Vertical banded gastroplasty

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Vertical   banded   gastroplasty

Authors
JL Alle
Mots-clés
morbid obesity,stomach,VBG,BMI,band
Type de vidéo
Durée
17'00''
Publication
2003-06
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Jun 2003;3(06).
URL: http://www.websurg.com/doi-vd01en1450e.htm

Vertical   banded   gastroplasty

1. Case presentation 00'12''
I have inserted 5 trocars. The 1st trocar is on the midline, slightly on the left of the patient, one handbreadth’s from the xiphoid appendix. The 2nd trocar is on the axillary line on the patient’s right. The 3rd trocar is at the left side of the xiphoid appendix. The 4th is symmetrical on the left from the 2nd one on the axillary line. The 5th is in the middle of the line between the 1st and the 4th trocar. All trocars here are 12mm ones in order to move with all the instruments, except the 5th one, which is a 15mm trocar. It’s not necessary in all procedures but it allows first to use green cartridges on the stomach and then to implant a band at the end of the operation that needs this kind of trocar. The patient is supine with the head slightly raised. Here I have a view on the hiatus. Here we have an important phrenogastric ligament that shall be opened later on in the operation and here I have the anatomy of the lesser curvature. Normally this operation begins with the dissection of the lesser curvature and I create a 5cm pouch along this curvature. The experience shows that we have second transverse vessels here where I always begin the dissection. I am a left-handed surgeon. I am here on the left side of the patient. Normally a right-handed surgeon works between the patient’s legs. I perform the dissection with electrocautery. It is essential to obtain a good view at the beginning, because if we don’t begin with the dissection of this vessel, there is a persistent risk of bleeding. This is the lower part of my dissection. I intend to reach the posterior part of the stomach slowly. For this purpose, I begin to progressively roll the stomach on itself, a little rotation this way. As I introduce the circular stapler this way, I’m forced to have a relatively wide opening of 3 to 4cm. I’m reaching the deeper part of the lesser omentum. I introduce a little towel. We’re expecting to open the lesser sac and I reach my target landmark. The lesser sac is opened. Here’s the clamp I use inside the abdomen. This clamp is designed with one target zone here, here is the circular and another perpendicular lower one. The lower part is not symmetrical. It’s designed to be used with the circular stapler. The principle is to catch the nasogastric tube by the higher circular target zone. The NG tube (34) is exactly at this angle and I ask the anesthesiologist to push it along the lesser curvature and introduce it slowly. The tube is there now. I like this tube to be as far as possible because during this maneuver it is possible to lose it. You can see that the tube is on the lesser curvature. I will catch the tube with the clamp. At this stage, I must avoid to roll the gastric tissue. It’s interesting to have a good traction on the stomach. I shall expose it very well to be sure we are at the right place. I control its vertical position. The posterior part of the stomach becomes the right side of the stomach and the other side, the anterior side becomes the left part. I introduce the optical system by the left side of the patient, which allows me to have a very good view on the right part of the patient. I introduce Mayo scissors to enlarge the opening. I use a 25mm. Now I have 2 trocars on the left side that are free. I use the lateral one to take and catch the anvil. I put it on hold on the liver. I have a free 5th trocar to introduce the white tip. You see the safety of the system allowing to hold this in place during all these maneuvers. I’m closing the instrument for safety reasons and passing on the liver, we shall maximum ascension of the target zone. I open it completely to be sure I’m going inside the right place. And if I’m sure that there is no liver there, I can push once this way. It’s finished. We’re going to the other side safely. I perform the reverse maneuver and the anvil on hold here is introduced. At this stage, if I use two half turns for closing, I’m sure that the anvil shall not go out because it’s clicked. Then I perform maximum ascension of the trocar, open the clamp and slowly maneuver it to retrieve it. Now we have a good view on the left. I avoid taking the lesser omentum. Normally we shall see the tube rolling on the circular stapler. I’m stapling at the moment. After 4 half turns, you can see the donuts. I get out with the circular stapler and reintroduce the trocar. At this stage, I will pass the circular stapler in the fenestration. To help me, I will ask the anesthesiologist to push on the NG tube to get the best suction on the stomach and improve its verticality. Now I can staple this. We can now see the 1st stapling line thanks to the 5th trocar. I shall pass from the anterior to the posterior part and dissect progressively. Now we will try to enter the posterior part this way. I will use the blue cartridge, 6cm. I’m passing through the tunnel until I reach the angle of His. I will close it. You can see now that the stapling is complete and the vertical stapling partition is achieved. I will now place the band. We change the position of the retractor and intra-abdominally, here is the band. Here is a 3mm silicone thin and soft tube through which I introduce a Nylon non-absorbable suture. The band is 53mm in length so it gives us an 11 to 12mm diameter inside. Now the anesthesiologist can retrieve the NG tube slowly and ask him again to reintroduce the NG tube. I have now placed the band. And the tube can be removed. The procedure is now complete. In this case, I don’t fix the stomach. The liver comes back to its original place and this is finished.