Laparoscopic gastric banding in a female patient with a BMI of 40

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Laparoscopic gastric banding in a female patient with a BMI of 40

Authors

M Vix, J Marescaux

Keywords

obésité morbide,gastric banding,anneau gastrique

Media type

Surgical video

Duration

05'00''

Publication

2005-02

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E-publication

WeBSurg.com, Feb 2005;5(02).
URL: http://www.websurg.com/doi-vd01en1653.htm

Laparoscopic gastric banding in a female patient with a BMI of 40

1. Case presentation 00'08''

This is the case history of a female patient in her fourth decade with a Body Mass Index of 40. Preoperative examination is uneventful. The patient does not snack, she consumes sweets. We propose a gastric banding procedure to be performed on this patient.

2. Trocar placement 00'27''

Here the xiphoid process and the umbilicus can be seen. Here is the costal margin. We do not mark it immediately because insufflation may change its position. The incision that is performed for placement of the optical trocar is approximately a hand’s breadth underneath the xiphoid process. This incision is used for introduction of the optical trocar. It will also be used as the site of the injection reservoir. A retracting port is placed in the right anterior axillary line subcostally. The subcostal operative ports are now placed in the mid-clavicular line bilaterally as well. Except for the optical port, all ports are 5mm in size.

3. Retrogastric tunnel 01'17''

The pars flaccida has been opened. This opening facilitates access to the right crus of the diaphragm. Two structures can be distinguished: the vena cava is noted with the left dissector, and the right crus which is identified here, and its structure aids in the creation of a retrogastric tunnel. Depending on the patient, the procedure can be more time-consuming when the liver is hypertrophic or floppy, making retraction more difficult. We find a 5mm mouldable liver retractor, the most useful and atraumatic for the liver. Dissection starts with the opening of the peritoneum at the junction between the fatty portion and the fat-free portion of the right crus as seen here. Once this is done, an operative plane is found. This usually is immediately adjacent to the crura. Here the crus is highly visible. Contact is maintained with the crus as dissection is continued slowly. This dissection is entirely bloodless to avoid any vascular damage that may hinder dissection. The left crus, as you saw, was approached. Care is taken in this portion of the procedure as proper dissection here will pave the way for rapid success of the procedure. As can be seen, the grasper is now situated beneath the peritoneum and brought through. It is now on the left side of the gastrum and is left in place for the moment.

4. Band preparation and insertion 02'54''

Now the gastric band is flushed with sterile sealing. The band is prepared by flushing air from the balloon and the catheter. The band is inflated with 10cc of saline solution taking care not to introduce any bubbles. The content of the band is aspirated. The air is now out of the system. A stitch will now be made at the tip of the catheter to keep it watertight. The band is now introduced into the abdominal cavity with the grasper that is situated in the left upper quadrant via the optical port. A catheter is placed in the abdominal cavity and the reservoir will be placed at the end of the procedure.

5. Positioning of the band 03'48''

After the entire catheter is in the abdomen, the band is retrieved inside the abdomen after insufflation is returned. A grasper that is situated cephalad on the lateral gastric fat is used again. This band device has a temporary suture which can be used to grasp the band. The band will then slowly be advanced through the retrogastric tunnel so as to avoid any vascular damage. The position of the band is now perfect as the balloon can be seen on both sides in the correct position.

6. Pouch calibration 04'23''

Anesthesiology is now asked to introduce a balloon-tipped gastric tube. A fenestrated grasper is then introduced into the closure mechanism, and the grasper retrieves the suture. Here we see the balloon insufflated by the anesthesiologist. It is well in site and can be palpated with the grasper. The anesthesiologist is now asked to pull back the inflated gastric tube until it catches at the cardia level. The balloon is inflated with 15cc of sterile saline, hence creating an appropriate-sized gastric pouch. The band is now below the balloon-tipped gastric tube. The band is now closed completely.

7. Band fixation 05'14''

A gastric cuff will now be fashioned around the band to help prevent slippage of the stomach wall through the band. Permanent suture is used to create the cuff. The first stitch is made to the right portion of the stomach. This allows for a rotation of the band and gastric cuff, thereby exposing the lateral posterior part with a 2nd stitch that we made. The needle is retrieved immediately and an extracorporeal knot-tying is utilized saving time and minimizing exposure of the needle to the band. Here we see rotation of the band and now our second suture. This suture will fix the stomach to either the left portion of the diaphragm or the left crus depending upon the presence of vessels in those structures. Again extracorporeal knot-tying is completed and the suture will be cut. Our final stitch in this patient will be made here to achieve complete closure of the band anteriorly. The band is now totally encircled in the anterior portion of the stomach wall. It will no longer move. The surgical field is noted to be bloodless, and complete removal of the balloon is also checked as the anesthesiologist retracts the nasogastric tube.

8. Reservoir fixation 06'48''

The tip of the catheter is held with a grasper and removed under visual control from the left upper quadrant port site. The trocars will then be removed under visual guidance. A subcutaneous passage is then created from the optic port site to the left upper quadrant site. The catheter is now in the site of where the optic port was. The reservoir is fixed to the aponeurosis with 2 non-absorbable braided sutures. These ligatures avoid the rotation preventing inaccessibility to the band. Our procedure is now complete.