Laparoscopic gastric banding in a female patient with BMI 38

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Laparoscopic gastric banding in a female patient with BMI 38

Authors

M Vix, J Marescaux

Keywords

obésité morbide, gastric banding

Media type

Surgical video

Duration

09'18''

Publication

2006-05

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E-publication

WeBSurg.com, May 2006;6(05).
URL: http://www.websurg.com/doi-vd01en1957.htm

Laparoscopic gastric banding in a female patient with BMI 38

1. Trocar placement 00'15''

We begin to open the pars flaccida here.

2. Start of procedure 00'35''

We can see segment I of the liver. Here, an incision is made in front of the right crus. The landmark is when we don’t see the muscle any longer, lower down when it goes underneath the fat. The retrogastric channel is created. Scissors are changed for a grasper. Here we want to identify the plane that lies in front of the crus and behind the stomach, you can see a little window that needs to be created under visual control.

3. Retrogastric tunnel 01'36''

You can see the crus on the other side. The 2 graspers aim to identify the window on the other side. We will ask the anesthesiologist to remove the nasogastric tube. At this moment, we introduce a 30-degree scope. An additional 5mm trocar is introduced. Too much fat is present here. Retraction will be necessary. The posterior aspect of the stomach is lifted by the grasper in the retrogastric channel. Several options are available here: you can place the grasper on the left hepatic ligament. You can also place it on the fat. I will place it with my grasper that I have inside. At this moment, we have to introduce the bands. This trocar will come out through the optical port.

4. Laparoscopic band positioning 03'17''

I change the insufflation port. We introduce the band first and not the catheter. You have to make sure that the band is really inserted in the abdominal cavity and not in the subcutaneous fat or in the space between the fascia and the peritoneum. Because the hepatic ligament lies in this region and you can place the band over this ligament. Then you can place the catheter inside and the optical trocar can be introduced again. Here you can see that the band is inside. I remove the first one. I retract the grasper to this channel. I pull on the catheter so you can see that the band is coming over. The band is placed automatically in a good position. We ask the anesthesiologist to place a nasogastric tube with a balloon in order to calibrate the upper gastric pouch.

5. Gastric pouch calibration 05'09''

This is the first closure position. We can see the balloon coming into the stomach. The balloon is insufflated with 15 CC of air. When you have a big hiatal hernia, it is a contraindication. I will now close the band just under the bulge of the calibration tube. Here is the tip of the calibration tube and over the band you can find the bulge here just under my grasper. The first stitch is going to be made. We have to put a wrap of stomach around the band to avoid the migration of the stomach wall through the band. We will take a part of lower stomach and fix it this way to make a nice stomach wrap around. These are the 3 stitches that we will make. The 1st stitch will be placed on the right side of the stomach close to the lesser curvature.

6. Fixation of band 06'35''

We have to take enough tissue to make a wrap. I must see if I have the resistance of the gastric wall before removing the needle. At this moment, I ask the anesthesiologist to remove the air of the balloon and to remove the orogastic tube as well. If there is a big fat pad at the top of the stomach, you have to remove it but don’t forget if you have an injury of the gastric wall, you can have a penetration of the band through the gastric wall. This injury can be followed by intragastric migration. We have to remove the catheter and to fix it to the insufflation port. To do so, I take the catheter out through the left lateral trocar.

7. End of procedure 07'55''

I will make a subcutaneous tunnel between the lateral trocar and the optical trocar. Then we will remove the optical trocar, close the fascia and then dissect a little part of the fascia on this anterior part of the abdominal wall. We fix the insufflation port to the fascia with 2 stitches. Here you can see the insufflation port. It is easy to put a needle inside under direct visual control and to insufflate the band.