LAP-BAND® to Sleeve Revision

Hello, this is Dr. Mathew St. Laurent. Today I am presenting a laparoscopic gastric band conversion to a gastric sleeve. Our operation begins with a 5-millimeter optical trocar entry. Once we've obtained access into the abdomen, we insufflate with carbon dioxide to create a working space. We utilize a five-trocar technique, which includes a Nathanson liver retractor to elevate the left lobe of the liver. Once we elevate the liver, we begin taking down the perigastric adhesions, using ultrasonic shears. This helps control any bleeding during the process of the dissection. Here, we were taking away some dense adhesions between the stomach and the liver. Here, part of the tubing can be identified. We continue with this dissection until we actually identify the anterior surface of the gastric band. We continue to take down these adhesions until we have fully separated the liver from the gastric band. Here, you can see the last attachments are being taken down by the ultrasonic shears. Once this is accomplished, we can then fully insert the Nathanson liver retractor to elevate the left lobe of the liver. Here, some of the redundant tubing is actually being removed from the abdominal cavity. Here, you can see the gastric band has been separated completely from the liver and we then insert the Nathanson retractor all the way up to the hiatus. We continue to take down the adhesions overlying the anterior surface of the stomach, now using the hook electrocautery. We need to free up this entire pseudo-capsule off the actual band in order to divide and eventually remove the band from the stomach. Here, you can see the remaining anterior attachments are taken down from the band to completely free up the anterior surface. Now, we proceed with the gastric sleeve. We identify the pylorus and we begin our dissection 1 to 2 centimeters proximal to this. Using ultrasonic shears, we take down the short gastric vessels supplying the lateral edge of the stomach. We gain access into the posterior gastric space. We begin working our way upstream, taking down the short gastric vessels until the entire lateral surface of the stomach has become completely freed. Here, my assistant provides good lateral traction in order to well visualize these small gastric vessels. We continue with this dissection in an upstream fashion until we encounter the posterior aspect of the band and the left hemidiaphragm. Here, we begin to separate the stomach off the left hemidiaphragm. Once the stomach has been entirely separated off the left hemidiaphragm, we can then visualize the posterior pseudo-capsule. We then utilize the hook electrocautery to begin taking down the pseudo-capsule posteriorly. We work our way to the anterior surface, separating these adhesions and taking down the plication sutures where the stomach has been folded over the band to hold it in place. Once the plication sutures have been completely taken down, the band is then freely mobile and can easily be removed from around the stomach. We divide the band with Endo Shears and then pull it around on the posterior aspect of the stomach. We then remove the band from the lateral 15-millimeter port side. Once the band is actually removed, we can then begin working on repairing the patient's hiatal hernia. Here, the left side of the esophagus is dissected free from the diaphragm. Once this is accomplished, we then direct our attention tot he right side. We open up the rest of the lesser omental window until the right side of the diaphragm is identified. We then take down the phrenoesophageal attachments between the actual diaphragm and the esophagus. Here, we utilize the harmonic scalpel in order to control hemostasis during this dissection. We also dissect along the anterior surface to circumferentially dissect esophagus away from the diaphragm and the hiatus, as seen here. Once good posterior control of the stomach and the esophagus has been obtained, we can then insert our articulating band instrument. This allows us to retract the esophagus and stomach superiorly to facilitate the remaining take down of the loose areolar adhesions between the posterior diaphragm and the esophagus. Here, we continue to utilize the ultrasonic shears to take down these loose areolar attachments and dissect in the posterior space. We continue with this dissection until both leaflets of the diaphragm are well exposed so that this will facilitate an easy repair. At this point, you can see both the right and the left crus of the diaphragm have been completely mobilized from the esophagus and stomach. You can also see the aortic artery here, indicating a complete dissection of this area. Once this dissection has been completed, we then proceed with performing a posterior repair of the diaphragm. We utilize interrupted sutures of 2-0 silk in a figure-eight pattern in order to facilitate this