Retrogastric Tunnel Research Articles

Laparoscopic Band-Separated One Anastomosis Gastric Bypass.

This video demonstrates laparoscopic band-separated one anastomosis gastric bypass-combining the advantages of banding and gastric bypass without stapler and cutter use. This is basically a gastrojejunal loop bypass above an obstructive band in the upper stomach. An adjustable low pressure "Medsil" gastric band was introduced in the abdomen and retracted through the retrogastric tunnel. The front wall of the stomach below the band was displaced in the upward direction through the ring band, increasing the size of the anterior portion of the stomach pouch so that a gastroenteroanastomosis could be created at this point. Gastro-gastric sutures were placed to create a gastro-gastric plication around the band and hold it in position. The band tubing was exteriorized and connected to a special port, which was secured to the abdominal wall fascia. A jejunal loop was created about 200cm from the ligament of Treitz and anastomosed to the gastric pouch by hand using Vicryl 2/0 sutures. Between November 2015 and February 2016, the study was performed on 10 patients. The average operating time for all cases was 75min (range 63-87). There was no morbidity or mortality. No complications were observed, including band erosion and band infection. Operation costs were about $2000 lower with this method than with standard gastric bypass surgery. Postop the patients lost weight by 3-4kg per month. Preliminary results show that laparoscopic band-separated one anastomosis gastric bypass have feasibility, safety, efficacy, and reduced operating costs.

Modified single-incision laparoscopic adjustable gastric band

This video describes a modified single-incision laparoscopic approach for adjustable gastric band placement. The patient was a 28-year-old female with a BMI of 48.75 with no prior surgery but with numerous comorbidities. With the patient placed in a split-leg position and in steep reverse Trendelenburg, a 12-mm optical trocar is placed 12 cm distal to the xiphoid process in the left paramedian location. A Nathanson liver retractor is placed through a midepigastric 5-mm incision. Two 5-mm low-profile trocars are placed next to the 12-mm trocar through separate incisions (this maintains stability of each cannula) and a 5-mm 45 ° laparoscope is used. Using an automated suturing device, a stay suture is placed high on the fundus and externalized for retraction. An articulating band passer dissects the phrenogastric attachments at the angle of His. The 12-mm port is removed and the gastric band is inserted. The GE junction fat pad is excised and the Pars Flaccida membrane is divided using conventional instruments. A second traction suture is placed to retract the lesser curve fat and right crus fat pad. A peritoneal bite is also taken in the left lateral subcostal area such that when this suture is externalized, it acts as a pulley. An articulating 5-mm grasper is used to develop the retrogastric tunnel. Then the band is fed into position and its buckle is locked. Three interrupted sutures are placed to create an anterior gastric plication and a fourth antislippage suture is placed below the band along the lesser curve. The band tubing is externalized and the port is implanted by joining the three working trocar incisions into a single 4.5-cm incision. The patient did well postoperatively with no complications. A modified single incision approach for laparoscopic gastric band placement is feasible and provides patients with improved cosmesis.

Right-Sided Upper Abdomen Single-Incision Laparoscopic Gastric Banding

Single-incision laparoscopic surgery (SILS) was recently implemented for performing gastric banding. However, concern exists regarding the safety of single-incision laparoscopic adjustable gastric banding (SILS-LAGB) compared to standard laparoscopy, and the operative technique is still evolving. We describe our preliminary experience of a new technique for SILS gastric banding based on a unique incision location, which allows a better view and improved dissection capability. During a period of 6 months, ten patients underwent SILS-LAGB in our institution. The operative technique consisted of a 4-cm skin incision placed in the right upper quadrant (RUQ), starting from the midline and extending to the right, located above the mid-distance between the xiphoid and umbilicus. Through that incision, three trocars (two 5-mm trocars and one 15 mm) are inserted. The liver retraction was achieved through the additional subxiphoid skin puncture wound using Nathanson retractor. Ten patients (eight females, two males) underwent SILS-LAGB. Mean age was 31.4 years (21-49) and mean BMI 40.9 kg/m(2) (39-44). In nine out of ten patients, the procedure was completed through the original skin incision. In one case, one additional trocar was inserted due to poor surgical field visualization. The operative time declined from 80 to 60 min along the learning curve. The mean hospital stay was 1.1 days (1-2). There was no mortality or morbidity. The location of the incision in the RUQ enabled a better view of the retrogastric tunnel and facilitated the dissection, and therefore should be of comparable safety to a standard laparoscopic procedure.

