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A 34 year-old female with a previous history of high blood pressure and a cesarean. She suffered from morbid obesity, with a 50 kg/m2 BMI (height 1.63, - weight 133Kg).
She came to our hospital stating that she had had a laparoscopic adjustable gastric band placed in another center 4 years before. She claimed that there never was a subcutaneous reservoir and it wasn’t found in the physical examination.
With this procedure she lost a maximum of 30Kg and then regained it all.
In the interrogation there was no pain, symptoms of GERD or dysphagia. The upper GI endoscopy and series were normal, revealing only the gastric pouch produced by the device.
Surgical revision was performed by laparoscopy. The patient was placed in the supine position with open legs. The leading surgeon stood between the legs with one assistant on each side of the patient.
A total of five trocars were used. A 12mm port in the supraumbilical position for a 30° scope, three 12mm trocars placed at the epigastrium and each flank a last 5mm trocar placed more laterally on the patient’s left flank.
As in all revisional bariatric procedure there are adhesions, specially if a device has been placed. Scissors must be used to individualize the stomach from the liver. Dissection must be delicate and the surgeon must avoid major gastric injuries.
Usually tissues tend to bleed. Suction can be used to clarify the planes and perform blunt dissection. We believe that the bipolar device is more accurate to achieve hemostasis in this situation.
If a clear avascular plane is identified the hook provides sharp dissection and improves hemostasis. At the same time it can be used for blunt dissection. The assistants helped with the exposure, performing traction of the liver and the greater curvature of the stomach.
As dissection progressed the surgeon identified the device previously placed. There was no reservoir. Blunt dissection was performed to achieve the initial detachment. The correct plane was identified and the individualization continued more safely.
The hook can be used by sliding it between the device and the surrounding tissue. Step by step the device was released. It was not a band; it was a gastric ring that was not properly hooked. Gastric bands produce a fibrotic ring that separates them from the stomach and makes removal easier than in this case.
Due to the local characteristics of the gastric wall, the surgeon decided to revise for hemostasis, leave a drain and perform delayed conversion.
Surgery took 45 minutes. Oral intake started on the next postoperative day and the patient left hospital the same day with no drainage. She underwent an uneventful conversion into a sleeve gastrectomy three months after the removal of the ring; four years later she maintains an 86% excess weight loss.
