Laparoscopic gastroplasty with placement of gastric band

WeBSurg est une université virtuelle accessible mondialement sur Internet. Notre objectif est de fournir aux chirurgiens, aux sociétés savantes et au secteur médical un enseignement médico-chirurgical de pointe en ligne en chirurgie mini-invasive et toute information concernant les dernières avancées en chirurgie laparoscopique, dont notamment la Chirurgie Endoscopique Transluminale par les Voies Naturelles (NOTES) et la chirurgie assistée par robot.

Naviguez dans
l'Université Virtuelle
Français ▼

Laparoscopic   gastroplasty   with   placement   of   gastric   band

Authors
M Vertruyen, M Vix
Mots-clés
operation,gastric band,morbid obesity
Type de vidéo
Durée
31'00''
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-vd01en1056e.htm

Laparoscopic   gastroplasty   with   placement   of   gastric   band

1. Case demonstration 00'25''
I will demonstrate a laparoscopic gastroplasty using the Lap-band by BioEnterics. Now to the patient’s position. The patient lies supine and I’m standing between the patient’s legs. The 1st assistant is sitting just on the right side of the patient, holding the optical system. The 2nd assistant is just on the patient’s left side. Now to the position of the trocars. Before introducing them, it’s important to inflate the patient since trocar position is very different when the patient’s abdomen is inflated and when he’s not. In obese patients, it makes a big difference. First in insert a Veress needle in the umbilical area in order to inflate the abdomen, and then I can introduce the ports. The first port is a 10mm one, introduced about 5 fingerbreadths below the xiphoid appendix. I use a 30 degree optical system. Trocar number 2 is a 10mm one and I introduce it just below the subcostal area on the typical mammary line. The 3rd trocar is a 5mm one introduced half-way between the 1st trocar and the 2nd one. A 4th 10mm trocar is introduced here in a subcostal area in order to accommodate a liver retractor. The last trocar is a 5mm one introduced on the right side of the patient below the ribs. The 1st operative step is to retract the liver. Sometimes I can have a very big liver. In each case, we perform an ultrasonography preoperatively to get an idea about the thickness of the liver. If we have a very big liver, we put our trocars on the patient’s left side because it’s impossible to lift the liver so then we retract the liver from the left to the right side. I’m going to suction a few drops of blood from one trocar in order to get a good view. First, I have to create my 1st landmark. I have to create a window just on the gastrophrenic ligament about 1cm on the left side of the left crus. So I have to retract the omentum in order to have a better view. I take it and hold it. And if I want, I can use the stomach like a retractor. So I aspirate to have a better view. My 1st landmark is on the gastrosplenic ligament that you see here, 1cm on the left of the crus. I have to cut this first. It’s important to make a very small window in order to avoid injuring the angle of His. I’m just getting the peritoneum here and this will be the end of my retrogastric channel. This dissection is finished. Now I’m going to ask the anesthetist to introduce a nasogastric tube. It’s already done. This is a NG tube with a balloon at its extremity in order to know where I have to start the dissection on the right side of the stomach. It’s essential to know where to begin. Sometimes we have a lot of fat and you don’t know where the Z-line is, where the stomach starts, where the esophagus ends so the best thing is to introduce the NG tube. I ask the anesthetist to inflate it with 25cc. Now you can see the bulge. Then when it’s done, I ask the anesthetist to pull the NG tube back until it’s against the hiatus. This NG calibration tube is inside the BioEnterics package along with the gastric band. I have my bulge of 25cc and I have the landmark, which is the equator of the balloon so I have to start my dissection here. For a good dissection, I have to put the tissue under tension. So I grasp here and ask the assistant to maintain it so. And I’m going to open the peritoneum. It’s important to stay as close as possible to the gastric wall in order to avoid any hemorrhage and avoid damaging the nerve of Latarjet here. So I stay as far as possible from this nerve. It’s important to control the vessels and skeletonize them, and after that you can cut it. I use tension with a grasping forceps here as well as the tension of the bulge originating from the calibration tube. Now I have to dissect. When you have bleeding, you have to dissect a little bit the vessel in order to be sure that you’re not too close to the gastric wall, and I’m going to coagulate this vessel. I try to stay as close as possible to the gastric wall. If you dissect into the fat, you can get bleeding problems. Now I ask the anesthetist to deflate the balloon and put it away because I start the dissection on the posterior part of the stomach. We can see the bulge of the crus here and it’s important to reach the other part of the gastric window under visual control. At the beginning of the experience, it’s important to know the direction of the retrogastric channel, especially if you take this way above the reflection of the peritoneal sheet, if you go first inside the lesser sac, you have a lot of landmarks but if you go this way above the reflection of the peritoneal sheet covering the lesser sac, sometimes it’s difficult to know the landmarks and know where you have to dissect. And one of the good landmarks is the left crus. It’s important to maintain a good orientation for the dissection; if you’re too much to the left side, you can dissect into the mediastinum and this can be dangerous because you can damage the pleura. If you’re going too much to the right side of the dissection, then you come right out here between the gastric vessels and so you create a pouch, which is too large. So it’s important to go straight so for the dissection. At the beginning of our experience, in all