Creation of a retrogastric tunnel in laparoscopic gastric banding – the Liverpool Landmark

Laparoscopic placement of a gastric band requires the creation of a retrogastric tunnel to allow for safe passage of the band through the pad of fat behind the gastro-oesophageal junction. We describe an anatomically constant area through which a closed instrument may be passed safely to emerge at the angle of His. Following minimal dissection in the angle of His 1–2 cm medial to the spleen, the pars flaccida is divided with diathermy. As the lesser curvature of the stomach is retracted to the left of the patient, an easily identifiable feature is a transverse fat plane running across the lower one-third of the right crus (Fig. 1). Incising the adipose tissue 2 mm medial to the right crus at the level of this fat line allows easy retrogastric passage of a grasper or Goldfinger (Ethicon Endo-Surgery, Ohio, USA) in front of the crurae to arrive at the angle of His. The instrument should pass ‘like a hot knife through butter’. This ‘Liverpool Landmark’ has proved its worth now for many years in our unit. Figure 1 The Liverpool Landmark (x).

Laparoscopic adjustable gastric banding after previous Roux-en- Y gastric bypass

Weight regain and inadequate weight loss after gastric bypass remain significant concerns, with potential effects on multiple quality measures. Poor restriction of oral intake owing to dilation of the small gastric pouch or the gastrojejunostomy is a potential cause of recidivism. Operative revision of the pouch or anastomosis can be technically difficult, carrying significant perioperative risk. Placement of a laparoscopic adjustable gastric band around the gastric pouch is an alternative for intervention in this patient population. We reviewed the pertinent data and describe our technique for laparoscopic placement of an adjustable gastric band after previous gastric bypass. The essential aspects of intraoperative anatomy, dissection, and decision making are covered, including the options for band fixation according to a particular patient’s history of previous gastric bypass and remnant tube gastrostomy. Methods The present case (and the corresponding video) was that of a 53-year-old morbidly obese woman with multiple comorbidities, including back pain, depression, and significant gastroesophageal reflux disease, with changes in Barrett’s esophagus after laparoscopic Nissen fundoplication. She had undergone laparoscopic Roux-en-Y gastric bypass with takedown of her previous fundoplication and decompression of her gastric remnant by tube gastrostomy. She had recovered well from that operation, with improvement of her gastroesophogeal reflux disease symptoms. However, she experienced poor (50%) excess weight loss during long-term follow-up, despite ongoing dietary evaluation and behavior modification counseling. Her principle complaint was an inadequate sense of restriction of oral intake. She completed an extensive workup, including a contrast swallow study and flexible upper endoscopy, which revealed a dilated gastrojejunostomy measuring approximately 3 cm in diameter. She subsequently underwent endoscopic suture plication of her gastrojejunostomy 29 months after her bypass, with minimal additional weight loss. After discussion of her options for additional intervention, she elected to undergo placement of an adjustable gastric band over her bypass. The pneumoperitoneum and our standard laparoscopic adjustable gastric band (LAGB), 5-port setup, were established. We then proceeded with careful dissection of the anterior small gastric pouch, Roux limb, and gastrojejunostomy away from the overlying liver, which was then elevated with a Nathanson retractor. A combination of ultrasonic, electrosurgical, and blunt dissection was used to identify the pars flaccida and angle of His. The pars flaccida was divided to reveal the right crus and distinguish it from the more laterally lying inferior vena cava. An opening for the retrogastric tunnel was created by dissecting along the medial aspect of the right crus. An esophageal dissector was then passed bluntly through the retrogastric tunnel and articulated to expose the tip at the angle of His. An AP standard LapBand (Allergan, Irvine, CA) was introduced into the patient’s abdomen and passed through the retrogastric tunnel using the esophageal dissector. The LapBand tubing and buckle were secured in the standard fashion. This patient’s gastric remnant remained fixed to the anterior abdominal wall with extensive adhesions from the previous tube gastrostomy, precluding safe use for band fixation. Therefore, we fashioned a piece of DermaMatrix (Musculoskeletal Transplant Foundation, Edison, NJ), measuring approximately 2 cm 8 cm, and secured it with permanent 2-0 Ethibond suture (Ethicon, Somerville, NJ) to

