foot, the omental bursa was opened with an energy device (LigaSure™ retractable L‑hook; Medtronic, Minneapolis, MN, USA). The first stapler 45-mm purple cartridge (Signia™Stapling System; Medtronic, Minneapolis, MN, USA) was placed and fired at a right angle from the small curvature. Next, in the direction of the angle of Hiss a second to fifth stapler 60-mm purple TRS Reinforced Reload cartridge (Medtronic, Minneapolis, MN, USA) placed against a 34 Charrière gastric tube.

The Treitz ligament was then identified, and the small intestine brought up antecolically at approximately 180–200 cm from the ligament of Treitz. The stomach pouch was opened close to the staple row with a LigaSure™ retractable L‑hook, as far as possible towards the greater curvature, after which the dorsal side of the gastroenterostomy was made using a 30-mm vascular cartridge (Medtronic, Minneapolis, MN, USA). The ventral side of the gastroenterostomy was closed using a V-Loc™ (Medtronic, Minneapolis, MN, USA) running suture in two layers.

The integrity of the gastrojejunostomy and gastric pouch staple line was tested intraoperatively for anastomotic leaks using methylene blue. The efferent arm was sutured to the gastric remnant with Vicryl 3‑0 suture. Sites of the trocars were locally anesthetized with 10 cc Bupivacaine + 10 cc lidocaine 1%. All trocars were removed under view. The skin was closed with metal clips.

The postoperative outcomes registered included postoperative length of stay in the PACU and hospital, pain during rest and mobilization (VAS 0–10), nausea (VAS 0–10), vomiting (± and number), fatigue (VAS 0–10), dizziness (VAS 0–10), and time for mobilization out of bed (±). Registrations were performed every 15 min in the PACU and every 2 h on the ward. Mobilization was defined as out of bed and walking at least 3 m.