closure. It's important to close this defect in order to prevent any herniation of the stomach in the postoperative period and to help control any problems with reflux. Often times, it's necessary to place several of these sutures to close very large defects. It's important not to close this defect too tightly; otherwise, it can cause problems with the patient's swallowing. At this point, we identify the band pseudo-capsule and begin the dissection to remove it off the anterior surface of the stomach and the esophagus. We utilize the hook electrocautery to facilitate this dissection. Good countertraction is utilized to take down the loose areolar attachments and to completely separate the pseudo-capsule off of the anterior surface of the stomach and the esophagus. It's important to remove the entire pseudo-capsule so that no staples are actually placed in it, which could increase the risk of these coming out or the patient developing a leak. For the most part, good countertraction is able to easily help separate the pseudo-capsule off the anterior surface of the stomach. Any bleeding is also controlled using the hook electrocautery. Once we have completely taken down the pseudo-capsule, we can then begin in the formation of our actual gastric sleeve. Here, the remaining part of the pseudo-capsule is removed off of the lateral surface of the stomach and then the pseudo-capsule is removed from our larger 15-millimiter port. At this point, we can begin to resect our stomach. We start our resection approximately 1 to 2 centimeters proximal to the pylorus, utilize linear staplers to perform the resection. We incorporate a tissue reinforcement strip with the staple line to help control any bleeding at the actual staple line. For our first two linear staplers, we do not utilize an intragastric calibrating tube. This will tend to cause kinking or twisting of the actual stomach. Once we have placed our third stapler on the stomach, we then pass an intragastric calibrating tube. We utilize a 34 French bougie calibrating tube in order to size the actual pouch. Once this is in place, we then fire our third staple line. This helps prevent any narrowing at the sharp angulation of the stomach. At this point, we utilize successive firings of the linear staple, hugging the bougie calibrating tube tightly in order to complete the resection. We utilize good lateral countertraction to pull all the stomach laterally and hug the actual calibrating tube. This helps create a nice, slender gastric tube and will help facilitate control of the patient's eating volume in the postoperative period. Here, you can see bleeding along the staple line is well controlled with the tissue reinforcement strip utilized in the linear stapler. Here, you can see our last staple line being placed. We make sure to place this just lateral to the junction of the esophagus and stomach. This is important so that no staples are placed on the esophagus, increasing the risk of a leak. Once the last staple line is complete, we then divide the tissue reinforcement strip and proceed to remove the resected specimen from the abdominal cavity. We use the 15-millimiter port on the right side to extract the stomach. Once it has been removed, we then proceed with removing the intragastric calibrating tube. Here, you can see a nice, slender gastric tube has been created. At this point, we perform an upper endoscopy to evaluate the internal staple line. Here, the upper abdomen is filled with saline and the staple line is placed underneath to check for a leak. The upper endoscope evaluates the internal staple line. We then perform an air insufflation test to check for any air bubbles along the actual staple line. Once we've reassured ourselves that there is no leak, the irrigation is removed as well as the endoscope. Once the irrigation is removed, we then examine the gastric sleeve. There are some additional anterior adhesions due to the pseudo-capsule that need to be taken down. This helps prevent any narrowing, especially here at the sharp angulation of the stomach. Once these are taken down, we can see that we have a nice, vertical sleeve gastrectomy extending all the way to the pylorus. At this point, we cover up our lateral staple line using some of the lateral gastric fat. We then remove our Nathanson liver retractor and abdominal closure is undertaken. We close our 15-millimeter fascial defect using a suture needle passer and a 0 Vicryl absorbable suture. Once the larger port site has been closed, we can then remove our remaining 5-millimeter trocars. We then evacuate the remaining carbon dioxide from the abdomen and the operation is completed. The patient's postoperative course was unremarkable. She had an upper GI performed the same day of surgery, which was normal. She was subsequently started on a clear liquid diet on post-op day one and eventually discharged the day after surgery.