Laparoscopic Conversion of Adjustable Gastric Banding to Sleeve Gastrectomy in 10 Steps

This column recruits expert surgeons to share step-by-step technical pearls on bariatric procedures.

Column Editors: Raul J. Rosenthal, MD, FACS, FASMBS, and Daniel B. Jones, MD, MS, FACS

This Month’s Technique: Laparoscopic Conversion of Adjustable Gastric Banding to Sleeve Gastrectomy in 10 Steps.

This Month’s Featured Experts: Fernando Safdie, MD PGY-4 Cleveland Clinic Florida Surgical Residency Program, Cleveland Clinic Florida, Weston, Florida; Abraham Betancourt, MD, PGY-1 Cleveland Clinic Florida Surgical Residency Program, Cleveland Clinic Florida, Weston, Florida; and Samuel Szomstein, MD, FACS, FASMBS, Associate Director of the Bariatric Institute and Section of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, Florida, and Clinical Associate Professor of Surgery, Florida International University.
Funding: There was no funding for the preparation of this manuscript.

Disclosures: The authors reports no conflicts of interest relevant to the content of this article.

Bariatric Times. 2013;10(11):8–9.

Introduction
Laparoscopic placement of adjustable silicone gastric band (LAGB) was first described in the early 1990s,1 and it remained as one of the most popular bariatric procedures for almost a decade. This popularity was due to the perception of its reversibility, the initial good results in terms of weight loss (EWL 54–58% at 5 years), resolution of comorbidities, and low operative morbidity[3–5] However, several reports with extended follow-up showed significant weight regained rates (20–56%) and band-associated complications, such as pouch dilation and slippage.[6,7] These led to an increase in band removal/conversion procedures. Laparoscopic sleeve gastrectomy (LSG), initially described as a first step for the more complex duodenal switch, became not only one of the most popular procedures among bariatric surgeons but has also been adopted as one of the favorite options for conversion of a failed adjustable gastric band. This article describes how we perform laparoscopic conversion to sleeve gastrectomy for nonresponders or complicated LAGB at The Bariatric and Metabolic Institute, Section of Minimally Invasive Surgery at the Cleveland Clinic Florida.

Preoperative Work up
Every patient undergoing revisional surgery for conversion of band to sleeve gastrectomy receives an extensive preoperative work up, including medical, cardiac, and psychological clearance. Nutritional evaluation, as well as esophagoduodenoscopy and upper gastrointestinal series are also performed.

Procedure
Position. Patients are placed in the supine position, arms are tucked, and the pressure point should all be well padded. Head up and slight left side up are often required.
Operative approach and port distribution. We use a seven-trocar technique. The trocar disposition is represented in Figure 1.

Step 1—Access the abdominal cavity. The abdominal cavity is accessed through a supraumbilical incision with the Optiview trocar (Ethicon, Inc, Cincinnati, Ohio). The subcutaneous port is removed at this time with the optiview technique (Figure 2).
Step 2—Adhesiolysis. Adhesions between the left lobe of the liver and the band are taken down either with ultrasonic energy or with sharp technique (Figure 3).

Step 3—Take down of the gastro-gastric placation. This allows the exposure of the band and access to the retrogastric space through the lesser sac (Figure 4).

Step 4—Hiatus exposure. The buckle of the band is carefully exposed and the right and left crus of diaphragm are dissected out allowing complete exposure of the esophagogastric junction (Figure 5).

Step 5—Removal of the adjustable gastric band. In order to avoid inadvertent injury to the gastric wall, the band is cut with cold scissors and removed together with the port
(Figure 6).

Step 6—Excision of the capsule. The capsule is dissected and excised on the greater curvature side of the gastric wall, allowing better staple line formation and preventing staple line disruptions (Figure 7).

After performing steps 1 through 6, you can proceed with the sleeve gastrectomy procedure.

Step 7—Creation of the sleeve. Using ultrasonic energy, the vascular supply of the greater curvature of the stomach is divided (Figure 8). We start dividing 5cm proximal to the pylorus and up to the angle of His.

Step 8—Calibration of the sleeve. We use a 38-42Fr gastric bougie (Figure 8b)and create the sleeve by means of an endoscopic linear stapler. We pay special attention to the proximal third of the stomach; this area has increased thickness of the gastric wall at the level of the previous band (Figure 8c). We use 4.1-mm (green) cartridges for the gastric transection at this level, whereas a 3.5-mm (blue) is utilized for the rest of the stomach.

Step 9—Reinforcement of staple line. We buttress the staple line with a seroserosal vicryl 2-0 running suture in all cases (Figure 9).

Step 10—Drainage of the intrabdominal cavity. We leave a 19Fr round drain in all revisional cases that is removed during the first postoperative office visit (Figure 10).

References
1.    Belachew M, Legrand M, Vincenti V V, et al. Laparoscopic placement of adjustable silicone gastric band in the treatment of morbid obesity: How to do it. Obes Surg. 1995;5(1):66–70.
2.    Favretti F, Segato G, Ashton D, et al. Laparoscopic adjustable gastric banding in 1,791 consecutive obese patients: 12-year results. Obes Surg. 2007;17:168–75.
3.    Gagner M, Gumbs AA. Gastric banding: conversion to sleeve, bypass, or DS. Surg Endosc. 2007;21:1931–5.
4.    Cunneen SA. Review of meta-analytic comparisons of bariatric surgery with a focus on laparoscopic adjustable gastric banding. Surg Obes Relat Dis. 2008;4(3 Suppl):S47–55.
5.    Foletto M, Bernante P, Busetto L, et al. Laparoscopic gastric rebanding for slippage with pouch dilation: results on 29 consecutive patients. Obes Surg. 2008;18:1099–103.
6.    Dapri G, Cadière GB, Himpens J. Feasibility and technique of laparoscopic conversion of adjustable gastric banding to sleeve gastrectomy. Surg Obes Relat Dis. 2009;5:72–76.

Funding: There was no funding for the preparation of this manuscript.

Disclosures: The authors reports no conflicts of interest relevant to the content of this article.

Category: Past Articles, Surgical Pearls: Techniques in Bariatric Surgery