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Technical challenges and diagnostic dilemmas in revisional bariatric surgery
Abstracts: Plenary Session/Surgery for Obesity and Related Diseases / 1 (2005) 222–283
dominal complaints despite normal results from multiple radiologic and endoscopic evaluations. A contrast study via the excluded stomach can confirm the diagnosis. Surgical treatment involves duodenojejunostomy using a portion of the common channel. PII: S1550-7289(05)00134-6
V2.
SIMPLIFIED LAPAROSCOPIC VERTICAL BANDED GASTRIC BYPASS APPROACH WITH NEW MODEL OF SILICONE BAND Almino Cardoso Ramos, Manoela Galvao, Andrey Carlo, Edwin Canseco, Abel Hiroshi, Manoel Galvao Neto, Gastro Obeso Center, Sao Paulo, Brazil.
Purpose: Gastric bypass is considered one of the most complex procedures in laparoscopy. Any maneuver or approaches that can improve its feasibility are welcome. We have performed ⬎1000 laparoscopic bypass procedures using a simplified approach with good results and time savings. This approach has allowed (at the surgeon’s discretion) placement of a silicone band (our design) over the gastroplasty. Its technique is highlighted. We have demonstrated on video the technical steps of the so-called simplified gastric bypass with silastic nonadjustable silicone band placement over the gastroplasty. Methods: The procedure includes 5 trocars, similar to Nissen’s procedure; His angle dissection; small curvature dissection; vertical gastroplasty with linear staples between the second and third vessels of the gastric lesser curvature (first firing horizontally, followed by consecutive vertical firings); silicone band placement with dissection 2 cm above the end of the gastroplasty from the greater curvature into the lesser curvature with the help of a goldfinger instrument, adapting the band stitch to the instrument and passing the band behind the gastroplasty (the band is closed with stitches, choosing among one of the four reinforced holes at the end of the silicone band tips over a modeling gastric boogie). Next, the inframesocolic step is done with an antecolic approach. From the Treitz angle, the biliopancreatic limb is measured until it reaches the surgeon option. Then, without diving, the intestinal limb is guided to the supramesocolic space (as if it would be a Billroth II isoperistaltic limb). The gastrojejunostomy is done with a linear stapler; then the alimentary limb (left side of gastroplasty) is mobilized at the distance desired by the surgeon and a side-to-side enteroanstomosis with a linear stapler closed with a running suture is performed. The gastrojejunostomy is closed in the same way as the enteroanastomosis. At the end, the Billroth II-like limb is converted into a Roux-en-Y bypass by just dividing the biliopancreatic limb with a liner stapler (at the right side of the gastroplasty from the surgeon’s view). The defects are closed, and a methylene blue leak test is done. Conclusions: This approach to gastric bypass seems to be a valid option to simplify the procedure even when banded gastroplasty is the option. PII: S1550-7289(05)00135-8
227
V3.
DOUBLE PASS TECHNIQUE FOR LAPAROSCOPIC GASTRIC BANDING IN PATIENTS WITH EXCESSIVE PARIGASTRIC FAT Jeannine Giovanni, M.D., Minimally Invasive Surgeons of Greater Hartford, Hartford, CT. The laparoscopic adjustable gastric band is an acceptable restrictive weight loss procedure for patients with a body mass index ⬍50 kg/m2. However, certain patients may have excessive visceral and perigastric fat. In these instances, a standard pars flaccida technique may render the band too restrictive, resulting in postoperative gastroesophageal obstruction. This video illustrates a “double pass technique” described by others in the literature as an alternative means of band placement in patients with excessive perigastric fat. This patient was a 38-year-old man with a body mass index of 45 kg/m2. After standard port placement and establishment of pneumoperitoneum, the liver is retracted superiorly to expose the proximal stomach. The angle of His is bluntly dissected. The gastrohepatic ligament is elevated to expose the pars flaccidea. The pars flaccida is bluntly opened. The right crus is visualized. Creation of the retrogastric tunnel begins medial to the right crus. Dissection is limited to prevent band slippage. The goldfinger instrument is passed through this tunnel and is seen exiting at the angle of His. The empty band is placed intraabdominally. The tip of the catheter tubing is threaded through the goldfinger instrument and is directed through the retrogastric tunnel. The band is initally brought out through the pars flaccida but is redirected to a perigastric location. The gastrohepatic ligament is bluntly dissected close to the lesser curvature of the stomach. The goldfinger instrument is passed from the pars to the perigastric opening. The tip of the band catheter is brought through the perigastric opening. Once the band is fastened, the excessive perigastric fat is excluded. Gastrogastric sutures are placed overlying the band. The band is manipulated from side to side to demonstrate that it remains loose. The laparoscopic portion of the procedure is completed. A subcutaneous pocket is created for port placement, and the procedure is completed. For patients with excessive perigastric fat, the “double pass technique” may be a better alternative to avoid overly restrictive bands. The pars flaccida approach provides the benefit of a limited retrogastric dissection, and perigastric band placement excludes excessive fat that can lead to obstruction. PII: S1550-7289(05)00136-X
V4.
