Laparoscopic emergency gastric band removal for acute total food intolerance

Laparoscopic gastric banding is a procedure with very low postoperative morbidity and mortality, but presents different long-term complications very challenging to manage. We report the case of a 35-year-old woman in whom a gastric band had been placed 5 years ago. Her initial BMI was 42. The patient’s evolution has been perfect since she has considerably lost weight. Her current BMI is 28. However, a sudden complete food intolerance has occurred. A nasogastric tube is placed but does not help to relieve total food intolerance. Consequently, the removal of the gastric band is immediately decided upon.

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Laparoscopic emergency gastric band removal for acute total food intolerance

Authors

M Vix, J Marescaux

Abstract

Laparoscopic gastric banding is a procedure with very low postoperative morbidity and mortality, but presents different long-term complications very challenging to manage. We report the case of a 35-year-old woman in whom a gastric band had been placed 5 years ago. Her initial BMI was 42. The patient’s evolution has been perfect since she has considerably lost weight. Her current BMI is 28. However, a sudden complete food intolerance has occurred. A nasogastric tube is placed but does not help to relieve total food intolerance. Consequently, the removal of the gastric band is immediately decided upon.

Mots-clés

Laparoscopic emergency gastric band removal, total food intolerance

Type de vidéo

Vidéo chirurgicale

Durée

08'56''

Publication

2010-10

Popularité

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Sous-titres

E-publication

WeBSurg.com, Oct 2010;10(10).
URL: http://www.websurg.com/doi-vd01en2928.htm

Laparoscopic emergency gastric band removal for acute total food intolerance

1. Clinical case presentation 00'23''

We report the case of a 35-year-old woman in whom a gastric band had been placed 5 years ago. Her initial BMI was 42. The patient’s evolution has been perfect since she has considerably lost weight. Her current BMI is 28. However, a sudden complete food intolerance has occurred. A nasogastric tube is placed but does not help to relieve total food intolerance. Consequently, the removal of the gastric band is immediately decided upon.

2. Abdominal cavity exploration 00'55''

The abdominal cavity is explored as soon as the first trocar is introduced. This exploration shows a very large stomach. This could be evocative of a gastric dilatation above the band. The abdomen presents no other abnormality. At the most, a few adhesions can be found on the trocar introduction sites used for the placement of the gastric band. The gastric pouch is identified. It is indeed extremely dilated and inflamed.

3. Dissection of adhesions 01'34''

The catheter is easily found. It will be followed to reach the band’s closure mechanism. The lymphatic infiltration of the gastric pouch’s wall can be seen. Some adhesions can be found between the stomach and the liver. They will be taken down close to the band’s closure mechanism.

4. Catheter dissection 02'04''

The dissection is performed using the monopolar hook in order to properly identify the dissection planes. All the tissues are relatively infiltrated. The catheter is then cautiously dissected in order to reach the band’s closure mechanism. As a reminder, the band is fixated by 3-4 stitches achieving a gastric wrap around the band. The dissection is carried out cautiously in order not to cause any gastric opening on the sleeve. The catheter may then be divided and is removed from the abdominal cavity.

5. Gastric sleeve dissection 03'06''

The gastric sleeve is now cautiously dissected in order not to cause any gastric wound. In some cases, it is extremely complicated to remove the gastric sleeve, so it may be left in place. If it were so, the patient should be informed of that. This would be useful should the patient benefit from any other surgical procedure in the future. The dissection is uneasy. The plane between the superior and the inferior portion of the gastric sleeve is difficult to find. The band is searched for by means of the hook. It will be a solid contact. The dissection is carried out cautiously. It would be difficult to suture a gastric perforation on a dilated portion of the superior gastric pouch.

6. Freeing of omental adhesions 04'19''

A few omental adhesions are freed in order to better identify the gastric pouch and to perform a more accurate dissection.

7. Band identification 04'43''

The band is identified, visualized, and palpated. The different adhesions are divided in order to free the anterior aspect of the band as well as the superior gastric pouch.

8. Division of fixation stitches 04'55''

The fixation stitches are perfectly identified. They will be divided.

9. Dissection of the band\'s anterior adhesions 05'19''

The anterior aspect of the band is perfectly identified. The bridge situated between the band and the catheter is cautiously taken down. Some fibrous tissue is visible between the gaps of the band’s closure mechanism and will be taken down when performing the dissection.

10. Dissection of adhesions between band and stomach 05'49''

At this time in the procedure, the band’s strangulation mechanism can be clearly seen. The fibrous tissue that developed on the serosal surface of the stomach in contact to the band is visible here. Here the remaining part of the fixation mechanism is freed. The fibrous adhesions are clearly seen. They keep the orifices and the gaps between the band and the closure mechanism of the stopper in place. All these adhesions are freed in order to completely free the band, which becomes perfectly mobile.

11. Band removal 06'41''

After completely dissecting the fibrosis around the band’s closure mechanism, the band may be removed. The procedure is concluded by dissecting the fixation stitches that could still be present and by controlling that there is no gastric perforation.

12. Removal of fixation stitches 07'02''

The fixation stitches that were used when the gastric band was placed are removed in order to prevent any new adhesions from occurring, as this could lead to a more difficult dissection later on.

13. Closure of small serosal injury 07'21''

A sero-serosal stitch is placed on a small tissue abrasion found at this level. The fibrous tissue covering the surface of the stomach situated underneath the band is not dissected in order to avoid a future perforation. In this case, as the gastric pouch is extremely dilated at its superior portion, it will be difficult to carry out any subsequent surgical maneuver. It is preferable to perform either a sleeve gastrectomy or a gastric bypass two or three months later.