Salvage of Gastric Restriction following Staple-Line Dehiscence after Vertical Banded Gastroplasty by Insertion of an Adjustable Gastric Band

Vertical banded gastroplasty (VBG) has been a common and safe surgical treatment for morbid obesity. However, the complication of staple-line dehiscence (SLD) results in VBG failure. We present a minimally invasive revision procedure when SLD occurs: gastric restriction is salvaged by adjustable gastric banding (AGB), usually laparoscopically, providing that the previous restriction had achieved sufficient weight loss initially and was well-tolerated. 13 patients with unexplained weight regain after VBG were found to have SLD on endoscopy. AGB was performed to re-establish restriction. Weight loss and complications were compared with two control groups: the first undergoing uncomplicated VBG, and the second undergoing AGB alone. Follow-up of 4.3+/-0.1 (mean+/-SEM) years after salvage reoperation, including complications, reoperations and weight loss, were studied. Insertion of the band through the retrogastric tunnel was feasible in all cases, despite adhesions in the area of the VBG Marlex band, the proximal stomach, and left lobe of liver. There was no surgeryrelated mortality. Following "salvage AGB", weight loss and overall complication rates were similar between the study group and the two control groups. Salvage of gastric restriction by AGB after SLD secondary to VBG is safe and reliable, despite the possibility of adhesions. Morbidity is low and intermediate-term weight loss is comparable to patients with uncomplicated VBG.

Prospective study of 250 patients undergoing laparoscopic gastric banding using the two-step technique: a technique to prevent postoperative slippage.

The use of LAP-BAND adjustable gastric banding (LAGB) has gained tremendous popularity, but creation of the retrogastric tunnel is a considerable challenge, especially in the surgeon's early experience, and is associated with up to 10% band slippage and occasional gastric perforation. The two-step technique involves a crural dissection toward the angle of His through a pars flaccida approach. The technique facilitates passage of the band with no extensive posterior gastric wall dissection. A prospective study investigated 250 patients (207 women and 43 men) who underwent LAGB from January 1999 to May 2002 using a two-step dissection technique. The mean age of these patients was 37 years (range, 18-58 years). Their mean preoperative weight was 120 kg (range, 90-169 kg), and their mean body mass index was 44 kg/m2 (range, 36-68 kg/m2). All the procedures except two were completed laparoscopically, and there were no deaths. The mean operative time was 61 min (range, 35-150 min), and the mean hospital stay was 1.2 days (range, 1-5 days). At 3 years, the mean body mass index had decreased from 44 kg/m2 to means of 39.9, 37.3, 34.4, 32.4, and 31.7 kg/m2 at 3, 6, 12, 24, and 36 months, respectively. The mean excess weight loss was 42.1% at 1 year, 51.4% at 2 years, and 55.5% at 3 years. There were four band slippages (1.6%), no band erosion, and no major morbidity. The use of LAGB with the two-step technique is technically simple, avoids intimate posterior gastric wall dissection, and facilitates tight posterior band support. It therefore is associated with only minimal perioperative complications and a low slippage rate.

Laparoscopic banding: selection and technique in 830 patients.

Laparoscopic adjustable gastric banding (LAGB) with the Lap-Band has been our first choice operation for morbid obesity since September 1993. Results in terms of complications and weight loss are analyzed. 830 consecutive patients (F 77.9%) underwent LAGB. Initial body weight was 127.9 +/- SD 23.9 kg, and body mass index (BMI) was 46.4 +/- 7.2 kg/m2. Mean age was 37.9 (15-65). Steps in LAGB were: 1) establishment of reference points for dissection (equator of the balloon inflated with 25 cc air and left crus); 2) creation of a retrogastric tunnel above the bursa omentalis; 3) creation of "virtual" pouch; 4) embedding the band. Mortality was 0, conversion 2.7%, and follow-up 97%. Major complications requiring reoperation developed in 3.9% (36 patients). Early complications were 1 gastric perforation (requiring band removal) and 1 gastric slippage (requiring repositioning). Late complications included 17 stomach slippages (treated by band repositioning in 12 and band removal in 5), 9 malpositions (all treated by band repositioning), 4 gastric erosions by the band (all treated by band removal), 3 psychological intolerance (requiring band removal), and 1 HIV positive (band removed). A minor complication requiring reoperation in 91 patients (11%) was reservoir leakage. 20% of patients who had % excess weight loss < 30 had lost compliance to dietetic, psychological and surgical advice. BMI declined significantly from the initial 46.4 +/- 7.2 to 37.3 +/- 6.8 at 1 year, 36.4 +/- 6.9 at 2 years, 36.8 +/- 7.0 at 3 years, and 36.4 +/- 7.8 at 5 years. LAGB is a relatively safe and effective procedure.