TECHNICAL CHALLENGES AND DIAGNOSTIC DILEMMAS IN REVISIONAL BARIATRIC SURGERY Ashutosh Kaul, M.D., Department of Surgery, New York Medical College, Valhalla, NY. This video highlights the technical challenges and diagnostic dilemmas faced in revisional bariatric surgery. A 32-year-old woman with a body mass index (BMI) of 47 kg/m2 (height 65 in., weight 280 lb) and history of prior open gastric bypass 3 years previously was evaluated for revision. The investigations revealed a dilated pouch and enlarged gastrojejunostomy. She underwent laparoscopic pouch excision and new
228
Abstracts: Plenary Session/Surgery for Obesity and Related Diseases / 1 (2005) 222–283
gastrojejunostomy creation. She was discharged home on postoperative day 4 but was readmitted on day 9 with increasing drainage from the drain site and tachycardia. On investigation, she was found to have a leak. After resuscitation, she underwent laparoscopic drainage of the abdominal collection, attempted closure of the leak from the perforation present anterior to the staple line. A feeding jejunostomy was also done. Her postoperative course was complicated by persistent drainage from the drains. Upper gastrointestinal endoscopy done about 4 months after the first surgery revealed both drains eroding into the lumen. These were removed, and endoscopic fibrin glue was applied. At 1 year of follow-up, the patient had lost 65 lb and about 45% of her excess weight. Questions raised by this case include indications for reoperative surgery and the best interventions in failed gastric bypass cases. The importance of early detection and treatment of leak is highlighted. The possible reasons for this complication are also discussed. PII: S1550-7289(05)00137-1
V5.
LAPAROSCOPIC HIATAL HERNIA REPAIR AFTER LAGB Duane Fredericks, M.D., Nyu Prog. Surgical Weight Loss, New York, NY. Severe reflux sypmtoms after laparoscopic band placement (LAGB) may be attributed to several factors. The symptoms may be secondary to a hiatal hernia or gastric prolapse, or a combination of both. In this video, we present a 41-year-old woman who had undergone LAGB. Initially, she did very well; however, during the past year, she developed worsening gastroesophageal reflux disease that was refractory to medication. Her esophagram showed a hiatal hernia without gastric pouch dilation. We, therefore, performed hiatal hernia repair without revision of her gastric pouch. The patient tolerated this procedure well and was without any reflux symptoms at last follow-up. PII: S1550-7289(05)00138-3
V6.
CONVERSION FROM PURELY RESTRICTIVE BARIATRIC PROCEDURES TO LAPAROSCOPIC ROUXEN-Y GASTRIC BYPASS Jorge Motalvo, M.D., Antonio Spaventa, M.D., Alejandra Gil, M.D., Miguel F. Herrera, M.D., Mexico City, Mexico. Purely restrictive bariatric operations may require revision surgery because of weight regain. The present video shows the technical details of three laparoscopic conversions. 1. From vertical banded gastroplasty to standard Roux-en-Y gastric bypass in a 26-year-old woman who developed progressive weight regain and highly symptomatic gastroesophageal reflux owing to staple line disruption 4 years after surgery. 2. From vertical banded gastroplasty to a ringed gastric bypass in a 35-year-old woman who gained weight 3 years after the initial operation. 3. From adjustable gastric band to standard gastric bypass in a
36-year-old patient who presented with intolerance to the band and weight regain. PII: S1550-7289(05)00139-5
V7.
