Laparoscopic gastric banding

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Laparoscopic   gastric   banding

Authors
M Vix, J Marescaux
Keywords
morbid obesity,operation,stomach,gastric band,laparoscopy
Media type
Duration
15'00''
Publication
2004-09
Popular
Favorites
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Audio
en
Subtitles
en
E-publication
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1624e.htm

Laparoscopic   gastric   banding

1. Case presentation 00'14''
The first port that we insert is placed one handbreadth under the xiphoid process, not on the umbilicus, which is 5cm lower and we make an open laparoscopy. This scar is a little bit larger because we will insert the insufflation port in this place at the end of the procedure. After that, you have to place 3 to 4 trocars, the first one is the liver retractor. You see that in this case, we have a big left lobe, we prefer to put the liver retraction trocar on the right side outside on the axillary line. Another 2 operating trocars placed a little bit above the optic trocar on the mid-clavicular line, the last trocar is placed on the left part of the patient, on the axillary line on the left. With the inside view, you see that we have retracted the liver, the 2 instruments go together and stay in the region you want to operate, it is important not to have contractions of the patient’s wall. First of all, I will open the pars flaccida with cautery. We open it largely upwards, and especially very low downwards to have enough space to see the right crus. Behind the pars flaccida, you can see the vena cava, it is here, the caudate lobe and here you have the right crus. I open the peritoneal sheath very gently, so you see the retroperitoneal space and we will begin the dissection of our channel just here in front of the right crus. There are no tubes at the moment in the stomach because I think it is more difficult to make the dissection with the tube and you have no calibration to make when you use the pars flaccida technique. When you use the technique around the stomach, you need to have a calibration tube with the balloon inside the stomach to know where you have to begin the dissection. Very gently under visual control, we look for the retrogastric channel until we see the peritoneal sheath on the other side. Is the rule to follow the fat? It is to follow the line between the fat and the muscle. You must have the muscle on the lower part and the fat around the stomach on the upper part. I am going very carefully because I am very close to the spleen, you see here my grasper on the other side. Everything is done under visual control, it is not a large hole, it is very small. After that, there are 2 possibilities, keep this grasper in the retrogastric tunnel during the introduction of the band, you can use the gasper to do a “hand-shake” inside, this will keep the grasper in this position and make sure it doesn’t go away. The other possibility when you have only 3 trocars, you can use some fat and you grasp the fat. The retrogastric channel is made, now we have to introduce the band. To introduce it, we have a little trick, take the grasper and take it through the optic scar. Here you see the band, it is a BioEnterics band, a new type of band called Vanguard, you have the band with the balloon at this place, and the catheter that will be put on the insufflation port in the subcutaneous fat. We remove all the air out of the balloon and we put the band inside the abdomen and we’ll introduce all the length of the catheter inside. You have to avoid putting the catheter in the subcutaneous fat, it’s the reason why I have one finger in the peritoneum and the other one to put the catheter inside. You can see the band on my grasper, I remove the grasper and I take the tip of the catheter here; with my right hand grasper, I release the “hand-shake” and I give the catheter to the grasper that is in the retrogastric channel. Go around and put the band in place in this retrogastric channel. With this band, you have no problem of orientation, the band comes alone in the right position, you just have to pull sometimes, you have to avoid taking the balloon with the grasper. At this moment, we have to put the catheter into the closing mechanism, I just put the tip, and at this moment, you have to avoid knots with your catheter. I close the band in its first position; after the calibration, we can close the band completely. We ask the anesthesiologist to put the orogastric tube with the calibration balloon inside the stomach. We insufflate to 15cc, you see the bulge of the balloon here. We ask the anesthesiologist to pull on the nasogastric tube so that we can calibrate a 15cc part of stomach over the band. We close the band just here in this position and you see the balloon over the band. The band is 2cm from the diaphragm. We will do a wrap with the stomach wall around the band, with non-absorbable sutures. The first stitch that I put is an internal stitch in order to begin the wrap. So you see the suturing here of the first part of the wrap. At this moment, we have an important part to do, we will put a stitch between the stomach and here the left crus. This is the more difficult part of the stitching, we have to remove the catheter as it is always in the place that you don’t want it to be. You can take the catheter to put it in the region of the spleen. Why are you fixing to the left crus because usually most of the people are fixing stomach to stomach? I fix to the left crus because I want to close this posterior space because in this technique in the anterior part, we fix the band in the posterior channel you have no space to make a dilation, the only possibility you have is to have the posterior part, the upper part of the greater curvature that develops the dilatation going through the band. We have no more difficulties in that way, when you re-operate a patient with a dilatation, I think it is easy to follow your catheter and you find your closure mechanism even in this position. Don’t you think that putting the stomach over the buckle is more dangerous than to cover the other part of the system? I am not sure because the erosion is not on the part that covers that is under the band, and you have the pressure distributed on all the band, and sometimes the erosion is on the posterior part of your stomach. We had in out experience about 200 cases of erosion, the closure mechanism wasn’t under the stomach in this case. The anesthesiologist removes the balloon at this moment, we will see if we fix the balloon inside the stomach or not. We have a look at the spleen, there is no major problem as you see. Removing the catheter, I do it through one of the lateral ports and after that, I have a subcutaneous fat way and I make my insufflation port under the umbilicus. If I have an infection of my insufflation port, I can remove it but keep the catheter a long way from the abdominal part. We will exsufflate. It is a Vanguard band, it is a little bit larger than the 11 one from BioEnterics, I am not sure that the dimension of the band is very important because you have to insufflate your balloon after that and you have a calibration with the insufflation. So we will close the fascia, we have some retractors that allow to go very deep and to grab in the fat to find the fascia. I will show you how the catheter goes in a subcutaneous fat way, I put some string here and I take one laparoscopic grasper to go over the fascia in my subcutaneous fat to make this passage. I take the tip of my catheter and with the string, the catheter can disappear and when I need it, it comes back. I will place the insufflation port. The port is fixed and we just have to close the scars and the operation is over.