Gastric banding by laparoscopy

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Gastric banding by laparoscopy

Authors

Type de vidéo

Vidéo chirurgicale

Durée

18'00''

Publication

2005-10

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Favoris

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Audio

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E-publication

WeBSurg.com, Oct 2005;5(10).
URL: http://www.websurg.com/doi-vd01en1848.htm

Gastric banding by laparoscopy

1. Patient and trocar placement 00'11''

I’m going to show you how to place a gastric band. Now to the position of the trocars. The patient is in a decubitus position with a tilt of 25 degrees. You see the umbilicus is here and we put the first port that is the optic one handbreadth’s below the epigastrium. Afterwards, we insert using an open approach the first trocar in the abdomen and we put 3 additional trocars. The first one is the epigastric one for the liver retraction. If the liver is very large, I put this trocar to the right of the patient. The 2 other trocars are placed on the anterior axillary line, quite on the same line as my 10mm or 12mm optical port. These are the two 5mm operating ports. First of all, we’ll see the region of the pars flaccida. We retract the liver, and you see here the opening of the pars flaccida. We open it upwards and it’s important to open it very low in order to get a better view on the right crus. You see here the vena cava and the right crus.

2. Retrogastric tunnel 02'13''

The beginning of the retrogastric channel will be just over the fat and underneath the crus at the point where the crus is disappearing under the fat. With scissors we open just the peritoneum and afterwards, under visual control, using a blunt dissection I will begin to create the retrogastric channel. I will change my scissors for a grasper, and very gently and slowly so that I can control where I am, I’ll go to the other side. If you have a hiatal hernia at this point (more than 2-3cm), it’s not an indication for a gastric band and you have to change the technique. At this moment, you can perform a vertical banded gastroplasty. Do you think the amount of dissection behind the esophagus affects the slippage rate? When you’re just in the region of the crus, you have a reduction in slippage because if you’re on the perigastric ring we will begin here with the calibration of the tube, a lot of slippage can occur; in the literature, more than 20% of slippage is noted in the 2 years after the operation. And here it’s decreasing below 1%. We are behind the stomach. You saw that I made the channel.

3. Banding positioning 04'27''

We will introduce the band in the abdomen. For this, I remove the optical port. It’s a lap-band from Inamed. It’s a vanguard band and I put directly through the skin using the optical port incision hole and I’ll put the band totally inside the abdomen before putting the optical port back. This way, you see the band is inside. I take the catheter. I ask the anesthesiologist to remove the nasogastric tube that was placed for the induction and you see the band is coming easily through the retrogastric channel. That’s the moment I choose to pull on the catheter and the band will come into place. How do you decide to use the normal size band Inamed or the vanguard band, the larger one? Today, all the time, I use the vanguard band and I think that the pressure on the stomach wall is lower and the surface of the band is higher in contact with the stomach. It’s better to prevent intragastric migration. When you put the band really around the channel, you take your catheter again and put it through the locking system. Then I will pull it until the 1st position you’ll see. Do you have experience with the bands from other companies, say the Swedish band? Yes sometimes, differences are with the locking systems For the Swedish band, I feel that the locking system is not as easy as the one from Bioenterics and you have to pass your band first behind the stomach. And with the catheter, it’s easier at the beginning of your experience.

4. Calibration tube positioning 07'33''

I now ask the anesthesiologist to place the calibration tube. What do you think affects erosion? Since the pars flaccida technique is used to have a decrease in erosion and in the literature too, but with bands around the stomach, you can have 2 to 5% of intragastric migration reported in the literature. You can inflate the calibration balloon with 15cc. You can see the bulge of the balloon here and I’ll ask the anesthesiologist to pull it back. It stops at the lower part of the esophagus and I’ll close the band just under the bulge of the balloon to be sure that I have a calibration of a little gastric pouch. The band is closed. In this case, you see that the bulge is coming under the band. Inflate now to 20cc. At this moment, I have to make a gastric wrap around the band. I prepare the 1st stitch on the lesser curvature just near the fat and I will then put a 2nd stitch very high in the greater curvature. Sometimes I can fix it on the diaphragm or on the left crus in order to close the plane under the volume that you have on the posterior part of the stomach. So I begin the wrap. It’s easy to place the knots inside even if you have traction on the tissue. The 2nd stitch I have to place is very far in order to close the place behind the band. Because the fixation of the band is quite anterior and never posterior, so the 2nd stitch must be placed as far as possible from the left part and I fix it to the left crus or to the diaphragm to close the space and avoid a large pouch from coming from under the band and going through the band over it. Because when you have some pouch prone to slippage, you can have some necrosis of the stomach. I’ll use the same device for closing the knots. I had one case of early migration 3 or 4 months after the operation with the greater curvature coming through the band and since then I try to close the space behind. Where do you usually put the lock of the band on the right side or left side? I prefer to put it on the right side because when you have to remove the band I think it’s easier to find the locking system and cut and dissect it. Because on the left side, you don’t know where the spleen is when you have a lot of adhesions. I think it’s safer to put it on the right side. At this moment, the anesthesiologist has removed the calibration balloon and you see the stomach wrap around the band; when the patient will be standing, the band will have this position. In this case, I’ll insufflate the band a bit and it’s better for the patient to have a little dysphagia at the beginning. It’s a small injection, no more than 1 or 2cc and we wait for 2 months afterwards to really begin the calibration of the band. All the time, we do calibration under X-ray control to be sure the position of the band is good and when we put saline inside, make sure we don’t have too much dysphagia otherwise you will have to deflate the band shortly afterwards.

5. Port placement 14'58''

You can now remove the liver retractor. We don’t close the pars flaccida. We will have to take the catheter out. I’m closing the fascia and I will put the insufflation port here. To do so, I’ll take the catheter and I will use a subcutaneous way that can be interesting when you have an infection of the insufflation port. And so you can remove it and keep the catheter inside. You just have to open it on the left side. You cut the catheter first. You put it in the cavity and through the middle scar, you remove your insufflation port. I just have to dissect a place to be able to put the stitches for the insufflation port.