LAPAROSCOPIC REVISION FOR INADEQUATE WEIGHT LOSS. REDUCING GASTRIC POUCH FROM NONDIVIDED OPEN GASTRIC BYPASS Michel Gagner, M.D., Kazuki Ueda, M.D., Gregory F. Dakin, M.D., Division of Bariatric Surgery, Department of Surgery, Weill Medical College of Cornell University, New York, NY. The safety and efficacy of a laparoscopic approach to Roux-en-Y gastric bypass for morbid obesity has been well established. However, reoperative procedures for inadequate weight loss will be necessary in up to 20% of patients and have been traditionally performed through an open approach. This video demonstrates the technique of laparoscopic revision of a gastric bypass after inadequate weight loss. The patient was a 32-year-old woman with an initial body mass index (BMI) of 46 kg/m2 who had undergone open gastric bypass in 2001. After 1 year, she had reached a BMI of 31 kg/m2. However, she regained weight and presented for evaluation with a BMI of 46 kg/m2. Her workup included an upper gastrointestinal series and endoscopy, which revealed an enlarged gastric pouch. She elected to undergo revision of her gastric pouch. After establishing the pneumoperitoneum, adhesions to the old gastric pouch were lysed with a combination of blunt and sharp dissection. The alimentary limb was divided from the gastric pouch with the linear cutting stapler. The enlarged pouch was mobilized from the adherent gastric remnant. A retrogastric tunnel was created behind the enlarged pouch. The pouch was divided, creating a new smaller pouch. Rather than remove the adherent remaining portion of the old pouch, it was anastomosed to the gastric remnant. A circular stapled gastrojejunostomy was then created between the new pouch and the Roux limb to complete the revision. The patient had an uncomplicated postoperative course and was discharged uneventfully. In the few months after surgery, the patient had lost 7 kg. PII: S1550-7289(05)00140-1
V8.
LAPAROSCOPIC REVISIONAL BARIATRIC SURGERY—A SYSTEMATIC APPROACH Sashidhar Ganta, M.D., Harvard, IL. We present 2 cases of laparoscopic revisions in this video in an attempt to identify a systematic stepwise approach to revisions. The first presentation is an unusual case of incomplete laparoscopic gastric bypass that we revised to a laparoscopic Roux-en-Y gastric bypass. The second presentation is of a failed open vertical banded gastroplasty that we revised to a Roux-en-Y gastric bypass using the laparoscopic approach. We identified the following steps in a laparoscopic revision. 1. Approach: adhesiolysis to achieve optimal trocar placement.
dominal complaints despite normal results from multiple radiologic and endoscopic evaluations. A contrast study via the excluded stomach can confirm the diagnosis. Surgical treatment involves duodenojejunostomy using a portion of the common channel. PII: S1550-7289(05)00134-6
V2.
SIMPLIFIED LAPAROSCOPIC VERTICAL BANDED GASTRIC BYPASS APPROACH WITH NEW MODEL OF SILICONE BAND Almino Cardoso Ramos, Manoela Galvao, Andrey Carlo, Edwin Canseco, Abel Hiroshi, Manoel Galvao Neto, Gastro Obeso Center, Sao Paulo, Brazil.
Purpose: Gastric bypass is considered one of the most complex procedures in laparoscopy. Any maneuver or approaches that can improve its feasibility are welcome. We have performed ⬎1000 laparoscopic bypass procedures using a simplified approach with good results and time savings. This approach has allowed (at the surgeon’s discretion) placement of a silicone band (our design) over the gastroplasty. Its technique is highlighted. We have demonstrated on video the technical steps of the so-called simplified gastric bypass with silastic nonadjustable silicone band placement over the gastroplasty. Methods: The procedure includes 5 trocars, similar to Nissen’s procedure; His angle dissection; small curvature dissection; vertical gastroplasty with linear staples between the second and third vessels of the gastric lesser curvature (first firing horizontally, followed by consecutive vertical firings); silicone band placement with dissection 2 cm above the end of the gastroplasty from the greater curvature into the lesser curvature with the help of a goldfinger instrument, adapting the band stitch to the instrument and passing the band behind the gastroplasty (the band is closed with stitches, choosing among one of the four reinforced holes at the end of the silicone band tips over a modeling gastric boogie). Next, the inframesocolic step is done with an antecolic approach. From the Treitz angle, the biliopancreatic limb is measured until it reaches the surgeon option. Then, without diving, the intestinal limb is guided to the supramesocolic space (as if it would be a Billroth II isoperistaltic limb). The gastrojejunostomy is done with a linear stapler; then the alimentary limb (left side of gastroplasty) is mobilized at the distance desired by the surgeon and a side-to-side enteroanstomosis with a linear stapler closed with a running suture is performed. The gastrojejunostomy is closed in the same way as the enteroanastomosis. At the end, the Billroth II-like limb is converted into a Roux-en-Y bypass by just dividing the biliopancreatic limb with a liner stapler (at the right side of the gastroplasty from the surgeon’s view). The defects are closed, and a methylene blue leak test is done. Conclusions: This approach to gastric bypass seems to be a valid option to simplify the procedure even when banded gastroplasty is the option. PII: S1550-7289(05)00135-8
227
V3.
