Laparoscopic gastric banding in a female patient with a BMI=40

This video demonstrates the elegant pars flaccida approach to place an adjustable gastric band around the cardia of the stomach. A retrogastric tunnel is created by blunt dissection but always under visual control to minimize complications such as vascular and gastric injury. This video is suitable for digestive and bariatric surgeons. This video shows the case of a patient with a BMI of 40 and a long history of morbid obesity despite numerous diets and behavioral studies that have all failed. The preoperative assessment was performed by associating endocrine, cardiac and psychiatric evaluations. The procedure consists in fitting an inflatable gastric band (BioEnterics® Lap-Band® System) around the superior portion of the stomach. Five trocars are used (1 of 12 mm and 4 of 5 mm). A 15 mL bag must be left touching the esophagus. This video describes the dissection of a retrogastric tunnel entirely under visual control, followed by the gastric band fitting and the covering of the band by a gastric wrap. This video demonstrates an elegant approach for placing a gastric band around the cardia. The patient is a woman with a BMI of 40. Using 5 trocars (1 of 12-mm, 4 of 5-mm), the author describes the dissection of a retrogastric tunnel under visual control. After creating the retrogastric tunnel, the author places the noninsufflated gastric band (Lap-Band System, Allergan, Inc, Irvine, CA) in the abdomen. Using a lateral trocar through the camera port, the author gently pulls the tip of the catheter and then the band through the posterior gastric channel with the grasper. The procedure continues with the use of a gastric wrap to cover the band.

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Laparoscopic gastric banding in a female patient with a BMI=40

Authors

Abstract

This video demonstrates the elegant pars flaccida approach to place an adjustable gastric band around the cardia of the stomach. A retrogastric tunnel is created by blunt dissection but always under visual control to minimize complications such as vascular and gastric injury. This video is suitable for digestive and bariatric surgeons. This video shows the case of a patient with a BMI of 40 and a long history of morbid obesity despite numerous diets and behavioral studies that have all failed. The preoperative assessment was performed by associating endocrine, cardiac and psychiatric evaluations. The procedure consists in fitting an inflatable gastric band (BioEnterics® Lap-Band® System) around the superior portion of the stomach. Five trocars are used (1 of 12 mm and 4 of 5 mm). A 15 mL bag must be left touching the esophagus. This video describes the dissection of a retrogastric tunnel entirely under visual control, followed by the gastric band fitting and the covering of the band by a gastric wrap.

This video demonstrates an elegant approach for placing a gastric band around the cardia. The patient is a woman with a BMI of 40. Using 5 trocars (1 of 12-mm, 4 of 5-mm), the author describes the dissection of a retrogastric tunnel under visual control. After creating the retrogastric tunnel, the author places the noninsufflated gastric band (Lap-Band System, Allergan, Inc, Irvine, CA) in the abdomen. Using a lateral trocar through the camera port, the author gently pulls the tip of the catheter and then the band through the posterior gastric channel with the grasper. The procedure continues with the use of a gastric wrap to cover the band.

Mots-clés

morbid obesity, gastric band, gastric wrap

Type de vidéo

Vidéo chirurgicale

Durée

08'30''

Publication

2007-05

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, May 2007;7(05).
URL: http://www.websurg.com/doi-vd01en2110.htm

Laparoscopic gastric banding in a female patient with a BMI=40

1. Trocar placement 00'06''

Here is an external view to show you the position of the trocars. Five trocars are used. The 1st one is the optical port, one handbreadth’s underneath the xiphoid appendix. It’s a 12mm port. In the epigastrium, I have one 5mm trocar for the liver retractor; on each side, two 5mm trocars to allow for dissection, and one retracting trocar on the left side very far and on the mid-axillary line. The reservoir will be placed on the scar of the midline trocar that is the optical trocar. This will give a subcutaneous way for the catheter coming out of the abdomen using the left trocar on the mid-clavicular line and going through the subcutaneous fat until reaching the opening of the midline trocar to put the reservoir inside. The BMI of this patient is not very high, it’s 40, and what about her eating habits, she’s not a binge eater or a sweet eater, and I think that in this case, you can place a band. If you are dealing with binge eaters or sweet eaters or if the BMI is over 45, it’s better to do a gastric bypass.

2. Incision of pars flaccida 01'38''

Here you see the opening of the pars flaccida, this nice little window without a lot of fat, and you see for lower BMI that you have no fat on the pars flaccida even in very fat people. The pars flaccida is widely opened, and you can see here the right crus, and very close to the crus, the vena cava here. We will begin to open the peritoneum just in front of the point where the muscle disappears under the fat.

3. Retrogastric tunnel 02'30''

With blunt dissection, I will create the retrogastric channel. Very gently under visual control, this is the pars flaccida way. So we’re very far away from the right part of the stomach, and you can see here the window and we see by transparency the other side, and we will try to open it. You see the spleen through the little window. I put my grasper through here. And we will go to the other side. We grasp the fat here, and keep the grasper behind the stomach and the channel. I can now prepare the band and remove the air and put some water inside. The band is not insufflated.

4. Gastric band placement 03'55''

I put it in the abdomen just before I use the lateral trocar through the camera port, and I come back to find the grasper and I put it on the fat. I give the tip of the catheter to this grasper here, and I will pull gently back. Here the liver is really bulging and it’s quite difficult with the liver retractor, and I pull the catheter and then the band through the posterior gastric channel. The design of the band makes it easy to go around the stomach, very natural, and you have no maneuver to do; on the left side, you see the band comes alone around the stomach. Today, you have a lot of surgeons who are able to do the bypass, and there are better results in the long term with the bypass, and we have also bigger patients today. They didn’t know at the beginning how to perform the bypass and the only procedure available was the band.

5. Calibration of gastric pouch 05'41''

We will put the balloon in the stomach in order to calibrate the upper pouch. You see here the bulge of the calibration balloon and that makes an upper pouch of the band from 15cc, and I will fix my band with a gastric wrap at this moment to avoid gastric slippage through the band. Here is the maneuver.

6. Anchoring of band 07'19''

I will try to fix there the stomach on the left crus to avoid the space allowing for any gastric slippage. We have to avoid picking in the balloon of the band because it does not work otherwise. I just want to clean my operative field now.