Laparoscopic sleeve gastrectomy after gastric band removal: two different clinical cases

Sleeve gastrectomy after gastric band is a challenging procedure due to the alteration of anatomy caused by the band; the identification of anatomical landmarks is crucial. The objective of this video is to successively demonstrate two different sleeve gastrectomy cases after gastric band removal.

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Laparoscopic sleeve gastrectomy after gastric band removal: two different clinical cases

Authors

M Vix, F Costantino, J Marescaux

Abstract

Sleeve gastrectomy after gastric band is a challenging procedure due to the alteration of anatomy caused by the band; the identification of anatomical landmarks is crucial. The objective of this video is to successively demonstrate two different sleeve gastrectomy cases after gastric band removal.

Mots-clés

Laparoscopic sleeve gastrectomy after gastric band removal, clinical cases

Type de vidéo

Vidéo chirurgicale

Durée

18'52''

Publication

2010-05

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, May 2010;10(05).
URL: http://www.websurg.com/doi-vd01en2979.htm

Laparoscopic sleeve gastrectomy after gastric band removal: two different clinical cases

1. Introduction 00'07''

The objective of this video is to successively demonstrate two different sleeve gastrectomy cases after gastric band removal.

2. Trocar placement 00'19''

Trocars are placed conventionally. The optical trocar is placed one handbreadth and a half underneath the xiphoid process. An epigastric trocar will ensure the liver’s retraction. Two operating trocars are placed on each side of the optical trocar slightly more elevated. Finally, a retraction trocar is placed in the left hypochondrium: it will be used most often as an aid for exposure purposes. With regards to team position, the surgeon stands between the patient’s legs, with 2 assistants on each side. The scrub nurse stands to the surgeon’s right.

3. First case 01'07''

The first trocar is placed under visual control. In this patient, fairly tight adhesions between the omentum and the anterior abdominal wall are encountered.

4. Dissection of adhesions 01'20''

All adhesions will be taken down before the actual procedure can be started. It is sometimes uneasy to find the right dissection plane, but it is nonetheless essential to find it again in order not to leave non-vascularized tissues on the wall. Here the dissection of the round ligament is shown. When all adhesions between the omentum and the abdominal wall have been dissected, the procedure is carried on towards the stomach. Once again, adhesions between the omentum, the anterior aspect of the stomach, and the inferior surface of the liver are often identified. The different anatomical landmarks are found again.

5. Stomach dissection 02'14''

Meticulous dissection is performed in contact to the liver in order not to devascularize the gastric wall. Here the adhesions are sufficiently loose to allow for a smooth dissection. Attention is then turned to the superior portion at the level of the cardia, which represents the most difficult part of the dissection. The stomach is manipulated in such a way as to expose the angle of His, which is dissected with extra care in relation to the adjacent spleen and omento-splenic adhesions; such adhesions, if taken down, might cause bleeding and thus necessitate a splenectomy for hemostatic purposes. As soon as the cardia has been dissected and the splenic flexure has been totally freed, the procedure is then carried out towards the inferior portion of the stomach in order to re-dissect the omento-gastric adhesions that might have formed at this level.

6. Lesser sac opening and gastrolysis 03'46''

The lesser sac is then opened to initiate the gastrolysis. The opening of the lesser sac is performed in the middle portion of the stomach where the omental thickness is less important, and access to the lesser sac is made easily. Next dissection is carried out towards the superior portion reaching the dissection performed earlier in contact to the cardia. Attention is then turned to the inferior portion to complete the dissection, which is stopped 6cm from the pylorus. The different adhesions at the posterior aspect of the stomach are taken down in order to correctly calibrate the gastric pouch.

7. Linear stapler application 04'41''

A first application of the Endo-GIA® linear stapler, green cartridge separates the antrum from the fundus. There is no calibration at this moment. It will be performed subsequently. We opt for this option since it allows to standardize the ingress of the calibration tube, which is pushed into the small gastric residue that has just been cut with the Endo-GIA®. Once it reaches the inferior part of this small gastric residue, the calibration tube can simply be pushed into the remaining gastric tunnel. The gastric pouch is manipulated trying to keep the tube underneath the anterior portion of this pouch and avoiding that it enters the posterior portion that is more bended. Here is the tube in place. It will be pushed until the duodenum. The posterior part is further dissected and further rows of Endo-GIA® staples are applied as they allow to separate the stomach that will be resected from the remaining gastric tunnel. Here a blue stapler is used. In case of re-intervention, most of the time we prefer to use green staples to avoid staple line injuries intraoperatively since the gastric tissue remains fairly inflammatory and the thickness of the gastric wall is too large for the use of a blue stapler. The thickness of the gastric wall is appreciated for each staple’s application. Here we estimated that a blue stapler was sufficient in relation to the stomach’s thickness. The gastric resection is completed staying in contact to the calibration tube. Here the last dissection is performed close to the cardia and a last application of the cutting forceps helps to completely separate the external portion of the stomach from the gastric tunnel. A few posterior adhesions are still visible here and will be resected meticulously before removing the specimen. This dissection is uneasy to perform before starting the gastric division and we do not always carry it out because we want to preserve the cardia’s best vascularization. As soon as the entire pouch has been freed totally, it is placed in a bag.

