Robot-assisted and laparoscopic removal of a gastric band followed by a sleeve gastrectomy

Dysfunction is one of the common long-term complications of laparoscopic adjustable gastric banding (Lap-Band) that classically requires surgical treatment. Revision surgery is technically challenging and should be performed only by experienced surgeons. This is the case of a 50-year-old patient who benefited of a gastric band 3 years before. This gastric band is no longer functional. The patient declares that he would like to benefit from another type of surgery. The dissection is performed using the DaVinci S robot system (Intuitive Surgical®).

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Robot-assisted and laparoscopic removal of a gastric band followed by a sleeve gastrectomy

Authors

M Vix, J Marescaux

Abstract

Dysfunction is one of the common long-term complications of laparoscopic adjustable gastric banding (Lap-Band) that classically requires surgical treatment. Revision surgery is technically challenging and should be performed only by experienced surgeons. This is the case of a 50-year-old patient who benefited of a gastric band 3 years before. This gastric band is no longer functional. The patient declares that he would like to benefit from another type of surgery. The dissection is performed using the DaVinci S robot system (Intuitive Surgical®).

Classification

new techniques, robotic

Keywords

Robot-assisted, laparoscopic removal, gastric band

Media type

Surgical video

Duration

14'32''

Publication

2009-10

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Subtitles

E-publication

WeBSurg.com, Oct 2009;9(10).
URL: http://www.websurg.com/doi-vd01en2719.htm

Robot-assisted and laparoscopic removal of a gastric band followed by a sleeve gastrectomy

1. Introduction 00'19''

This is the case of a 50-year-old patient who benefited of a gastric band 3 years ago. This gastric band is no longer functional. The patient declares that he would like to benefit from another type of surgery. The patient’s BMI shifted from 40 to 36. Port placement is carried out under visual control. First, we will have the gastric band removed. We will check if the quality of the stomach is sufficient to simultaneously perform a new bariatric surgery or if we have to postpone it.

2. Dissection of the adhesions using the DaVinci S robot 00'52''

The DaVinci S surgical robot is used to dissect the various adhesions between the stomach, the band and the liver. The interest of using this robot relies on the improved degree of freedom when using the instruments; hence the tip of the hook used here can be orientated along different axes and allows for a more precise and adequate dissection of these adhesions. The difficulty when removing the band comes when freeing multiple adhesions originating between the anterior aspect of the stomach and the liver. The catheter is used as a guide to identify the closure mechanism of the band. The dissection is carried on slowly in order to find the correct dissection plane. Tractions exerted on the different tissues between the liver retractor and the robotic forceps allow to identify these different places fairly easily. Bleeds should be reduced to a minimum by all means in order to maintain a good view of the spaces situated between adipose tissues and the liver. The band’s catheter guides us to identify the closure mechanism. We must be sure that the dissection is performed sufficiently high beneath the liver so as to remove the gastric wrap placed to block the band into position. The dissection carries on gradually. It is not easy to distinguish between gastric wall, fatty tissue and adhesions.

3. Exposure of the band’s closure mechanism 03'37''

The band’s closure mechanism is dissected and exposed. Once exposed, this mechanism helps to easily mobilize the band.

4. Identification of the gastrogastric fixation 03'55''

Here, gastrogastric fixation threads can be found on the wrap. A good traction is necessary to free this gastric wrap. Here we can see the benefit of using the robotic hook’s mobile extremity, as it allows us to resume the dissection in reverse. Dissection is performed slowly to avoid causing a gastric wound. The space between the lower and upper portion of the stomach is searched for. The band is freed at this stage.

5. Conventional approach 04'49''

A conventional approach is used: we stop using the robot as the robotic manipulation of a foreign body, namely the band, is difficult, and because traction on the band is required. The robotic forceps does not allow to mobilize it correctly. The dissection is continued posteriorly towards the left crus in order to completely free the gastric valve. The perigastric fat left in place during placement of the band renders the task even more difficult. Here an adipose fat pad covering the upper portion of the cardia is removed. It is divided using the Ligasure device in order to ensure a good hemostasis. The gastric wrap is fairly difficult to dissect towards the left crus. Dissection is continued cautiously in contact to the band. The band is finally seen in transparency. There remains only a fibrous shell. The gastric valve has been totally dissected. The scar below the band can be seen at gastric level. This scar is proximal to the place where a gastric division would be performed should it be either for a sleeve gastrectomy or for a gastric bypass procedure.

6. Division of the band 07'21''

Once the band is completely freed on the superficial aspects, we divide it. The band is removed from the retrogastric tunnel. We continue the dissection to remove all the non-absorbable stitches that had been placed to fix the gastric valve; these stitches have been the cause of a fibrosis. At the same time, we try to prepare the operative field for the next step. Because of the size of the scar located under the band and of the adhesions we encounter near the left crus, we decide to postpone any further surgical procedures for morbid obesity in this patient.

7. Band removal 08'15''

The band is removed.

8. Delayed sleeve gastrectomy 08'23''

Three months later, this patient benefited of the complete preoperative check-up for another morbid obesity surgery, and we go dissect the superior part of the stomach again with the robot.

9. Dissection of the adhesions 08'41''

The adhesions are encountered again although they seem looser than last time. The dissection is not really easier than the first time, but we know that the gastric valve was completely freed during the first procedure.

10. Freeing the cardia with the DaVinci S robot 08'55''

The cardia’s freeing is then performed with the robot in order to recover a 3D view and an excellent dissection tool mobility, in this case the hook. The dissection carries on towards the left crus, and like the first time, the dissection is difficult in this region.

11. Laparoscopic gastrolysis 09'28''

The cardia is finally completely freed. We will begin the sleeve gastrectomy itself after removing the robot. The lesser sac is opened and a complete gastrolysis is performed with the Ligasure® device. The gastrolysis performed is conventional; it is not more difficult than in the cases in which we perform it from the start. The dissection is continued until we are 6cm from the pylorus. The superior section of the stomach is completely freed. The adhesions between the stomach and the left crus will also be freed before beginning of the gastric division.

12. Gastric division 10'48''

The gastric division is started by using a green cartridge because of the depth of the gastric tissue between the antrum and the fundus. A hemostasis is performed immediately on the vessels that are bleeding macroscopically and a 36 French calibration tube is placed; its introduction is not always easy, especially as the stomach appears to be quite fibrotic at its superior section. Once this tube is passed towards the duodenum, we continue the gastric division. It is continued using green cartridges due to the fibrotic nature of the gastric tissue. A blue cartridge can be used here on the superior section of the stomach as the tissue is not as thick. A small artery is coagulated here and we complete the gastric division by a firing of a blue cartridge Endo-GIA linear stapler. A small gastric bridge remains proximal to the superior section: it is divided using the Endo-GIA linear stapler to avoid having a poorly vascularized angle. A few posterior gastric adhesions are freed and the operative specimen is introduced in an extraction bag.

13. Running suture 12'46''

A running suture using absorbable monofilament is performed in order to bury the stapling line, strengthen it and achieve a perfect hemostasis. The suture is prepared with a knot on its extremity to avoid having to tie the knot at the superior section of the abdomen, where it appears uneasy. The postoperative follow-up was straightforward, and the patient was discharged on the 4th postoperative day. A careful check-up of the hemostasis is performed in order to make sure that there are no other bleeding sources.