Redo bariatric surgery: laparoscopic adjustable gastric banding (LAGB) converted to Roux-en-Y gastric bypass (RYGB)

This is the case of a morbidly obese 35-year-old female patient. Placement of an adjustable gastric band was performed 5 years ago (BMI of 45) with good postoperative results (BMI of 38, 60% of overweight lost). Following an episode of acute dysphagia, deflation of the gastric band was performed and since then, despite size adjustments the band was no longer effective. In fact, the patient slowly regained the full weight that was previously lost (BMI of 45). Removal of the band and Roux-en-Y gastric bypass (RYGB) were carried out at the same operation.

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Redo bariatric surgery: laparoscopic adjustable gastric banding (LAGB) converted to Roux-en-Y gastric bypass (RYGB)

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Abstract

This is the case of a morbidly obese 35-year-old female patient. Placement of an adjustable gastric band was performed 5 years ago (BMI of 45) with good postoperative results (BMI of 38, 60% of overweight lost).
Following an episode of acute dysphagia, deflation of the gastric band was performed and since then, despite size adjustments the band was no longer effective. In fact, the patient slowly regained the full weight that was previously lost (BMI of 45).
Removal of the band and Roux-en-Y gastric bypass (RYGB) were carried out at the same operation.

Keywords

minimally invasive redo bariatric surgery, laparoscopic adjustable gastric banding, LAGB, Roux-en-Y gastric bypass, RYGB

Media type

Surgical video

Duration

17'00''

Publication

2007-11

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E-publication

WeBSurg.com, Nov 2007;7(11).
URL: http://www.websurg.com/doi-vd01en2152.htm

Redo bariatric surgery: laparoscopic adjustable gastric banding (LAGB) converted to Roux-en-Y gastric bypass (RYGB)

1. Dissection of adhesions around stomach 00'15''

This film shows the removal of a gastric band and the subsequent performance of a gastric bypass in the same patient. The patient is positioned as usual for a gastric bypass procedure with the surgeon standing between the patient’s legs. Exposure of the operative field is enhanced by a liver retractor held by an assistant while the inflation catheter of the gastric band is also used to provide an excellent means on exerting tension on the tissues to be dissected. The first step of the intervention consists of complete dissection of all the adhesions that have formed between the adjacent stomach and the liver and the catheter of the deflated gastric band. Such a clearance helps to identify the zone of gastro-gastric suturing that is usually placed to cover the band at the time of the first operation. In some cases, the band may only be covered by a thin strip of fibrous tissue, which can be easily divided. In all cases it is important not to injure the stomach and in particular the gastric wall should not be opened during this dissection. When the band is totally cleared of adhesions, the ring of the band may be cut allowing the band to be removed from the stomach.

2. Removal of band from the stomach 02'09''

Underneath, we can now clearly observe the fibrous ring that has developed over the part of the stomach that was in contact with the gastric band. It is often prudent to divide this tissue also. The gastric band is left anchored by its transabdominal catheter for now as it will be most easily removed at the end of the operation.

3. Fashioning of gastric pouch 02'30''

The gastric pouch of the bypass can now be fashioned and you can see that the angle of His has already been cleared. The medial attachments of the lesser curvature are dissected in order to clearly identify the vascular supply. The lesser sac is entered leaving in view the vascular arch that will supply the gastric pouch.

4. Gastric stapling 03'24''

The first line of division is made horizontally using a 60mm linear stapler loaded with a blue cartridge. Three other applications of this stapler are then applied vertically up towards the angle of His. The path of the stapler lies lateral to the scar tissue that lay underneath the band. This step completes the isolation of the gastric pouch.

