Laparoscopic Roux-en-Y gastric bypass after vertical banded gastroplasty

Patients who have undergone bariatric surgery and present with upper abdominal symptoms pose a diagnostic and management challenge. Laparoscopic vertical banded gastroplasty (VBG) is associated with high revisional rates. In the case of failed VBG, repeat VBG seems to be a poor option and conversion to gastric bypass yields better results. This is the case of a 35-year-old female patient who underwent a vertical banded gastroplasty by laparotomy 8 years ago and presents with dysphagia. A gastroscopy and a contrast swallow exam using radio-opaque markers do not show any fistulas, but peroperative surgical exploration discovers a gastro-gastric fistula. This video clearly shows all the technical aspects of a revisional bariatric procedure.

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Laparoscopic Roux-en-Y gastric bypass after vertical banded gastroplasty

Authors

M Vix, F Costantino, J Marescaux

Abstract

Patients who have undergone bariatric surgery and present with upper abdominal symptoms pose a diagnostic and management challenge.
Laparoscopic vertical banded gastroplasty (VBG) is associated with high revisional rates. In the case of failed VBG, repeat VBG seems to be a poor option and conversion to gastric bypass yields better results.
This is the case of a 35-year-old female patient who underwent a vertical banded gastroplasty by laparotomy 8 years ago and presents with dysphagia. A gastroscopy and a contrast swallow exam using radio-opaque markers do not show any fistulas, but peroperative surgical exploration discovers a gastro-gastric fistula. This video clearly shows all the technical aspects of a revisional bariatric procedure.

Classification

complex cases

Keywords

Laparoscopic Roux-en-Y gastric bypass, RYGB, vertical banded gastroplasty

Media type

Surgical video

Duration

16'04''

Publication

2009-04

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Audio

Subtitles

E-publication

WeBSurg.com, Apr 2009;9(04).
URL: http://www.websurg.com/doi-vd01en2596.htm

Laparoscopic Roux-en-Y gastric bypass after vertical banded gastroplasty

1. Clinical case presentation 00'10''

This is the case of a 35-year-old female patient who underwent a vertical banded gastroplasty by laparotomy 8 years ago. She lost 80% of her overweight thanks to this procedure. She then became pregnant and regained almost all the weight she had lost. She complains of dysphagia, which requires her to stick to a strict liquid diet. A stenosis of the lower portion of the neogastric pouch is envisaged. A gastroscopy and a contrast swallow exam using radio-opaque markers do not show any gastrogastric fistula. The operative report of the Mason procedure cannot be retrieved and the origin of the material used for the band remains unknown. Following a thorough preoperative work-up, exploratory laparoscopy is offered to the patient with the objective of performing a gastric bypass.

2. Dissection of the adhesions 01'04''

Once the ports have been introduced, a few omental wall adhesions are taken down before the dissection is performed at the upper portion of the stomach. A few adhesions between the liver and the lesser omentum are divided. The adhesions between the liver and the stomach are then dissected in order to completely respectively free the anterior and posterior aspect of the cardia.

3. Dissection of the posterior aspect of the cardia 01'24''

Freeing the posterior aspect of the cardia requires the division of some short gastric vessels immediately at the level of the left crus.

4. Identification of the gastro-gastric cleavage 01'33''

The anterior aspect of the stomach is then approached in order to identify the gastrogastric cleavage plane looking over the gastroplasty. This dissection is difficult to achieve, and therefore it must be performed cautiously to prevent the risk of a gastric injury. A non-absorbable suture is found on the upper portion of the stomach. The operative space is progressively visualized.

5. Intraoperative endoscopy 01'58''

A gastroscopic exploration is performed intraoperatively: it does not show any gastrogastric fistula. Once this extensive dissection has been completed, the upper gastric pouch is divided in order to perform the bypass.

6. Dissection of the lesser gastric curvature 02'16''

The dissection of the lesser curvature is started just above the gastroplasty. This dissection must be careful and progressive in order to limit the risk of devascularization of the lesser curvature. The lesser sac is opened.

7. Gastric pouch division 02'43''

The division of the gastric pouch is then started using an Endo-GIA linear stapler, blue cartridge 60mm.

8. Gastric division under endoscope calibration 03'08''

From then onwards, the posterior surface of the stomach can be explored and the gastric division is continued using the linear stapler with blue cartridges 60mm. The gastric pouch is calibrated by the endoscope that is used to search for the existence of a gastrogastric fistula.

9. Identification of the gastro-gastric fistula 03'24''

However, a non-identified gastrogastric fistula is clearly present as the lower portion of the stomach is bloated with air, and this despite the division of the upper gastric pouch above the calibration band. The gastric pouch is then delimited as demonstrated by the endoscope.

10. Partial polar upper gastrectomy 03'43''

A partial polar upper gastrectomy is decided upon by removing the gastric band and the upper portion of the greater curvature in order to remove the fistula. The lesser sac is opened as proximal to the greater curvature as possible in order to lyse the portion of the stomach to be resected. The gastrolysis is continued until the upper portion of the greater curvature. The stomach is then incised in order to deflate the gastric pouch before dividing it. Such a division allows to remove the upper portion of the fundus and the gastric band placed when the vertical banded gastroplasty is performed. The resected gastric pouch is placed in a bag. The stapling lines of the excluded stomach and of the upper gastric pouch are buried.

11. Biliary and gastrojejunal anastomosis 05'00''

The gastrojejunal anastomosis is performed transorally. A gastric incision is achieved to retrieve the orogastric tube with the anvil of the circular stapler on its tip. This tube has been placed by the anesthesiologists. It is retrieved in the intra-abdominal space until the anvil is placed. The anvil is then freed from its drain. A purse-string is achieved around the passage of the anvil. The gastric pouch is ready for the anastomosis. We then go to a submesocolic position in order to prepare for the Roux-en-Y anastomosis. We measure 75cm of biliary limb. This is then fixed to the stomach and marked to be identified correctly later. 150cm of alimentary limb is then measured: it is fixed to the biliary loop in order to prepare for the anastomosis at the foot of the loop. An opening is created using the hook in each loop in order to introduce the jaws of a 60mm linear stapler, white cartridge. The introduction sites of the Endo-GIA linear stapler are re-approximated using an absorbable suture. The mesenteric defect at the foot of the loop is sutured by a non-absorbable thread. The alimentary loop is then divided by a 60mm linear stapler, white cartridge. It is opened to allow for the introduction of the circular stapler. The gastrojejunal anastomosis is then achieved by connecting the anvil with the circular stapler. The introduction site of the circular stapler is closed once the blind extremity of the Roux-en-Y loop has been shortened using a linear stapler, white cartridge. The extremity of the resected Roux limb is also placed in the bag containing the gastric specimen. The line of staples internal to the circular anastomosis is strengthened by two stitches. Two stitches are placed on each side of the gastrojejunal anastomosis.

12. Closure of Petersen\'s space 11'24''

The Petersen’s space is closed by a purse-string made of a non-absorbable suture in order to avoid internal hernias.