DOUBLE PASS TECHNIQUE FOR LAPAROSCOPIC GASTRIC BANDING IN PATIENTS WITH EXCESSIVE PARIGASTRIC FAT Jeannine Giovanni, M.D., Minimally Invasive Surgeons of Greater Hartford, Hartford, CT. The laparoscopic adjustable gastric band is an acceptable restrictive weight loss procedure for patients with a body mass index ⬍50 kg/m2. However, certain patients may have excessive visceral and perigastric fat. In these instances, a standard pars flaccida technique may render the band too restrictive, resulting in postoperative gastroesophageal obstruction. This video illustrates a “double pass technique” described by others in the literature as an alternative means of band placement in patients with excessive perigastric fat. This patient was a 38-year-old man with a body mass index of 45 kg/m2. After standard port placement and establishment of pneumoperitoneum, the liver is retracted superiorly to expose the proximal stomach. The angle of His is bluntly dissected. The gastrohepatic ligament is elevated to expose the pars flaccidea. The pars flaccida is bluntly opened. The right crus is visualized. Creation of the retrogastric tunnel begins medial to the right crus. Dissection is limited to prevent band slippage. The goldfinger instrument is passed through this tunnel and is seen exiting at the angle of His. The empty band is placed intraabdominally. The tip of the catheter tubing is threaded through the goldfinger instrument and is directed through the retrogastric tunnel. The band is initally brought out through the pars flaccida but is redirected to a perigastric location. The gastrohepatic ligament is bluntly dissected close to the lesser curvature of the stomach. The goldfinger instrument is passed from the pars to the perigastric opening. The tip of the band catheter is brought through the perigastric opening. Once the band is fastened, the excessive perigastric fat is excluded. Gastrogastric sutures are placed overlying the band. The band is manipulated from side to side to demonstrate that it remains loose. The laparoscopic portion of the procedure is completed. A subcutaneous pocket is created for port placement, and the procedure is completed. For patients with excessive perigastric fat, the “double pass technique” may be a better alternative to avoid overly restrictive bands. The pars flaccida approach provides the benefit of a limited retrogastric dissection, and perigastric band placement excludes excessive fat that can lead to obstruction. PII: S1550-7289(05)00136-X
V4.
TECHNICAL CHALLENGES AND DIAGNOSTIC DILEMMAS IN REVISIONAL BARIATRIC SURGERY Ashutosh Kaul, M.D., Department of Surgery, New York Medical College, Valhalla, NY. This video highlights the technical challenges and diagnostic dilemmas faced in revisional bariatric surgery. A 32-year-old woman with a body mass index (BMI) of 47 kg/m2 (height 65 in., weight 280 lb) and history of prior open gastric bypass 3 years previously was evaluated for revision. The investigations revealed a dilated pouch and enlarged gastrojejunostomy. She underwent laparoscopic pouch excision and new
228
Abstracts: Plenary Session/Surgery for Obesity and Related Diseases / 1 (2005) 222–283
gastrojejunostomy creation. She was discharged home on postoperative day 4 but was readmitted on day 9 with increasing drainage from the drain site and tachycardia. On investigation, she was found to have a leak. After resuscitation, she underwent laparoscopic drainage of the abdominal collection, attempted closure of the leak from the perforation present anterior to the staple line. A feeding jejunostomy was also done. Her postoperative course was complicated by persistent drainage from the drains. Upper gastrointestinal endoscopy done about 4 months after the first surgery revealed both drains eroding into the lumen. These were removed, and endoscopic fibrin glue was applied. At 1 year of follow-up, the patient had lost 65 lb and about 45% of her excess weight. Questions raised by this case include indications for reoperative surgery and the best interventions in failed gastric bypass cases. The importance of early detection and treatment of leak is highlighted. The possible reasons for this complication are also discussed. PII: S1550-7289(05)00137-1
V5.
