Laparoscopic conversion of adjustable gastric banding to Roux-en-Y gastric bypass

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Laparoscopic conversion of adjustable gastric banding to Roux-en-Y gastric bypass

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Surgical video

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31'00''

Publication

2005-10

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WeBSurg.com, Oct 2005;5(10).
URL: http://www.websurg.com/doi-vd01en1859.htm

Laparoscopic conversion of adjustable gastric banding to Roux-en-Y gastric bypass

1. Beginning of procedure 00'10''

Trocar placement is the same as for any type of hiatal surgery, which means that I have a 12mm in the right upper quadrant for my left hand and I have an optical trocar which is a few centimetres higher than the umbilicus, and then I have two 5s, one is a little bit to the left of the xiphoid for the liver retraction, and then I have another 5mm which is on the anterior axillary line for the assistant, and for my right hand, I have another 12mm about half-way between the optical trocar and the 5mm trocar. So we start by retracting the liver and we will ask for a little bit more of reverse Trendelenburg. Now with this type of band I don’t have any experience at all. It’s a German band and I’ll start by cutting the tubing. I hope I will not forget to remove the port at the end of the procedure.

2. Dissection of the band 01'26''

So we’ll start by dissecting the band. I’m following the tubing all the way down to the band and then identify the band. Sometimes you run into a little surprise. More often than not, you’ll have an erosion. And again with this type of band, I’m not quite sure what to find. I’d resect the band and go on if I encountered an erosion. This is a blue band apparently. In the beginning, the first landmark is basically just the band itself and I try to free as much as I can as long as it’s safe and already you get a good view of the area by doing this. Let’s try to stay close to the band and once you get more to the right aspect here. I’m opening up the pars flaccida and then we find fairly easily the right crus. It looks like they used a perigastric technique in putting the band in. I think so. At this point, you could just cut the band and take it out. But I like to wait a bit with that because it’s a good retraction tool. I’m going here to free the right crus and I like to see that one. Just incise the peritoneum at the middle edge and free the lower edge of the liver. I’m not quite sure how they fixed the band. Now I’m trying again to free a bit the medial aspect of the crus and the reason why I’m doing that it’ll give me more space and it helps in identifying the esophagus of course and it’s already rather well separated from the liver, which continues bleeding a bit. So here again the landmark is obviously the band but also the right crus, which is also just medial to the cardiac lobe. So again let me go along the medial edge here. Open up just the peritoneum. So you’re mobilizing the esophagus as you might for a Nissen fundoplication? Exactly, because again I’m not sure what to find. The most reliable landmark is actually the esophagus and I’m now trying already to pull the esophagus anteriorly, and go in and open up the space between the band and the left crus, as we would do in a Nissen. I don’t want to create that window yet but at least have the landmarks of the V of the hiatus. I’m pretty sure that I’m out of trouble. So we have the band, the esophagus, the upper part of the stomach is here, and at this stage, I don’t think it’ll help me a lot to keep that band so I will cut it, which will allow me to more safely mobilize things here, and especially the left part of the stomach, so I’m trying to follow the edge of the liver, we will encounter sooner than later the spleen in the neighbourhood. When they had the tubing of the band which had actually migrated through the spleen, it was the last case in Austria I remember, very interesting. We’re close to the diaphragm. This is the lower edge of the liver, then I can lift; the diaphragm is here, it may be the fundus but that’s no big deal. But we can still use the band as a retraction. It’s like a sling around the upper part. This is more or less free. We have these stitches to the diaphragm. Now you have the bridge, there was some stitching over the band as you mentioned. Now I’ll try to find the section plane in between. Usually you can find some stitches. Here you can just burn them. We may have a little bit of blood vessels here. It’s the so-called esogastric positioning. There were a lot of publications on this, the guys from Innsbrück, another from Belgium and they’ve had excellent results. However, in my experience, as in any other positionings, that doesn’t work. But you see there is absolutely no morcelation with this technique. Now let’s cut the band.

3. Extraction of the band 11'17''

So I pull on this and see. So we’ll just put the band away somewhere. Another question is where we will do the transection? With the mere placement of the band, you noticed a whole bunch of scarred tissue here and I think it should be cut because it will still cause a waste in your gastric pouch and I like to transect it. Don’t you agree with me that this scarred and distorted tissue is not the ideal one for a gastroenterotomy? Of course not but I want to cut it anyway just like when I do a VBG, I cut the band also. I like to see at least some normal looking tissue.