Laparoscopic gastric banding with Lap-Band for morbid obesity: two-step technique may improve outcome.

Laparoscopic placement of an adjustable gastric band is an attractive alternative for patients who can benefit from a restrictive bariatric procedure. Creation of the retrogastric tunnel (RGT) may, however, be a considerable challenge early in the surgeon's learning curve. Recent reports described up to 10% band slippage and occasional gastric perforation associated with RGT. The two-step (TS) technique involves a crural dissection towards the angle of His through a gastrohepatic ligament approach. It facilitates passage of the band's tubing posteriorly with no wide posterior gastric wall dissection. Prospective data were registered for the 109 patients (92 females, 17 males) who underwent laparoscopic adjustable gastric banding from December 1998 to May 2000. In 11 patients the standard RGT approach was used, and in 98, the TS technique. The two groups were demographically similar. Mean age was 37 years (18-59); mean preoperative weight was 120 kg (90-165). All procedures were completed laparoscopically. The mean operative time was 59 minutes (31-150) and the mean hospital stay 1.2 days (1-5). Complications in the TS group were gastric wall hematoma in one patient, 3 days of intubation postoperatively in one patient, damage to a band demonstrated in a postoperative contrast study in one patient, and a port-site hernia in one patient. There was no band slippage in the TS group. Among the 11 patients undergoing RGT, there was band slippage in three (27%), immediately postoperatively in one and after 3 and 11 months in the other two. In a mean follow-up of 7 months (1-18), similar weight loss was found in both groups. The mean BMI decreased from 44 kg/m2 (36-61) preoperatively to 40, 38, 36, 34 kg/m2 at 1, 3, 6 and 9 months respectively. 52 patients required band adjustment; of these, 12 required two adjustments. Our experience with both the RGT and TS techniques indicates that the latter may offer better results, particularly in the early experience period. It is recommended that in their initial experience with the adjustable band, surgeons should become familiar with this approach.

Laparoscopic adjustable silicone gastric banding (Lap-Band): how to avoid complications.

The laparoscopic application of LAP-BAND is gaining widespread acceptance as a gastric restrictive procedure. At the same time the reported morbidities (i.e., gastric perforation, stomach and/or band slippage) are cause for some concern. From September 1993 until May 1997, 260 patients underwent LAP-BAND at the Department of Surgery at the University of Padova, Italy. The mortality rate was zero and the morbidity rate requiring reoperation was 3.4% (stomach slippage, gastric perforation, erosion). In order to avoid complications the key points of the technique are reviewed: (1) reference points for dissection (equator of the balloon, left crus); (2) retrogastric tunnel within the layers of the phrenogastric ligament; (3) embedment of the band; (4) proper outlet calibration; and (5) retention sutures. Attention to technical details is of paramount importance for a safe, standardized and effective operation.

Laparoscopic Placement of Adjustable Silicone Gastric Banding: Early Experience.

BACKGROUND: the authors describe a laparoscopic technique for the positioning of stoma adjustable silicone gastric banding (SASGB), which respects the main steps of the open procedure. METHODS: (1) patient position: supine with thighs abducted and 30 degrees reverse Trendelenburg; (2) Four 10 mm trocars (supra-umbilical, sub-xiphoid, right upper quadrant, left upper quadrant) and an 18 mm trocar (left subcostal); (3) exposure of the subcardial area; (4) measurement of the pouch; (5) dissection of the lesser and greater curvatures; (6) retrogastric tunnel; (7) introduction and placement of the band; (8) band closure and stoma calibration; (9) retention sutures. RESULTS: results obtained in a first (1992) series of five patients who underwent the laparoscopic application of the regular SASGB and results of a second series (1993-1994) of seven patients in whom the new LAP-ASGB was utilized are reported. CONCLUSION: this new approach can represent a major achievement in bariatric surgery, as it combines the minimal invasiveness of the laparoscopic approach with the reversibility of SASGB.