Laparoscopic Adjustable Gastric Band Removal and Conversion to Sleeve Gastrectomy

laparoscopic adjustable gastric band removal and conversion to sleeve gastrectomy

Weight loss failure after gastric banding or band-related complications requiring band removal. Insufficient weight loss is generally accepted as %EWL <25% (according to the Reinhold criteria), however, the decision for revisional surgery is determined on an individual basis based on %EWL, progression of comorbidities and patient preference.

Patients unable to tolerate general anesthesia and patient with severe portal hypertension.

N/A

The patient is placed supine on the operating room table with both arms out. Pressure points are padded. Sequential compression boots are placed and subcutaneous heparin and antibiotics are administered prophylactically. An orogastric tube is placed for gastric decompression. The surgeon stands on the patient's right and first assistant on the left.

Patients undergo a tailored multidisciplinary assessment by medical, psychological and nutrition specialists. Patients are placed on a calorie-restricted high-protein liquid diet for two weeks preoperatively. The band is usually empty before the patient comes to surgery.

The abdomen is entered under direct vision using an ENDOPATH XCEL OPTIVIEW trocar�® (Ethicon, NJ, USA) and a 10mm 0�° laparoscope in the left upper quadrant (E). Pneumoperitoneum is achieved with carbon dioxide to a pressure of 15mmHg. A 10mm 30�° laparoscope is introduced into the abdomen, and 3 additional trocars are placed along the mid-abdomen, two 5mm (B, C) and one 15mm (A). A percutaneous Nathanson liver retractor is placed in the subxiphoid region (D) to retract the liver ventrally.

The tubing is followed up to the band, which is covered with omentum and scar tissue. This is completely mobilized off the band buckle with electrocautery. The band is then unbuckled, the tubing is divided and the band slipped out of the tunnel. The band is brought out of the abdominal cavity and passed off the field as a specimen. The proximal stomach and gastric pouch are then mobilized off of the undersurface of the left lobe of the liver all the way up to the diaphragm. The gastric plication sutures are divided in order to unfold the stomach. The capsule overlying the stomach where the band was positioned is excised sharply in order to thin out the stomach wall.

The pylorus is identified and, starting five cm proximal to this point, the greater curvature is devascularized up to the angle of His using the Enseal�® (Ethicon, NJ, USA). The orogastric tube and esophageal temperature probe are removed and a 40-French bougie is introduced into the mouth by the anesthesia team and advanced into the stomach and pylorus. The bougie is aligned along the lesser curvature and put to suction. The gastric resection is performed beginning 4cm proximal to the pylorus and continuing up to the angle of His using sequential firings of a 60mm endoscopic linear stapler (Echelon Flex GST system�®, Ethicon, NJ, USA) with a combination of thick and medium cartridges, reinforced with SeamGuard�® (Gore, AZ, USA), according to the varying thickness of the gastric wall. The bougie is removed, off suction, and the staple line is examined. Staple line bleeding is controlled with the application of titanium clips. Neither a methylene blue test nor intraoperative esophagogastroscopy are routinely performed. The omentum is sutured to the staple line to prevent rotation of the stomach using interrupted 3-0 PDS�® sutures (Ethicon, NJ, USA) along the length of the sleeve. The staple line is covered with Evicel�® (Ethicon, NJ, USA) for hemostatic control. The resected stomach is retrieved from the abdominal cavity via the 15mm port by grasping the specimen and pulling it into the trocar. Once the specimen is partially extracorporeal, the trocar is removed and the specimen is pulled directly through the incision using Kocher clamps.
All trocars and the liver retractor are then removed. The fascial defect of the 15mm port is closed with 0 Vicryl�® (Ethicon, NJ, USA) suture.
The access port of the band is identified. An incision is made down to the subcutaneous fat and onto the port, which is then mobilized off the anterior fascia with electrocautery. This is drawn out of the wound along with the connected tubing and passed off the field as a specimen. This fascia is closed with 0 Vicryl�® suture. All wounds are infiltrated with local anesthetic and closed with a 4-0 Monocryl�® (Ethicon, NJ, USA) subcuticular suture.

Major complications of the gastric sleeve procedure include staple line bleeding, staple line leak, port site hernia, wound infections, sleeve stenosis, mesenteric vein thrombosis, pulmonary embolism, postoperative edema resulting in oral intolerance in the perioperative period, reflux and weight regain.

Major complications of the gastric sleeve procedure include staple line bleeding, staple line leak, port site hernia, wound infections, sleeve stenosis, mesenteric vein thrombosis, pulmonary embolism, postoperative edema resulting in oral intolerance in the perioperative period, reflux and weight regain.

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