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Websurg, e-Surgery 關於腹腔鏡手術
Clinical Case
GASTRIC PERFORATION DURING THE PLACEMENT OF A GASTRIC BAND FOR MORBID OBESITYM Vix, MD, J Leroy, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France 1. Description This case illustrates an operative complication during the placement of a gastric band for morbid obesity. The occurrence of a minimal perforation is not rare. As long as it is recognized and treated, it is possible to place the gastric band despite the incident. 2. KeywordsStomach, morbid obesity, gastric perforation 3. PatientFemale, 44-year-old 4. History of present illnessWeight of 114 kg, height of 1 m 56 with a BMI of 46.84. Indication for a surgical treatment to place a gastric band to restrict dietary intake. 5. Past medical history- non-contributory; - progression of the morbid obesity for many years, marked by ineffective dieting. 6. Preoperative workup- no evidence of biliary cholelithiasis; - no cardiac nor endocrine contraindication for the surgery. 7. Surgery7.1. First stepPlacement of the trocars was without any particular problem and the dissection begins after calibrating a stomach pouch of 25 cc in the area of the cardia. The dissection is done in contact to the posterior aspect of the stomach. Minor bleeding can lose the plane of dissection. Video 7.1.a (English) Video 7.1.b (French) 7.2. Stomach injuryDuring the dissection, a posterior wall of the stomach is entered.Video 7.2.a (English) Video 7.2.b (French) 7.3. Suturing of the perforationAt this moment of the intervention the question is asked as to the ideal treatment of this perforation, and how to position the gastric band to maintain an adequate conduite. It is decided to suture the perforation, and to place the band without inflating it.Video 7.3.a (English) Video 7.3.b (French) 7.4. Posterior dissectionThe posterior dissection is pursued.Video 7.4.a (English) Video 7.4.b (French) 7.5. Positioning the bandThe band is put into place and closed. The stomach is sutured over the band in such a way to prevent migration.Video 7.5.a (English) Video 7.5.b (French) 8. Postoperative courseThe patient is placed on antibiotic prophylaxis for one week. An abdominal CT scan is performed: it shows a minimal collection around the band. After one week of surveillance, the patient is symptom-free and she is discharged from the hospital. The patient is seen one week after discharge. She remains symptom-free. She has lost 5 kg. Three months after the surgery, the band is inflated with 3 cc of normal saline. She continues to be symptom-free. At 7 months, she has lost 14 kg. The routine follow-up fluoroscopy shows neither a leak of contrast nor a dilatation of the gastric pouch. 9. DiscussionThe incidence of a gastric perforation during the placement of a gastric band for morbid obesity is rare, 2.3% for Doldi et al. (2000), 0.3% for Cadière et al. (2000). For routine screening, an upper GI study using water soluble contrast is performed by most authors. If the perforation is detected intraoperatively, it is sutured and closed. There is no consensus of opinion regarding the placement of the band in spite of the gastric perforation. Certain authors renounce the placement of the band, others place the band in spite of the operative error; we have opted for the latter solution. This clinical case demonstrates the feasibility of placing the gastric band as long as the perforation is seen, controlled and sutured. On the contrary, if the perforation is detected postoperatively, reoperation is necessary with suturing of the gastric perforation and removal of the band (Chelala et al. , 1997). 10. References
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