VBG to Bypass Revision Surgery

I'm Dr. Matthew St. Laurent and today I will be presenting a VBG revision to a gastric bypass. The patient is a 34-year-old female with a gastrogastric fistula and outlet obstruction due to an eroding band. Our operation begins with a 5 millimeter optical trocar just lateral to the umbulicus. We use this to insufflate the abdominal cavity with CO2 to create a working space. On entry into the abdomen we see some fairly extensive midline adhesions secondary to her prior open operation. We continue with a 15 millimeter trocar in the right paramedian position so that we can begin taking down these adhesions. We introduced the harmonic scalpel and utilize this to take down the midline adhesions in order to help maintain a bloodless field. We proceed from an inferior to superior direction until the surface of the liver is encountered. As a result of the patient's operation being performed more than 10 years ago, these midline adhesions are fairly filmy and easy to take down. Unfortunately, as a result of the extent of the adhesions, this portion of the operation is fairly time consuming. After the initial midline adhesions are fully taken down we can now see the liver coming into full view. We now have ample room to insert our additional trocars. Once all the trocars are inserted we can then place a subsiphoid Nathanson liver retractor to begin lifting the left lobe of the liver. On elevation of the left lobe of the liver we encounter fairly extensive perigastric adhesions. As one can see the stomach is densely adherent to the under surface of the liver. We begin with sharp dissection utilizing endo shears to take down these filmy adhesions. At this point we can actually see the patients gastric band come into view. We continue to develop this plan utilizing sharp dissection. Again we proceed in an inferior to superior approach until we encounter the esophageal hiatus superiorly. The adhesions are fairly extensive and again this is a very time consuming process, requiring a meticulous dissection to separate the stomach from the liver and to prevent any injury. Good counter traction by my assistant is extremely helpful in facilitating this plane and taking down the adhesions. For the most part these adhesions are fairly filmy and very straight forward in taking down. The full extent of the stomach can now be visualized once the perigastric adhesions are taken down. We then proceed with our dissection along the lesser curvature of the stomach to gain access into the retro gastric space. We utilize a harmonic scalpel and dissect along the medial edge of the stomach to obtain access to the lesser sack. Proceeding with this dissection allows us to eventually gain access into the posterior gastric space. This then allows us to introduce our stapler and place our first staple line across the stomach transversely. Now that we have posterior control of the stomach we can begin to identify some of our landmarks. We can see that we have approximately 2 centimeters of intra-abdominal esophagus present. We can also identify the esophageal hiatus. Once this is accomplished and that we have posterior control we can then insert a calibrating tube. This is inflated it to 20 CCs and then it is gently pulled back to the hiatus. We can then identify the lower border of the stomach that we will be creating. We then insert our first stapler and place it at the lower border of where the gastric balloon was located. We utilize a 45 millimeter tan Tri-Staple load for initial staple line. We can now also identify the patient's previous vertical staple line. We want to make sure to stay medial to this in order to exclude the gastrogastric fistula that the patient has present. We now change our stapler to a 60 millimeter green load with a tissue reinforcement strip. We angle the actual stapler to where the angle of his is located. We then dissect in the posterior space again, until we can identify the esophageal gastric junction. We want to make sure to place our last staple line just lateral to this angle to prevent any staplers from being on the actual esophagus. We fire the stapler to complete the transection and the small upper stomach pouch. We have now created an approximately 15 to 20 CC proximal pouch once the staple line has been completed. We then complete the resection of the distal stomach by dividing just distal to where the eroding band was located. We utilize 60 millimeter purple Tri-Staple loads to complete this resection. Removal of the distal stomach is important to help prevent fistula formation to the upper small stomach pouch. Additionally it helps decrease the hormonal production of ghrelin, which in turn will help facilitate weight loss in the post operative period. Approximately 50 to 70% of the stomach is removed in this fashion. The stomach is eventually extracted through our larger left lateral port. We can now easily identify our distal gastric remnant as well as our small upper stomach pouch that was recently created. We now move on to the formation of the Roux limb for the gastric bypass. We start by identifying the omental fat apron draping over the transverse colon and small intestine. This is divided utilizing harmonic scalpel. We carry the dissection to the level of the transverse colon. This helps create a tension free path for the Roux limb so that it reaches the small upper stomach pouch without any tension. Once the omentum is fully divided we can now retract the transverse colon and omentum superiorly. This helps facilitate identifying the first part of the jejunum. We identified the ligament of Treitz at its origin just underneath the transverse colon mesentery. We then follow the small bowel distally approximately 45 centimeters. The small bowel is then divided using an endo GIA with a white load. The mesentery is then taken down for an additional short distance utilizing the harmonic scalpel. This provides adequate length to the Roux limb so that it reaches the small upper stomach pouch without any tension. The small bowel is then followed distally approximately 110 centimeters. The distal enastamosis is then created using a triple staple line technique. We create enterotomies in the two bowel segments utilizing the harmonic scalpel. A 45 millimeter tan Tri-Staple load is then passed distally in both the bowel segments. The stapler subsequently fired creating the first portion of the distal anastomosis. A second tan load stapler is then placed proximally in each of the bowel segments. This is subsequently fired completing the distal anastomosis. A 60 millimeter blue load with a tissue reinforcement strip, is then used to complete the closure of the enterotomies previously created. The distal anastomosis can now be seen complete utilizing the triple staple line technique. The mesenteric defect is then identified. We proceed with closing this to prevent an internal hernia. We use a running suture of 2-0 silk to complete the actual closure. The Roux limb is then brought up over the transverse colon to the proximal stomach pouch. As you can see there is plenty of length to reach the small upper stomach pouch without any undue tension. The anvil of our circular stapler is then passed transorally and brought out through a separate gastronomy created it the inferior border of the small upper stomach pouch. Here is seen the tube connecting the anvil and facilitating its withdrawal from the actual stomach. A 21 EEA stapler is utilized for the proximal anastomosis. We then created a separate enterotomy in the proximal Roux limb to facilitate the passage of the handle of the stapler. The handle of the circular stapler is then introduced through our lateral trocar site. The apical cone is then removed. The stapler is then introduced into the proximal Roux limb through the previous enterotomy created. We advance the handle approximately 5 to 10 centimeters. The spike of the handle is then advanced through the antimesenteric wall of the small intestine. The stapler handle is then mated to the more proximally located anvil. We make sure that the orange guideline is well inserted into the anvil. The stapler is then securely closed in order to make the two bowel segments. The stapler is fired completing the proximal anastomosis. The staple handle is removed from the small intestine segment. Two complete tissue rings are identified. The staple handle is closed down and subsequently removed from the left flank incision. The redundant portion of Roux limb that is overhanging the actual anastomosis is then resected using an additional firing of the Endo GIA with a 60 millimeter white load. The resected specimen is then placed in an EndoCatch bag and brought out through the left lateral incision. In anastomosis is then reinforced by placing Lembert sutures along both the left and right lateral edges as well as anteriorly. The completed anastomosis can now be visualized. We then test the anastomosis for its patency by doing air insufflation test. The Roux limb is clamped distally and endoscope was advanced into the small upper stomach pouch. We then proceed to insufflate with air under a saline bath to check for any leaks. The internal anatomy is also identified and the patient's found have a widely patent anastomosis with a hemostatic staple line. The residual air in the stomach and upper small intestine is then removed with the endoscope. The endoscope is then withdrawn. The upper abdominal cavity is then thoroughly irrigated and once this is accomplished abdominal closures undertaken and the operation is complete. The patient's postoperative upper GI was normal. She was started on a clear liquid diet and discharged the morning after her surgery.