Laparoscopic vertical banded gastroplasty

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Laparoscopic   vertical   banded   gastroplasty

Authors
JL Alle
Mots-clés
Laparoscopy,vertical banded gastroplasty,VBG,morbid obesity,stomach
Type de vidéo
Durée
17'00''
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-vd01en1627e.htm

Laparoscopic   vertical   banded   gastroplasty

1. Case presentation 00'08''
It is a reverse Trendelenburg position with open legs. The first trocar, that is the medial trocar for the optic is one handbreadth below the xiphoid. The second port is very lateral on the right side of the patient for the future fenestration, the third port is just under the xiphoid, the fourth one is on the anterior axillary line and is also a 12mm, all these 4 are 12mm. To have an easier operation, I use a fifth trocar at the far left and a 5mm trocar is enough. The principle of the technique is to have a fenestration 5cm under the hiatus. I usually dissect on the lesser curvature, normally 5cm under this hiatus. The normal place for this fenestration is the second transverse vessel. In this situation there, I am not sure that this is the right place because there is a hiatus hernia. Exceptionally, I begin the dissection by dissecting completely the hiatus to be sure that I have reduced it. Even though it is described that we have very good results on reflux with VBG, I think that it is very changing, there are patients with very interesting and important improvements of their reflux but there are more patients that develop reflux after this operation. I think that we cannot say that it is a way to cure it. Do you always use the hook or the scissors or any kind of dissection? Always the hook in reflux procedures, gastrectomies and in bariatric surgery at this place. Little opening on the membrane to have a good partial reduction of it. I don’t think it is necessary to have complete dissection of the hiatus. I am using a 0 degree scope. I have had a lot of experience in reflux problems in restrictive procedures. I agree but there is a lot of literature that would support that VBG is an excellent anti-reflux procedure. I don’t think that VBG really cures reflux. I agree too but when you obtain a good result for weight loss, most of the pressure inside the abdomen decreases, people can learn from time to time to eat slowly and of course the reflux is improved. Compliance of the patient is the most common problem. Now I am ready to open progressively along the wall and go to the lesser sac. The problem is that it’s a little bit different than with the bands or the gastric bypass because I need to have a wider opening because I have to pass a 25mm circular stapler. You cannot change your mind during the operation for any reason without telling the patient first. I am reaching the lesser sac, I will now introduce 2 things: first the anesthesiologist will help us to have a calibrating nasogastric tube introduced through the mouth, it is a 34 French tube, and this one will be stretching the lesser curvature to present it. We are entering progressively the tube along the lesser curvature, you see the end of the tube. We use it to stretch the stomach, the tube is here, we see it here. I will use the calibrating clamp, you see the target zone here, this is designed to have a target zone to show us where we have to introduce the circular stapler. The clamp is not completely closed but when I’m sure that I am in the right position, I will close it completely. The problem is to avoid having tissues here in the target zone. For the circular stapling, I change position as I am coming from the left of the patient and going between the legs but with this trocar design, it is not difficult for a right-handed person to remain between the legs. We change the position of the optic to have a good view of the right side of the patient. This is the clamp, we take the retractor out, and we also take the right trocar out. I am introducing the circular stapler through the right side, you can see here my finger, we open a little bit more. I introduce it directly through the wall, it is a 25mm stapler. I used a 21mm one for a long time but for security purposes, I use a 25mm one. I open it completely and I use this 5mm trocar here on the lateral left side to take the anvil out and to hold the anvil in waiting without danger of losing it. With the 5 trocar system, I have the opportunity to have another trocar free to introduce the white tape. This allows me to be very secure. Security first, I close it, and then we shall perforate the stomach from the right to the left. You see the presentation here and we are looking for the target zone of the clamp, you see it now. I open the instrument, present the circular stapler at the right place. I like to have a direct introduction. Before I start, I control the other side to show you, it has already passed. I am at the left of the patient, I’ll show exactly where it’s coming out inside the clamp. I come back to the middle, you see this is passed, and here you have a view of the other side. Reverse maneuver first, here you have a security with the clamp because it is blocking the instrument. I am sure with this clamp that the circular stapler remains in place and as the anvil is ready, it is not so difficult to introduce it to be secure. If you do 2 half turns, you are sure that the anvil is blocked and that no problem may happen. The next step is to retrieve the clamp, it is an easy maneuver, take it out and introduce the retractor to have a good view and show you the circular stapling. I close the instrument and I use traction on the lesser omentum to be sure to avoid taking the stapling in, you can see here the calibration by rolling off the nasogastric tube. Progressively the nasogastric tube is coming, we take it out, we can see the doughnuts and the fenestration. I take it out and introduce a trocar to replace. Next step is to begin the vertical partition. Here is what the fenestration looks like, here is the nasogastric tube and the aim of the operation is to be very close to this. I think I am in a good position, this is the first stapling. You see that it is complete and the opening shall show for it. We have done all we can to cure the hiatus hernia. I have tried to show you a reproducible operation, I think the band should be reproducible, now the good way to put a band is to have a calibrated prepared band, rather than a mesh. This is a CALIGAST by Helioscopie, it is a band without the inflation system designed for this purpose. It is very easy to put.