Difficult case of laparoscopic sleeve gastrectomy after removal of a gastric band for morbid obesity

Laparoscopic sleeve gastrectomy as a redo surgery after gastric band removal is a challenging operation. Many technical problems are encountered during this procedure. Care must be taken in finding anatomical planes, understanding the type of adhesions and avoiding a gastric injury, especially in the region of the lower end of the esophagus. This video shows a difficult case of laparoscopic sleeve gastrectomy two months after the removal of a gastric band that was placed 10 years ago.

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Difficult case of laparoscopic sleeve gastrectomy after removal of a gastric band for morbid obesity

Authors

M Vix, J Marescaux

Abstract

Laparoscopic sleeve gastrectomy as a redo surgery after gastric band removal is a challenging operation. Many technical problems are encountered during this procedure. Care must be taken in finding anatomical planes, understanding the type of adhesions and avoiding a gastric injury, especially in the region of the lower end of the esophagus. This video shows a difficult case of laparoscopic sleeve gastrectomy two months after the removal of a gastric band that was placed 10 years ago.

Classification

basic techniques

Keywords

Difficult case, laparoscopic sleeve gastrectomy, removal gastric band, morbid obesity

Media type

Surgical video

Duration

09'35''

Publication

2009-11

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E-publication

WeBSurg.com, Nov 2009;9(11).
URL: http://www.websurg.com/doi-vd01en2725.htm

Difficult case of laparoscopic sleeve gastrectomy after removal of a gastric band for morbid obesity

1. Case presentation 00'19''

This is the case of a 50-year-old woman who wishes to have a sleeve gastrectomy two months after the removal of a gastric band that was placed 10 years ago. The band was no longer efficient as a superior gastric pouch had been identified.

2. Freeing of adhesions 00'33''

The various omental parietal adhesions are taken down as we gradually work our way to the superior portion of the stomach to entirely dissect the cardia. Multiple adhesions are identified at that location and they are taken down using a hook or the Ligasure® device according to the situation and possibilities. The difficulties at that moment consist in finding anatomical planes, understanding the type of adhesions and avoiding a gastric injury, especially in the region of the lower end of the esophagus. Following the resection of a gastric band, the type of adhesions we expect to see are located between the stomach’s anterior surface and the liver’s inferior aspect, or between the stomach, the liver and the greater omentum that seals off this region in its entirety. The adhesions that we are taking down here are quite dense; no previous dissection planes can be found and they must be recreated in a careful way to avoid a gastric defect. The adhesions between the liver and the stomach can be tricky, sometimes literally sealing the stomach and the liver together.

3. Gastric wall dissection 02'15''

The dissection is difficult: a dissection that is too close to the stomach’s wall can cause, as is the case here, a small serosal breach. We are tempted by leaving a thin layer of liver on the anterior surface of the stomach as we face a bleed, not very profuse in this case, but that will spoil the operative field. The dissection is carried out in a very careful fashion and we can see the diaphragmatic section of the cardia appearing. The dissection is continued until the left crus can be identified. The adhesions are particularly dense around here and make the stomach’s superior portion very difficult to uncover. The serosal defect in the stomach’s anterior surface is stitched up. The risk of encountering a complication in these patients is far superior to that of a patient undergoing a gastric surgery for the first time. It is therefore important to be very careful in order to not increase the risks of a complication occurring. The dissection aiming at identifying the left crus is continued carefully.

4. Left crus identification 04'21''

The left crus appears slowly; in this case, the dissection is almost continued into the liver.

5. Intraoperative endoscopy 05'08''

In order to benefit of guidance, a simultaneous endoscopy is performed to identify the cardia and the end part of the esophagus.

6. Opening of lesser sac 05'18''

As soon as the cardia is completely dissected, the sleeve gastrectomy is carried out in a very conventional fashion through the opening of the lesser sac performed on the left portion of the greater curvature. The lesser sac is now free.

7. Gastrolysis 05'33''

We then check if we can identify the cardia by its posterior aspect; then dissection through a complete gastrolysis is performed. The gastrolysis enables to totally detach the omentum from the greater curvature. A devascularized portion of the omentum is resected here. The superior part of the posterior aspect of the stomach is also freed from its vascular attachments. The endoscopy will always allow to make sure that there is no defect in the gastric wall. Here, a double channel endoscope is used for calibration purposes.

8. Stomach division under endoscopic control 06'32''

The stomach is divided on the endoscope. Staplers used are either green for the first stapling between the antrum and the fundus or blue on the stapled line. Blue or green cartridges are used depending on the thickness of gastric tissues encountered. Division is continued until necessary and the resected gastric portion is placed into a bag.

9. Stapling line defect closure 07'35''

During the division, a defect of the stapling line is observed. It is caused by the stomach’s wall being too thick for the stapler’s cartridge and having a few stitches placed too close to the defect. Interrupted stitches with intracorporeal knots are used to delimit both aspects of the defect. Extracorporeal knots can also be tied: they can facilitate this closure. Closure of the gastric defect is completed. A methylene blue or an air test can be performed to rule out any leakage in the suture.

10. Running suture 08'38''

Then, an absorbable running suture is carried out to bury the staple lines over the whole length of the gastric catheter using an absorbable monofilament material. The most difficult part of this procedure remains the dissection of the cardia with a complete loss of anatomical landmarks.