Recorded live laparoscopic gastric band placement in a woman aged 26 with a BMI of 40

This video shows a laparoscopic gastric banding in a 26-year-old woman. She presents with a BMI of 40. She has a history of dieting with some success but no long-term success with weight loss. All steps are presented in this video recorded at the IRCAD Advanced course in laparoscoic bariatric and metabolic surgery held last September 17-18, 2010.

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Recorded live laparoscopic gastric band placement in a woman aged 26 with a BMI of 40

Authors

M Vix, J Marescaux

Abstract

This video shows a laparoscopic gastric banding in a 26-year-old woman. She presents with a BMI of 40. She has a history of dieting with some success but no long-term success with weight loss. All steps are presented in this video recorded at the IRCAD Advanced course in laparoscoic bariatric and metabolic surgery held last September 17-18, 2010.

Mots-clés

Recorded live laparoscopic gastric band placement, BMI of 40

Type de vidéo

Vidéo chirurgicale

Durée

14'38''

Publication

2010-10

Popularité

Favoris

Favorites Media

Audio

E-publication

WeBSurg.com, Oct 2010;10(10).
URL: http://www.websurg.com/doi-vd01en3081.htm

Recorded live laparoscopic gastric band placement in a woman aged 26 with a BMI of 40

1. Introduction 00'20''

Our patient is a female, 26 years old. She presents to us with a BMI of 40. She has a history of dieting with some success but no long-term success with weight loss. She has no medical history. She has a history of an open appendectomy that was done when she was a child, and through an incision at McBurney’s point and her preoperative work-up was completely normal. I’ll now turn over to Mr. Vix who is in the operating theatre.

2. Trocar position 00'52''

Our case is a gastric banding. This young woman absolutely wanted to have a gastric banding and so we will show you how to place it. The position of the trocars: you have an extended view. See here the first trocar that is inserted: it’s the optical trocar one hand’s breadth under the xiphoid process, one hand’s breadth, it’s a little bit higher than for the other procedures because we are only working at the upper part of the stomach. You have one 5mm trocar for the liver retraction. In my left hand, we have a 5mm trocar to help with the dissection. This is really to the left of the patient, a 5mm trocar also for my assistant to help me with retraction, and the second operating trocar here for my right hand.

3. Opening of the pars flaccida 01'45''

The first thing we have to do is to open the pars flaccida. See the upper part of the stomach, the angle of His here and we will just open the pars flaccida that is here. I will open here very largely with the scissors and behind I will find the right crus. I open it very low in order to have a good direction to create my retrogastric channel. Here you can see the crus. If you go a bit more to the side, you can see the vena cava here and so we will open the peritoneal sheet here just in front of the right crus at the point where the right crus will disappear under the fat. I will use the hook for that.

4. Retrogastric passage 03'14''

After that, just using blunt dissection, I will go behind the stomach. So we will see the right crus, we’ll see the left one. Very gently you see I have a very nice view, and I’m staying here just on the fat and this fatty tissue. This is of course the most difficult part of the operation, and sometimes you can go a little bit too much upwards and you will find the mediastinum: you have to avoid that. If you are too deep, you will find the lesser sac and when you open the lesser sac, you absolutely need to close it because if the lesser sac is opened, you have the risk of a posterior slippage of your band. When you think that you are quite on the other side, you can have a look and you see here my grasper coming out. I will take my grasper here on the left liver ligament and the channel is made; it’s time to prepare the band.

5. Band preparation 04'39''

It’s an Allergan™ band, it’s a small one that is inflatable for 10cc of saline. I will begin to inject 10cc of saline inside the band and so you see that you have water and air inside, I will just remove all the air outside the band to be sure that there is only saline inside. When this is done, I put on the catheter a little tip that will allow to put it through the retrogastric channel very easily. The little tip is here. It’s well fixed here. And I will have to put the band inside the abdomen.

6. Band insertion in the abdomen 05'42''

Usually for this band, you need a 15mm trocar and there’s a little trick to put the band inside. I put the camera inside the abdomen again and I will use one of my graspers to help grasp the band. See here. I will use the grasper of my assistant and I will go here through this optical trocar here. I push it out. I put the band on this grasper here; I take it inside the abdomen. It’s quite easier to do that this way. Then you need to pull in to push in the catheter of the band. It’s easier to do like this with this little trick. So the band is inside the abdomen. You need to find the tip of the catheter here. The tip is here. You have some small markers on the catheter to help you find the end, because the catheter is quite long inside the abdomen. See the little markers here. So you know where, in which direction you have to pull or to push to take the tip. I will give it to the grasper that is on the retrogastric area. I will give the tip of the catheter. I try to give it in the good direction to avoid disrupting some tissues in the retrogastric channel.

7. Band positioning 07'49''

After that, this is done. I have just to pull on the catheter and you will see that the band will come in place quite alone due to its shape. Ok, the band comes in place. It turns around the stomach very easily. That’s just the closure mechanism that is a little bit larger. I will use the tip again to close the band.

8. Orogastric tube insertion and band calibration 08'44''

You see this is the first lock position you have here, so the catheter cannot go away. So we will ask the anesthesiologist to push down an orogastric tube with an inflatable balloon at its tip. You see the tip coming down. Ok, perfect. I ask for insufflation at 15cc of air or saline. You see here the bulge. I will ask to pull and I will push, you see, the bulge here. Stop. You see the bulge over the band here. I will just have to close the band under this bulge. Here the band is closed. So I calibrated with the balloon and I have just to fix here at this moment the band in place and I will do a wrap with the stomach and I will just take some tissue here. I will fix it over the band. Sometimes, you destroy the calibration balloon.

9. Wrap creation 10'50''

I am just concentrated on my stitch here. That can perhaps explain the dysphagia you have at this time. So this will be the third and last stitch. The first one is close to the lesser curvature. The second one is at the upper part of the stomach, very high, close to the crus, just to close the space you can have, close to this crus to avoid some lateral posterior slippage. So the band is in place. Just have a look on the anterior aspect. I can perhaps close a little better here. I’ll put an additional stitch here. We had that two or three times. So the wrap is done and I will take out the catheter at this time. I take the tip here, and I take it out through this trocar here. At this time, we can deflate. The intra-abdominal work is finished. And so we can remove all the trocars we have inside under view control. We exsufflate and we will close the fascia.

10. Final view after laparoscopic step 12'54''

When the fascia is closed, we will take you have an extended view and we will take this catheter in the subcutaneous fat to bring it here. And so, we will adapt this little piece. You can insufflate through and adapt the volume of the inside of your band with this insufflation port here that will be placed here down. That will close the procedure. There are two bands. Today we put very few bands. Here is a little trick: I put a thread just around the band here. You can\\'t see it very well. So, when I pull, even if my catheter is going inside, I can take it out afterwards. I have also to remove the air on the catheter on the other side. So, you see here the insufflation port is placed. I will put two or three stitches to fix it on the fascia to avoid migration or tilting of that insufflation port. Then, we will ll take it down and we will put it close to the fascia and we will make some sutures on the fascia. The additional part will be pushed inside the abdomen and I bring it quite deep here inside. So, you can at this moment remove the thread here and the operation is quite finished. I have just to fix the insufflation port to the fascia.