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Laparoscopic re-exploration for persistent abdominal pain after gastric bypass for morbid obesity

Authors

Abstract

This is the case of a 38-year-old female patient who benefited from a gastric bypass some 18 months ago. She lost 40 kilos. She complained of cramp-like pain on a regular basis. This video shows the laparoscopic exploration.

Mots-clés

Laparoscopic re-exploration, abdominal pain, gastric bypass, morbid obesity

Type de vidéo

Durée

05'43''

Publication

2011-04

Popularité

Favoris

Audio

Sous-titres

E-publication

WeBSurg.com, Apr 2011;11(04).
URL: http://www.websurg.com/doi-vd01en3109.htm

Laparoscopic re-exploration for persistent abdominal pain after gastric bypass for morbid obesity

1. Clinical case presentation 00'19''

This is the case of a 38-year-old female patient who benefited from a gastric bypass some 18 months ago. She lost 40 kilos. She complained of cramp-like pain on a regular basis. The scanner demonstrated no particular abnormality. A surgical exploration is consequently decided upon.

2. Identification of mesenteric defect dehiscence 00'38''

On introducing the ports, one is immediately stricken by the appearance of the jejunojejunostomy, where a dehiscence of the mesenteric defect is found. The suture used to close the defect is still there but because of the patient’s weight loss, an opening may have formed, hence making it possible for the small bowel to go through. This portion corresponds to the divided part of the biliary loop, which looks slightly long. It is nothing but the blind loop, which was used to create the anastomosis. The mesenteric defect is well visible here.

3. Common loop 01'24''

The common loop is seen coursing caudally.

4. Biliary loop 01'27''

The biliary loop is also identified. It will be followed until reaching the duodenojejunal flexure. It will then be repositioned.

5. Alimentary loop 01'51''

The alimentary loop is then identified and followed over a few centimeters in order to rule out the presence of any posterior defect in the meso at this place.

6. Resection of the blind portion of the loop 02'10''

Decision is made to resect the blind portion of the loop, which is a little too long, and the meso is opened by means of the forceps to allow for the introduction of a 60mm Endo-GIA linear stapler, white cartridge. The blind loop is therefore divided. The meso will then be cut following this resection in order to make sure that the vascularization of the right side of the anastomosis has been well preserved. The specimen is placed in a bag.

7. Mesenteric defect closure 03'05''

The mesenteric defect will then be closed using separate non-absorbable stitches, paying attention not to injure the mesenteric vessels. External knots are tied using a braided, non-absorbable suture material. Several stitches are necessary to completely close the mesenteric defect.

8. Exploration of Petersen\'s space 04'01''

Exploration is also carried out at the level of Petersen’s space in order to obstruct this small persistent channel, which could also induce an internal hernia. Once again, the first fixation suture is still visible. The patient’s weight loss made it possible to re-open part of the defect, which is therefore re-approximated using separate, non-absorbable stitches. The patient’s postoperative outcome was marked by the absence of cramp-like pain. No direct proof of internal hernias was demonstrated. However, the defect was sufficiently large and the patient’s clinical signs were sufficiently telling to mandate the treatment of such intermittent internal hernias. The entire alimentary loop is visualized to rule out the presence of any other abnormalities in this patient. The bag is removed at the end of the intervention when ports are taken out.

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