Single Incision Laparoscopic Surgery (SILS): gastric banding removal for acute gastric pouch dilatation

In a significantly short time, Laparoscopic Adjustable Gastric Banding (LAGB) for morbid obesity has become a common operation in Europe and elsewhere. Recent series show a high percentage of patients re-operated on, almost always with excision of the banding system. The reasons for re-operation are esophagitis, band erosion, pouch dilatation, leakage from the balloon, and esophageal dilatation. This video demonstrates the removal of a gastric band for acute gastric pouch dilatation. The procedure was completed using a single access technique, with conventional laparoscopic instrumentation. A 2cm incision is performed on the port site and the same one is removed first maintaining the connection tube on site in order to place traction on the band. A 10mm port is inserted using an open technique, and two further 5mm ports are placed anteriorly just to the left and to the right side of the previous one.

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Single Incision Laparoscopic Surgery (SILS): gastric banding removal for acute gastric pouch dilatation

Authors

N Perrotta, A Cappiello, C Giudicianni, N Andriulo, T Marinelli, D Loffredo

Abstract

In a significantly short time, Laparoscopic Adjustable Gastric Banding (LAGB) for morbid obesity has become a common operation in Europe and elsewhere.
Recent series show a high percentage of patients re-operated on, almost always with excision of the banding system. The reasons for re-operation are esophagitis, band erosion, pouch dilatation, leakage from the balloon, and esophageal dilatation.
This video demonstrates the removal of a gastric band for acute gastric pouch dilatation. The procedure was completed using a single access technique, with conventional laparoscopic instrumentation. A 2cm incision is performed on the port site and the same one is removed first maintaining the connection tube on site in order to place traction on the band. A 10mm port is inserted using an open technique, and two further 5mm ports are placed anteriorly just to the left and to the right side of the previous one.

Classification

single port

Keywords

Single Incision Laparoscopic Surgery, SILS, gastric banding removal, acute gastric pouch dilatation

Media type

Surgical video

Duration

05'22''

Publication

2009-10

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E-publication

WeBSurg.com, Oct 2009;9(10).
URL: http://www.websurg.com/doi-vd01en2748.htm

Single Incision Laparoscopic Surgery (SILS): gastric banding removal for acute gastric pouch dilatation

1. Clinical case presentation 00'08''

This video demonstrates the removal of a gastric band for acute gastric pouch dilatation. The procedure was completed using a single access technique, with conventional laparoscopic instrumentation in a 39-year-old female patient managed with gastric banding placement 3 years ago. A good result in terms of weight loss was recorded (her BMI has decreased from 46 to 28, her weight from 121 to 68 Kg). The patient presents with severe dysphagia and obstructive syndrome in the emergency department. An upper GI radiography was performed. It confirmed a very large anterior gastric pouch dilatation and the band displacement with a mechanical stenosis at the level of the gastric pouch. A laparoscopic procedure was planned with the intention of removing the band. Considering the necessity to practice a larger incision in order to remove the subcutaneous port, we have decided to use this one to perform a single site access.

2. Patient position 01'05''

The patient is placed in a supine position. The main surgeon stands between the patient’s legs, the camera on his left and the assistant stands to the right side.

4. Trocars insertion 01'13''

Laparoscopy shows the important gastric pouch dilatation and the adhesions between the stomach, the band and the connection tube port-band.

5. Freeing of adhesions 01'23''

Following the same tube, we begin to expose the band in the site of the closure zone, freeing the adhesions using the hook. In order to achieve better band exposure, tractions are placed on the connection tube first, and then on the same band. Once the adhesions are taken down with electrocautery, the band is free to be cut and removed.

6. Prosthesis dissection 02'55''

In the absence of roticulating instrumentation, and the following difficulty to have a good angle to cut the band with scissors, we need to use the Harmonic® dissector for the division of the prosthesis. Then, the same was removed through one of the two 5mm ports.

7. Fibrotic tissue division 04'05''

In the last step of the procedure, we restore the normal anatomy by division of the fibrotic area at the site of the previous banding, which continues to determine a stenotic effect on the gastric surface. The image of the stomach at the end of this dissection is clear with no evidence of stenosis or ischemic lesions of the gastric wall. The procedure ends with the positioning of a perigastric drainage tube.

8. Postoperative control 05'16''

The GI radiography confirms the normal passage of the contrast medium into the stomach and we demonstrate the cosmetic results of the procedure. The procedure was carried out using a single access technique in two hours time. No intraoperative or postoperative complication occurred. After radiographic examination, the patient was discharged on postoperative day 6. In our experience, single incision laparoscopic surgery approach is feasible and safe even in the case of a re-operation. Procedures for gastric banding removal appear to be a good indication of this approach, considering the necessity to perform a larger incision for port extraction.