5. Oversewing of the staple lines 04'42''

A running suture for the purposes of ensuring hemostasis is then placed to cover the staple lines on both the side of the gastric remnant and on the side of the gastric pouch. Retraction on the tied end of the suture greatly assists the fluency and accuracy of the suturing by both invaginating the staple line and tenting up the part of the stomach wall to take the suture. In this way, the entire staple line can be completely oversewn. After the gastric remnant is secured, the same suture technique is done for both the vertical and then the horizontal staple lines of the gastric pouch. All the knots are tied intracorporeally.

6. Access to submesocolic space 07'12''

The submesocolic region is now accessed in order to create the Roux loop. By retracting on the omentum and then the mesocolon of the transverse colon, the ligament of Treitz is identified. This marks the duodenojejunal flexure.

7. Construction of biliary limb 07'36''

The first 75cm of the jejunum will form the biliary limb of the Y construct. This is measured by rotating the jejunum clockwise while calculating its length by comparison against the forceps you see to the right of the screen. This instrument has been calibrated preoperatively as you can see by the band near to its tip. Once the 75cm point is reached, the jejunum is temporarily fixed to the stomach using a stay suture. This point represents the terminal limit of the biliary limb and the jejunum will later be transected at this point to allow the jejunum distal to this area to be hitched up to the gastric pouch as the alilentary limb. It is prudent therefore to mark the afferent side of this loop with a marker.

8. Positioning of alimentary limb 09'17''

Once securely fastened, a further 150cm is then measured distally along the jejunum. This represents the length of the alimentary limb. The point reached by this measurement is also held with a stay suture this time to the bilary limb. This will facilitate subsequent performance of the jejunojejunal anastomosis or the angle of the Roux-en-Y construct.

9. Creation of jejunojejunal anastomosis 10'42''

The 2 adjacent loops are then opened with the cautery hook to facilitate the fashioning of the jejunojejunal anastomosis. The broader jaw of a 60mm linear stapler this time loaded with a white cartridge is introduced first to one side. The stapler’s head can then be rotated to allow the more slender jaw enter the adjacent loop of bowel. The stapler is fired and the opening that allowed the entry of the stapler is re-approximated using a 2/0 absorbable suture. Again the knots are tied intracorporeally and you can see here that the anastomosis is secure.

10. Closure of mesenteric defect 12'26''

The mesenteric opening at the foot of the loop is now closed using a monofilament, non-absorbable 2/0 suture in order to obviate the risk of an internal hernia occurring. The running suture is extended along the mesentery and on to the serosa of the bowel in order to ensure complete closure.

11. Introduction of anvil of circular stapler and snugging into the gastrotomy 13'13''

The anvil of a circular stapler is now attached to the tip of a fine bore nasogastric tube that is introduced per ora. The gastric pouch is now opened and this allows caudal traction on the NG tube to draw the strut of the anvil snuggly into the gastrotomy.

12. Purse-string around strut of anvil 14'11''

A purse-string is then fashioned around the shaft of the anvil in order to secure it in this position.

13. Jejunal transection 14'39''

We now return to the site of the jejunojejunal anastomosis. The jejunum is transected just beyond this anastomosis at about the point of its fixation to the anterior gastric wall. Again a 60mm linear stapler is used to perform this maneuver.

14. Creation of gastrojejunal anastomosis 15'15''

This free end of the stapled jejunum represents the part of the alimentary limb to be used in the creation of the gastrojejunal anastomosis. It is opened with the cautery hook in order to allow the introduction of the head of the circular stapler into the segment of bowel. The wall of the small bowel is pierced through by advancing the tip of the stapler, which is then safely removed. The anvil placed in the stomach and the circular stapler’s head in the jejunum are then mated so that the anastomosis can be completed. The stapled cuffs are then checked to ensure they are complete.

15. Closure of mounted jejunal limb 16'38''

The site of stapler entry on the mounted loop is then closed using again the 60mm stapler.

16. Removal of gastric band from the abdomen 16'56''

This portion of resected bowel is then placed into a bag along with the gastric band, which had been held in the abdomen by its trans-abdominal catheter. The bag is closed and both pieces are removed from the abdomen.