LAPAROSCOPIC HIATAL HERNIA REPAIR AFTER LAGB Duane Fredericks, M.D., Nyu Prog. Surgical Weight Loss, New York, NY. Severe reflux sypmtoms after laparoscopic band placement (LAGB) may be attributed to several factors. The symptoms may be secondary to a hiatal hernia or gastric prolapse, or a combination of both. In this video, we present a 41-year-old woman who had undergone LAGB. Initially, she did very well; however, during the past year, she developed worsening gastroesophageal reflux disease that was refractory to medication. Her esophagram showed a hiatal hernia without gastric pouch dilation. We, therefore, performed hiatal hernia repair without revision of her gastric pouch. The patient tolerated this procedure well and was without any reflux symptoms at last follow-up. PII: S1550-7289(05)00138-3
V6.
CONVERSION FROM PURELY RESTRICTIVE BARIATRIC PROCEDURES TO LAPAROSCOPIC ROUXEN-Y GASTRIC BYPASS Jorge Motalvo, M.D., Antonio Spaventa, M.D., Alejandra Gil, M.D., Miguel F. Herrera, M.D., Mexico City, Mexico. Purely restrictive bariatric operations may require revision surgery because of weight regain. The present video shows the technical details of three laparoscopic conversions. 1. From vertical banded gastroplasty to standard Roux-en-Y gastric bypass in a 26-year-old woman who developed progressive weight regain and highly symptomatic gastroesophageal reflux owing to staple line disruption 4 years after surgery. 2. From vertical banded gastroplasty to a ringed gastric bypass in a 35-year-old woman who gained weight 3 years after the initial operation. 3. From adjustable gastric band to standard gastric bypass in a
36-year-old patient who presented with intolerance to the band and weight regain. PII: S1550-7289(05)00139-5
V7.
LAPAROSCOPIC REVISION FOR INADEQUATE WEIGHT LOSS. REDUCING GASTRIC POUCH FROM NONDIVIDED OPEN GASTRIC BYPASS Michel Gagner, M.D., Kazuki Ueda, M.D., Gregory F. Dakin, M.D., Division of Bariatric Surgery, Department of Surgery, Weill Medical College of Cornell University, New York, NY. The safety and efficacy of a laparoscopic approach to Roux-en-Y gastric bypass for morbid obesity has been well established. However, reoperative procedures for inadequate weight loss will be necessary in up to 20% of patients and have been traditionally performed through an open approach. This video demonstrates the technique of laparoscopic revision of a gastric bypass after inadequate weight loss. The patient was a 32-year-old woman with an initial body mass index (BMI) of 46 kg/m2 who had undergone open gastric bypass in 2001. After 1 year, she had reached a BMI of 31 kg/m2. However, she regained weight and presented for evaluation with a BMI of 46 kg/m2. Her workup included an upper gastrointestinal series and endoscopy, which revealed an enlarged gastric pouch. She elected to undergo revision of her gastric pouch. After establishing the pneumoperitoneum, adhesions to the old gastric pouch were lysed with a combination of blunt and sharp dissection. The alimentary limb was divided from the gastric pouch with the linear cutting stapler. The enlarged pouch was mobilized from the adherent gastric remnant. A retrogastric tunnel was created behind the enlarged pouch. The pouch was divided, creating a new smaller pouch. Rather than remove the adherent remaining portion of the old pouch, it was anastomosed to the gastric remnant. A circular stapled gastrojejunostomy was then created between the new pouch and the Roux limb to complete the revision. The patient had an uncomplicated postoperative course and was discharged uneventfully. In the few months after surgery, the patient had lost 7 kg. PII: S1550-7289(05)00140-1
V8.
LAPAROSCOPIC REVISIONAL BARIATRIC SURGERY—A SYSTEMATIC APPROACH Sashidhar Ganta, M.D., Harvard, IL. We present 2 cases of laparoscopic revisions in this video in an attempt to identify a systematic stepwise approach to revisions. The first presentation is an unusual case of incomplete laparoscopic gastric bypass that we revised to a laparoscopic Roux-en-Y gastric bypass. The second presentation is of a failed open vertical banded gastroplasty that we revised to a Roux-en-Y gastric bypass using the laparoscopic approach. We identified the following steps in a laparoscopic revision. 1. Approach: adhesiolysis to achieve optimal trocar placement.