Laparoscopic gastric banding in a patient with a BMI of 40

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Laparoscopic   gastric   banding   in   a   patient   with   a   BMI   of   40

Authors
JM Zimmermann, D Fölscher
Mots-clés
operation,morbid obesity,gastric band
Type de vidéo
Durée
21'00''
Publication
2004-09
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1114e.htm

Laparoscopic   gastric   banding   in   a   patient   with   a   BMI   of   40

1. Case presentation 00'18''
This is a patient with a BMI of 40. She weighs a 105 kilograms and is a 159cm tall. She’s 30 years old and has had 2 previous caesarean sections. The position of the patient is very simple. The patient is 45 degrees head up. First, we abduct the thighs to 80 degrees and thereafter, the head is elevated to 45 degrees. This means the patient is sitting on the thighs and the buttock and there is no pressure on the popliteal fossa. The patient is also fixed to the table. The 1st trocar is placed by open laparoscopy in a position one hand’s breadth below the costal margin to the left of the midline. This is placed by the open technique. The other trocars are only placed after inspection. A 15 or 18mm trocar depending on the band used is placed one hand’s breadth to the left of the first. Next the trocar for the liver retractor is placed just below the xiphoid process. It is 10 or 11mm depending on the type of liver retractor used. The 4th trocar is a 5mm trocar under the right costal margin. This position is very important as it determines the correct axis of dissection around the stomach. This will be the angle of dissection and the position of the band provided the inside view corresponds with our drawing. We can anticipate that this is where the angle of His will be on laparoscopic inspection. It’s important that this 2nd trocar is not too near the costal margin as this will interfere with manipulation. Is it always in the mid-clavicular line? Yes, it’s in the mid-clavicular line. In this case, an 18mm trocar will be used but we will first use this 12mm trocar for initial manipulation. Next, I will place a liver retractor in the subxiphoid position. The coagulation is working well. The first thing I do is to open up this lesser omentum. Can you show us the porta hepatis? Now I’m above the porta hepatis in the pars flaccida. I try not to cut the accessory left hepatic artery or the vagus nerve to the gallbladder and normally this is high enough because I show you the axis of dissection. Now we go here on the right crus of the hiatus and now I’ll open here. At the bottom, the left crus is now appearing and there’s the canal. I dissect immediately below the left crus and use gentle blunt dissection to open up this passage. There we go. One can now see that the passage is finished and there’s still a little peritoneal window remaining and as you can see, under vision, I’ll now open it. There we go. The retrogastric passage is completed. And now the difficult part of the procedure is finished. The tract extends below the right and left crus and it terminates above the angle of His. And now I ask the anesthetist to inflate the balloon with 15cc and I push the balloon down into the stomach. It will be pulled back and locked into the cardia after placement of the band. The balloon is larger than the one we used previously, which had a length of 9 to 10cm. this one is now 11cm. It’s the 2nd generation band, which I now routinely use. This evolution is important as it is designed to prevent slippage of the balloon and the band. I put water in the band to get rid of air and I leave 2cc of liquid in it. OK, I insert the securing spigot and now the whole system is ready to be introduced. I also now put water in the reservoir. All these needles and buttons are part of the pre-packed product. Now I will change the trocar. If you can hand me the bigger trocar. This is the 12mm Ethicon trocar that was used for initial dissection. It is now changed. I introduce a bougie as a guide for the 18mm trocar. Here we go. It slides over it and it will dilate its own tract into the peritoneal cavity. The balloon is being inserted through this port and the spigot is now grasped by the retrogastric instrument. The catheter should be handled very gently. Instances of catheter rupture have already been described. The catheter is pulled through in a gentle and smooth manner. So your window is not too big, is it? No, no the window should never be too big and never bigger than the band; this prevents posterior slippage. The spigot is pulled through the hole in the end of the balloon and secured at the 1st lock. It can be seen that it is passing comfortably underneath the stomach. The anaesthetist is asked to pull the balloon right up against the cardia. It’s important that it’s right against the gastroesophageal