8. Running suture on staple line 08'00''

A running suture is placed to bury the staple line, as conventionally performed in our team. Here we use an absorbable monofilament material. The objective is to reduce the risk of fistula as well as the risk of bleeding on the staple line. Now the running suture completely covers the staple line. Here two clips allow to stop the running suture. A bag is used to perform the extraction of the specimen through the optical port site. Most of the time we use an open laparoscopic approach. The bag will be extracted through this space.

9. Second case demonstration 09'06''

Our second case is interesting since our patient is heavier than in the first case. The liver has a different aspect but the adhesions that we find in this second patient are lesser and the dissection will be easier to reach on to the stomach and cardia. It must be understood that in this case the difficulty lies in the patient’s weight as well as in the importance of the supramesocolic fat along with the different adhesions that render dissection of the cardia uneasy. Trocar position is conventional. Five trocars are used as described earlier. Here the table position test is performed cautiously because of the patient’s weight. We control that there is no deleterious support areas and that the patient does not move with a proper strapping. The patient is known to present an alcoholic intoxication, however discontinued about 2 years ago. The liver has a cirrhotic aspect but can be retracted fairly easily. The anterior aspect of the stomach is then exposed.

10. Start of dissection 10'34''

The adhesions look quite loose and we always start by dissecting the superior portion close to the spleen in order to make sure that the resective procedure can be achieved later on. A few adhesions between the omentum and the diaphragm are taken down. The relationships with the spleen’s superior flexure are very narrow and dissection is continued slowly.

11. Lesser sac opening 11'06''

After ensuring that the procedure can be performed, the lesser sac is accessed in the middle portion of the stomach on the vertical part of the fundus. It is at this place that the omental attachment is the flimsiest and allows for an easy access into the lesser sac. The different lesions that one may cause at the level of the stomach are without any consequence here since this part of the stomach will be resected. The lesser sac is therefore opened. Using the Ligasure® device, the freeing can be continued cephalad to reach the first dissection that was achieved close to the cardia. The dissection is performed with a meticulous hemostasis, which is controlled in a stepwise fashion. The retraction is also performed step by step. It should be done painstakingly in order to divide the omentum.

12. Dissection of greater curvature 12'20''

As soon as the opening is sufficiently big, a retrograde dissection of the greater curvature is carried out. This dissection is stopped 6cm from the pylorus. Attention then turns to the superior portion. The interest of the inferior dissection is to allow for a complete rotation of the gastric pouch that will be attached only to the pylorus and at the level of the esophagus. The entire gastric pouch will have a rotation axis allowing to extensively expose its posterior surface. A few posterior gastric adhesions are visualized and the omental dissection is carried out at several levels. Here the difficulty lies in the gastric retraction in order to reach the posterior surface of the stomach that is extremely close to the splenic flexure. Dissection is performed cautiously in order not to cause any effraction of the splenic capsule that would render the hemostasis difficult to achieve and therefore require a splenectomy for hemostatic reasons. Here the splenic flexure is totally resected and the initial division area is completed with the dissection extended until the pylorus over a few centimeters. The posterior gastric surface is freed from all its adhesions in order to correctly identify the anatomical landmarks to achieve the gastric division.

13. First stapler application 14'20''

The first gastric division is performed using a green linear stapler. Without calibration, attention is paid to preserve an internal channel.

14. Calibration tube placement and completion of gastrolysis 14'40''

Placement of a calibration tube before performing this division is fairly difficult. This division helps in the placement of the calibration tube. Here the calibration tube has been placed. It is a 34 French tube and a certain number of staplers are applied to achieve a total gastric division. Here a green linear stapler is applied due to the thickness of the fundus, and we will achieve the resection of the gastric pouch by taking down the few posterior adhesions at the level of the left gastric vessels. Here the previous history of the gastric band renders the dissection fairly more difficult. Certain adhesions have been induced by the placement of this band. Here an adhesion at the apex of the spleen forces the surgeon to manipulate the resected gastric portion so that it can be dissected and divided completely without ever leaving any gastric tissue. The resected specimen is placed in a bag.

15. Running suture on staple line 16'10''

A running suture is then applied to bury the entire staple line and will strengthen it to prevent fistula formation and achieve a good hemostasis. When this running suture is applied, the staple line’s integrity is controlled. Here we are surprised to find a small serosal effraction on this staple line; this is evocative of a risk of fistula. Separate stitches are then placed on each part of the fragile area in order to close this serosal defect. In case of a complete disruption of the staple line, the management would be the same. This oversewing lengthens the operative time, but this maneuver is performed in all our sleeve gastrectomy patients. The postoperative outcome is uneventful in this patient. When this suture is achieved, a burying running suture is completed. This part is also covered with a running suture, which is entirely achieved under the protection of the calibration tube to avoid any stenosis induced by the thread’s application. The running suture at the inferior portion is not really easy because of the instruments’ position. The instruments\' positioning is more suited for the superior gastric portion than for its inferior portion.