Laparoscopic gastric banding in a young patient with a BMI of 47

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Laparoscopic   gastric   banding   in   a   young   patient   with   a   BMI   of   47

Authors
GB Cadière, M Vix
Mots-clés
morbid obesity,operation,stomach,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-vd01en0010e.htm

Laparoscopic   gastric   banding   in   a   young   patient   with   a   BMI   of   47

1. Case demonstration 00'22''
This is the case of a 22-year-old patient without any medical history except for hypertension. He has a family history of obesity. She weighs 120 Kilos and her BMI is 47. That is a good indication for placement of a gastric band. Here is the external view. Port placement is as follows: here are the subcostal ribs and here is the umbilicus. It’s exactly the same position as for a Nissen fundoplication. Now to the instrumentation. I use a USSC liver retractor. The patient is paced in a reverse Trendelenburg with a 20 degree tilt and because of the patient’s weight it sometimes is a problem and you have to fix very well the patient on the table. Here’s the nasogastric tube with the balloon. Inflate the balloon with 25cc. I inflate it with air and not water. Here’s the introduction of the balloon. You see here the tip of the nasogastric tube and the balloon. And now I ask the anesthesiologist to gently pull out the nasogastric tube. And when you are against the hiatus, you have to stop. You can keep a small traction. Now I ask the assistant to grasp and gently pull down and now I have the equator of the balloon, that is the level where I have to put my band. It’s 2cm below the Z line. First, I’d like to show you the Latarjet’s nerve. I just take the peritoneal sheet here. I have to avoid causing any local bleeding so I go very gently here. I try first to skeletonize the vein in order to take it. The best thing to do probably is to control and cut the vessels first above the vein. First, I’d like to try to isolate the lesser omentum that’s the reason why I cut first the vein close to the wall. We can control this one with the coagulating hook. The principle now is to isolate the artery from the gastric wall and if I can do that, I can coagulate. It’s important to suction the blood because if you have an operative field with a lot of blood, the light is diminished. What you showed beautifully here is the importance is localizing that bleed so it doesn’t then diffuse into the tissues around. I try dissecting all the thickness of the lesser omentum. What people find difficult here is finding the edge of the stomach? Can you feel it? Yes, I do. And now I ask the anesthesiologist to deflate the balloon and pull out the NG tube. Do you always take the balloon out at this point having started to dissect all the layers? When I reach the middle of my dissection. I go very gently here and stay close to the gastric wall. Now we can go above or below the reflection of the peritoneal sheet and now I try to go above. You see here the gastric cavity. It’s easier to go above and immediately through the phrenogastric ligament, but it’s clearer to show in the retrogastric cavity. Now I make a window on the phrenogastric ligament. I’d like to show the level where to make this window. You see here the left crus, the upper part of the spleen and you have to make the window here. This is a 30 degree scope. I don’t mean to put you off but that dissection at the back of the upper part of the fundus looked quite difficult there, I mean you made it look very nice and easy but suppose one made a hole at that stage with the subsequent insertion of the gastric balloon and so on, do you feel that that’s a contraindication to proceeding laparoscopically or what would you do if you’d breach the mucosa at that time at he earlier part? Would you have stopped? No I’d put a stitch but it try to avoid doing that. Now in fact, I’ve dissected the 2 layers of the lesser omentum as well as the anterior part of the peritoneal sheet. Now I can see from here the posterior peritoneal sheet of the phrenogastric ligament. I try now to dissect here with the coagulating hook. This is the posterior phrenogastric ligament here. And when I go through, I go through the posterior part of the phrenogastric ligament and because I have made a window anteriorly, I have to find the grasping forceps on the other side. I will introduce the prosthesis in order to do that. Here’s the external view. I enlarge the hole here with a small scar. And I change with an 18 trocar. So the trocar takes the direction of the upper part of the spleen and I quickly introduce the prosthesis inside and I pass the optical system through the trocar in order to avoid any problem with the cleaning. You see that I have put a stitch on the tip here. It’s easier to grasp the tube. Now I put the prosthesis around the stomach. I introduce the tip inside the lock. Now I ask the anesthesiologist to introduce the NG balloon with 15cc. First, I asked to inflate with 25cc because if I have a small hiatal hernia, I wanted to avoid that the balloon goes through the hiatus. Pull out the balloon now. I check that the balloon is adequately placed. The tip is here. I close the band. I check that the tip of the NG tube is through the band and you see here now the upper part of the stomach, which has a volume of 15cc. This means that once this pouch is full, the patient can’t eat any longer. Now to the fixation of the band. My first stitch is on the greater curvature and on the lateral side of the upper part of the stomach. Be careful when putting the stitch because sometimes you take just the fat so be careful to take also the serosa. I put a first stitch anteriorly. In fact, I create a channel and the band can move inside this channel. So you’re coming slightly more anterior now with the stitches. If you have a very large lipoma, does it become very troublesome? Then I prefer to dissect the lipoma. Because I went in the retrogastric cavity, I have to check if I have to put a stitch posteriorly. So I will open the lesser omentum. So there are 2 ways. We can go above the peritoneal reflection and so you don’t have to make a knot posteriorly. In this case, because I am below, you will see that it’s very important to put a stitch. You first open the lesser omentum. I try to go inside the retrogastric cavity. Why do you think this is so necessary? Because I’m afraid that the posterior gastric wall goes through the band and leads to a dilatation of the upper part of the stomach. Here is the retroperitoneal sheet and I’m above since I’ve just made a window so probably it’s not necessary to fix. So I leave the band like this. It’s enough to avoid the slippage of the band. To pull out the band, it’s very easy. Sometimes you have a lot of adhesions between the liver and the stomach so you dissect them, and when you see a small part of the band, you make a window, you take it, you cut it and it’s finished. One of the benefits of this procedure is that because of the laparoscopic access, it’s a minimally invasive surgery and also because we respect the integrity of the gastric wall. The outlet of the band can diminish if you inflate the band around the stomach. You can do that because the tube is linked with a reservoir and I’d like to show this reservoir here. So I’ll connect the tube with the reservoir. We will insert the reservoir on the right muscles and so in one month, it’ll be possible to make a puncture through the skin and an X-ray control and inflate the balloon depending on the weight loss and on the complications like reflux.