4. Retrogastric tunnelization 12'48''

We have a nasogastric placement just distal to the scarred tissue you just saw. I’m trying to go into the lesser sac like I’m now. And now I’ll do the transection of the stomach at that stage. I like to use green loads and they need a 15mm trocar and I don’t have that type of trocar personally. I use a little trick. I just cut the finger of a glove as a custom-made mini-trocar, put it in here and insert here. Now we take off the glove finger.

5. Gastric pouch 14'29''

My hook should still be there. So I transect horizontally. Maybe I could have gotten away with the blue load, but I prefer green. Now I will proceed to the vertical dissection, the posterior dissection. You always want to be much more medial than you would think so. And people who are used to doing VBGs know that, the angle of His is always located several centimetres more medial than you would think. Therefore, just lift the fundus and go as far medial as you can until you see there’s no more gastric tissue and there’s always vessels here, short gastrics and others, and here you know that you’ll have a pretty narrow tube. You’ll have once again to remove the trocar and place this little thing percutaneously. I’ll do the vertical transection. Let’s remove the little strings. We’ll replace the trocars for a second and we’ll do the final dissection. Suction a bit. Here the pouch is 6cm big. It’s one shot of the GIA, so it’s 6cm. I want to see where I am with the hook. Here I may want to do some more dissection so I can see better. I don’t want to incorporate too much fundus, if any at all. I may want to dissect a bit more at the level of the crus. See the left crus, the esophagus, and again the attachments to the left crus, which is here, redundant fundus so we’ll try to transect it nicely here. I have transected at least 1cm and it seems OK. You can feel it when you transect the end of the stomach. Let’s take a look at the pouch. That’s a total transection for sure and that’s one of the major pros that we encounter. This is a little bit of fat pad here that I felt when transecting it. Here is the GE junction, the vagus nerve, you have the opened capsule and you still have I’d say 2cm distal to it, and now we put the patient horizontally, and we lift the omentum from left to right.

6. Biliary limb 20'20''

We lift the mesocolon and we go and look for the angle of Treitz. And so we’ll unroll the small bowel in a clockwise fashion and I don’t measure that biliary loop but I’ll take the 1st loop that I know reaches easily. I almost never divide the omentum because at the beginning I divided it systematically and I’ve had so many problems with abscesses I personally thought were created by partial necrosis of the omentum. Some surgeons argue that the way to the omentum puts tension on the anastomosis. No I don’t think it’s important. But you do need to pull the omentum from left to right. My assistant is holding the biliary loop and I’m holding the alimentary loop and now I’ll do the anastomosis. I’m worried about vascularity. I’m going to take a good bite on the staple line. Remember this one did not have any Seamguard.

7. Gastro-jejunostomy 22'20''

These are sutures pre-knotted. I’m making a temporary knot and it helps me since it saves me some time. Help yourself with your needle and then put a good bite. I’m inside on the bowel. It’s my 1st knot. It’s the posterior wall. So I’m doing a 2nd corner stitch and I’m tying this to that. Now I have 2 sutures and I can cut the stomach. Make sure you enter the lumen well. And here on the small bowel, make sure you don’t enter the posterior wall. I’ll now continue with the left-sided suture that was in on the small bowel. Corner stitch on the stomach incorporating the Seamguard. Wide bite. I’m trying to make 2 punch-holes for the anastomosis. I’ll check the anastomosis at the end of the procedure. This is the end-to-end anastomosis. I’ll now do the alimentary loop and I personally don’t really measure that. See this is flaccid, this is more muscular. Now we’ll introduce the grasper. I’ve seen all kinds of measurements and they were not reliable. I’ve noticed that if you measure this, it will always come to 150cm.

8. Jejuno-jejunostomy 26'50''

I’m on the punch-hole here. I’ll just have to close this. It doesn’t conclude the procedure since we still have to close the defect. This is the 1st mesenteric defect when you pull this. To do so, we have to pull the bowel upwards. I use big stitches and big bites. People can take very small bites of mesentery and I’m pretty sure there’s no hole. I’m trying to take big bites as you see here and if it bleeds, it will but that’s no big deal. But having an incarcerated internal hernia is the end of the world and you know that many patients have died of that. I think that’s the only long-time danger that you experience with this type of surgery is the internal herniation. There’s some bleeding here but it doesn’t matter, we’ll tie that immediately. We still need to close Petersen’s.