cases, we tried to find the retrogastric cavity. So in fact, we dissect here. Maybe we can open the retrogastric cavity in order to show you. In fact, you can see it here. And if you dissect here, you make a way like this and when you put your band in the retrogastric cavity, it’s important to avoid the slippage and put a stitch on the posterior part of the stomach. So now because we’re above the top of the retrogastric cavity, it’s not necessary to put a posterior stitch and so to avoid slippage, we just have to put 4 stitches between the proximal pouch and the distal stomach. So I try to make it as close as possible. As you see, to go through the retrogastric channel, I use a normal forceps. So the band is inside the abdomen and now I grasp the extremity with the stitch in order to place it in the region of the end of my retrogastric channel. I hold the grasping forceps and I grasp the stitch and as you see, it’s easier to grasp the stitch than to grasp the tube. Now I’ll pull back my device. Now I have to pull the tube through the retrogastric channel. I’ll help the tube to avoid any resistance and so without any tension, I put it through. Once it’s done, I pull the tube through the channel. This is an atraumatic grasping forceps and I try to avoid damaging the Lap-band. Thanks to the good design of the band, it’s immediately in a good position. So I pull it through the channel. And you see the channel is just enough to let through the band. Then I’m going to take the tube in order to lock the band. I put it through the hole. I don’t knot the tube and so this is the 1st security. Now I’m going to ask the anesthetist to introduce the NG tube again through the band in order to know where I have to lock the band definitely. You have to do it under visual control because sometimes the NG tube goes against here and so you have to help it a little bit. You can see here the slow introduction of the NG tube. This is the tip of the tube. Now once it’s through the band, I’m going to ask the anesthetist to inflate it with 15cc. Now you can pull back. You see the 15cc bulge here. Then I’m going to lock the band and I’m sure that I have a 15cc pouch of gastric wall above the band. To lock the system, you can do it with 2 grasping forceps or you can use the special device by BioEnterics (but for this one, you’ll need a 10mm trocar). So we try to do it with this kind of device. I grasp here and hold this here. So now it’s closed and the procedure is finished. The only thing I have to do is to avoid slippage of the band on the gastric wall and to do so, I have to put 4 stitches from the proximal part of the stomach to the distal part of the stomach. To get a better view, I’m going to turn the band a little bit. To perform the 4 stitches, I’ll use the Endo-stitch. The 1st stitch is not an anterior one but a lateral one and you have to grasp the stomach as far as possible until you reach the gastrosplenic omentum. With one grasping forceps, I pull back the fat and with my other device, I expose the region and identify the short vessels. I’m going to grasp it here. Here you can see the gastric wall very well. Sometimes there’s a lot of fat and the Belsey fat as we call it in order to be sure that you are inside the gastric wall, you have to dissect this fat. How heavy this patient is? The BMI is 48. The patient weighs 128 kilos. We use a 2/0 silk stitch. Sometimes it’s better, when you turn with your needle, you can have a better feeling of what you do. How do you define somebody who’s very fat? It’s not a question of BMI; it’s a question of exposure due to the fat of the omentum and due to the hypertrophy of the liver. With a BMI of 48, we don’t have problems to expose the region. Have you found the tolerance of patients to this operation? Postoperatively how long for them does it take for them to get used to the presence of the band? Is there good compliance with the band afterwards? We don’t inflate the band during the procedure and we leave it so in order to avoid any vomiting postoperatively. The patient can eat immediately the day after the procedure and wait for about 2 to 3 weeks before inflating the band. What is the risk of perforating the entire gastric wall and deflating the balloon itself by doing the stitches? When you place your stitch too deep, you can fix the balloon to the wall. You have to maintain the balloon inflated during the time you place the stitch. Why so? Because if you deflate the balloon, if you grasp here, you can pull the stomach through the band and you’re not sure that there’s still some stomach above the band. So this is a guarantee that there’s still stomach above the band otherwise you just have sero-serosal stitches. There are 2 sizes for the Lap-band. We use just the biggest one (here the band is 975: we use it for patients with a BMI higher than 50). But there are no big differences between the 2 bands. In some very fatty patients with big liver lobes, it’s very difficult to localize the balloon when it is inflated with only 15cc. then you have to dissect the fat around the proximal pouch. It’s not a problem of obese patients but of the presence of the Belsey fat just here. If you’ve got quite an amount of fat here, you have to dissect it to be sure that you don’t have a hiatal hernia here. Sometimes in male patients, it’s not so easy and you have to dissect to be sure you don’t have a hiatal hernia and that the balloon is inflated here. What would you do if there was a hiatal hernia? When it’s a small one, we can put a band without any other treatment. In case of a symptomatic hiatal hernia, what do we do? With this type of band, it’s not possible to perform an anti-reflux procedure and to put this Lap-band. Several solutions exist: we can close the crura or do a Nissen fundoplication and to put a Swedish band just below this fundoplication. As you can see here, the band is covered with stomach and I’m going to put the band in a good position. Then I’m going to take the tube and pull it out through the 15mm trocar. It’s important that the curvature of the tube is in the splenic area.