Laparoscopic Adjustable Gastric Band Removal and Conversion to Sleeve Gastrectomy

Video Type: CVideo
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Author: Collin Creange
Published:
Specialties: General Surgery
Schools: New York University Medical Center
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Basic Info

Contributors: Melissa Beitner and Christine Ren-Fielding

This video shows the one-stage conversion of an adjustable gastric band to a sleeve gastrectomy.

DOI: http://dx.doi.org/10.17797/ygruogodll

Advanced

Procedure

laparoscopic adjustable gastric band removal and conversion to sleeve gastrectomy

Indications

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.

Contraindications

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

Instrumentation

Setup

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.

Preoperative Workup

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.

Anatomy and Landmarks

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.

Advantages/Disadvantages

Advantages: Patients rapidly regain weight after band removal, therefore, a concurrent procedure is desirable. The patient avoids 2 anesthetics and avoids weight regain. Some have found that revisional SG results in comparable short-term weight loss to primary SG. SG can then be converted to biliopancreatic diversion (BPD) in the future, if needed.

Disadvantages: A dense inflammatory reaction and "capsule" may surround the band. Therefore, a two-stage approach may allow time for scar tissue to soften and the stomach to regain its pliability. Similarly, the persistence of a "band outlet" from a persistent capsule may make insertion of the bougie more difficult and also lead to a higher complication rate. Other disadvantages may include a slightly higher leak rate and a higher perioperative complication rate compared to primary sleeve gastrectomy, as suggested by some publications but not others. Band conversion to SG may have a higher complication and mortality rate than band conversion to Roux-en-Y gastric bypass.

Complications/Risks

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.

Disclosure of Conflicts

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.

Acknowledgements

N/A

References

1.Aminian A, Shoar S, Khorgami Z, Augustin T, Schauer PR, Brethauer SA. Safety of one-step conversion of gastric band to sleeve: a comparative analysis of ACS-NSQIP data. Surg Obes Relat Dis. 2015;11(2):386-91.
2.Carr WR, Jennings NA, Boyle M, Mahawar K, Balupuri S, Small PK. A retrospective comparison of early results of conversion of failed gastric banding to sleeve gastrectomy or gastric bypass. Surg Obes Relat Dis. 2015;11(2):379-84.
3.Fernando Santos B, Wallaert JB, Trus TL. Band removal and conversion to sleeve or bypass: are they equally safe? Surg Endosc. 2014;28(11):3086-91.
4.Foletto M, Prevedello L, Bernante P, Luca B, Vettor R, Francini-Pesenti F, et al. Sleeve gastrectomy as revisional procedure for failed gastric banding or gastroplasty. Surg Obes Relat Dis. 2010;6(2):146-51.
5.Gibson SC, Le Page PA, Taylor CJ. Laparoscopic sleeve gastrectomy: review of 500 cases in single surgeon Australian practice. ANZ J Surg. 2015;85(9):673-7.
6.Gonzalez-Heredia R, Masrur M, Patton K, Bindal V, Sarvepalli S, Elli E. Revisions after failed gastric band: sleeve gastrectomy and Roux-en-Y gastric bypass. Surg Endosc. 2015;29(9):2533-7.
7.Gupta V, Biedenbach A, Stephens KW, Borst MJ, Lane B. Laparoscopic conversion of eroded adjustable gastric band to vertical sleeve gastrectomy. Surg Obes Relat Dis. 2010;6(5):548-50.
8.Maietta P, Milone M, Coretti G, Galloro G, Conzo G, Docimo G, et al. Retrieval of the gastric specimen following laparoscopic sleeve gastrectomy. Experience on 275 cases. Int J Surg. 2015.
9.Parikh M, Issa R, McCrillis A, Saunders JK, Ude-Welcome A, Gagner M. Surgical strategies that may decrease leak after laparoscopic sleeve gastrectomy: a systematic review and meta-analysis of 9991 cases. Ann Surg. 2013;257(2):231-7.
10.Ramos AC, Bastos EL, Ramos MG, Bertin NT, Galvao TD, de Lucena RT, et al. TECHNICAL ASPECTS OF LAPAROSCOPIC SLEEVE GASTRECTOMY. Arq Bras Cir Dig. 2015;28 Suppl 1:65-8.
11.Silecchia G, Rizzello M, De Angelis F, Raparelli L, Greco F, Perrotta N, et al. Laparoscopic sleeve gastrectomy as a revisional procedure for failed laparoscopic gastric banding with a "2-step approach": a multicenter study. Surg Obes Relat Dis. 2014;10(4):626-31.

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