junction. This ensures a small pouch of 15mL. It must be right up against the cardia and the balloon is above the band so that the band sits just below on the lower margin and it’s locked into place. I verify this good position. Yes, it’s 15mL and it sits right below the intragastric balloon. I now take a sufficiently loose bite of the fundus. I can do a floppy Nissen. This is about right here and this will be fixed to the diaphragm. See not on the stomach but to the diaphragm. I’m not worried about these arteries in the diaphragm. They always seem to be controlled by the stitch. Why I fix it to the diaphragm? Since one year now, I’ve been using this stitch in the diaphragm even to fix the area around the gastric balloon and prevent anterior dilatation of the pouch. I’ve modified my technique like this as there’s no dissection tract on this anterior surface like there is posteriorly. Now I take here a nice big bite. These details are important as improper fixing will definitely lead to band slippage and pouch dilatation and of course one should look at the fine details. As you see, the inferior stomach is pulled up and there is some tension on this. But there should be no traction on the stomach superior to the band on the pouch. Now I take the stomach here and I attach it to the right crus here. Therefore, the 1st stitch is attached to the diaphragm, the 2nd one is a gastro-gastric stitch, and the 3rd one is stomach to crus. This means there is only one gastro-gastric suture. There is an eventual risk if one doesn’t cover all of the band. Essentially, we have to ensure that the band does not slip. Posterior, it is not a problem because it is fixed by the normal gastric adhesions. Slippage is a all anterior or lateral, on the side of the spleen. Therefore, we cover the whole visible band and if there’s band protruding in the near area of its curvature, this means slippage and pouch expansion is possible. By locking the stomach onto the diaphragm in one unit, I therefore prevent the possible complication of anterior or lateral slippage. And now I think the band is well covered. So there’s been 2 evolutions to the original technique. I started with the same technique as everyone else and I did 1100 bands in this way. Analysing our data on the first thousand patients, we showed that we had a band slippage rate of a 129 patients. This translated to 11%. Analysing this complication, it was clear that it happens with the Obtech band when there was no contact between the stomach and the diaphragm. We now use a 10cm band, which is designed by McCain but in the Obtech position. Since then, we haven’t had any slippage. Therefore, band position is important. When the band is fixed only to the stomach, gastro-gastric invagination can occur. Because of this new more peripheral method of fixing, we use a larger balloon. All right. We now will take out the liver retractor under view as well as the port. This is very important as often hemorrhage occurs at this stage. Yes, I’ve had to do 2 re-operations due to hemorrhage. We cut the catheter. This is not a problem at this stage. It can be opened because the pressure must equilibrate. I always cut to leave the maximum length of catheter. And then the reservoir is connected like this. It must be correctly placed in this position. Well, one can get problems: the tubing can kink if it’s not correctly positioned. If we put it lateral, it will interfere with the costal margin during breathing and movement. Therefore, this is the best position. There’s a question if I have ever used a position below the costal margin as it is very easy to puncture. Yes, it’s easy to puncture below the costal margin but if it’s easy for me, it is also easy for the patient. I use finger dissection only to create a plane anterior to the rectus sheath. Blunt dissection is used. This makes a small hole and prevents movement of the reservoir. It will set like this. Now I do not need to verify again inside the position of the catheter. It’s finished. I know that it is in the right position. Initially, I didn’t worry about stitches and the length of the tubing. Why is it important? It’s very important that this reservoir is in a correct position to prevent movement and kinking of the tubing. I insert it like this and again verify the position with my finger. It’s important to fix it. The abdominal wall may change with changes in weight, with pregnancy, etc. and therefore proper fixing will ensure good results. Now the tube lies free like a wing in the abdominal cavity. And I can push the rest of the tubing into the inside and I can check with my finger that it’s indeed in the correct position and not subcutaneous. Do you ever close the aponeurosis? No, I don’t, we’ve had to re-operate and I’ve never seen a herniation even in the 18mm trocar hole; I therefore leave it alone.