Laparoscopic conversion of failed vertical banded gastroplasty (VBG) to Roux-en-Y gastric bypass (RYGBP)

WebSurg is a free virtual surgical university, accessible worldwide through the Internet. Our goal is to provide surgeons, scientific societies and the medical industry with the first online continuing medical education in laparoscopic surgery and information on the latest developments in laparoscopic surgery, including NOTES and robotics.

Create account

Browse the WORLD

Virtual University

Google translate

Summary
Chapters
Your comments
Ask the Experts

You need to log in to watch this media!

Click here to log in.

Laparoscopic conversion of failed vertical banded gastroplasty (VBG) to Roux-en-Y gastric bypass (RYGBP)

Authors

J Marescaux, M Vix

Media type

Surgical video

Duration

07'00''

Publication

2005-06

Popular

Favorites

Favorites Media

Audio

Subtitles

E-publication

WeBSurg.com, Jun 2005;5(06).
URL: http://www.websurg.com/doi-vd01en1725.htm

Laparoscopic conversion of failed vertical banded gastroplasty (VBG) to Roux-en-Y gastric bypass (RYGBP)

1. Case presentation 00'08''

This is the case of a 34-year-old female patient operated 3 years before for her morbid obesity with vertical banded gastroplasty. Her BMI was 45 at the time. After initial weight loss, the patient presents in the last 5 months with a weight gain of 15 kg and no feeling of restriction to food intake or satiety. Currently, her BMI is 40. The oral X-ray contrast examination revealed no pouch dilatation or gastro-gastric fistula. After discussion with the patient, the decision to perform a laparoscopic reversal Roux-en-Y was made.

2. Adhesiolysis 00'56''

After complete abdominal exploration, the procedure begins with the freeing of some adhesions from the previous surgery. The remnant stomach and the gastroplasty are tracted and the adhesions divided using an Endo-GIA and a Ligasure device. More dissection about the gastroplasty is then done to prepare the pouch for the anastomosis. It has been shown that inadequate access weight loss after pure restrictive procedures is reported in up to 20% of cases.

3. Gastric pouch creation 01'45''

After the posterior dissection is done, we will now create a gastric pouch as required by the bypass procedure. We use two 45mm green cartridges to divide the gastrum. We then tag the remnant gastrum with a suture.

4. Anvil placement 01'57''

The anvil of a 25mm circular stapler is sutured to an orogastric tube that is then advanced to the newly created pouch as is the standard procedure in our institution. A gastrotomy is made with electrocautery and the orogastric tube is advanced. We then place a purse-string suture about the gastrotomy to aid in a good anastomosis. We note some bleeding along the staple line and this is ligated with a second stitch.

5. Biliary limb creation 03'08''

Now to the small bowel bypass. Starting from the Treitz angle, a 75cm biliary limb is prepared. Pre-measured mark denoting 5cm at the tip of the retractor is helpful to accurately determine the length of the limb. The limb is then fixed to the stomach with a suture to obtain good exposure and to position the small bowel in preparation for the entero-anastomosis.

6. Enteroenteroanastomosis 03'40''

Now a 150cm long alimentary limb is prepared and sutured to the previous one. Note the blue mark denoting the proper orientation of the existent limb to the stomach. A mechanical side-to-side anastomosis is performed using one 45mm white cartridge. A continuous non-absorbable suture is then used to close the two enterotomies. We believe that laparoscopic reversal Roux-en-Y gastric bypass is feasible and safe and represents an effective surgical treatment after a failed restrictive vertical banded gastroplasty procedure. To avoid an internal hernia, we routinely close the mesentery defect with a continuous non-absorbable suture. We include the serosa of the bowel to obtain a good approximation of the defect.

7. Alimentary limb creation 05'21''

We create a mesenteric defect and utilize the Endo-GIA to create our alimentary limb for anastomosis with the gastric pouch. The extremity of the alimentary limb is then prepared for the insertion of the circular stapling device. We have found the cautery to be very useful when performing our enterotomies and gastrotomies.

8. Gastroenteroanastomosis 05'50''

A circular stapler is then introduced into the abdomen with the enlargement of the 12mm port located to the left of midline. An end-to-side anastomosis is performed and the two rings checked for a defect. As the mucosa is noted to be circumferential with both donuts, we then proceed to close the small bowel defect. We use an Endo-GIA to perform this; the resected specimen is then extracted with the use of an Endobag. Two non-absorbable interrupted sutures are then used to stabilize the anastomosis and reduce tension. A methylene blue dye is routinely injected through the orogastric tube to check the integrity of the anastomosis. Finally, Petersen’s space, which is the defect created by the antecolic gastrojejunal anastomosis, will be closed with a continuous non-absorbable suture. The transverse mesocolon and the alimentary limb are the structures in which we will approximate to close this defect. This completes our procedure.