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A 30-year-old female with a history of morbid obesity and a BMI of 41Kg/m2 underwent an uneventful laparoscopic RYGBP. In the outpatient clinic she complained of intermittent abdominal pain: No occlusion data were given.
A gastrografin swallow was performed and reported as normal so a clinical follow up was performed. Due to the persistence of the clinical manifestation a upper endoscopy and a CT scan were performed. They revealed a passage of the oral contrast from the pouch to the gastric remnant. The anastomosis had a preserved diameter with no mucosal lesion but there was a fistulous orifice.
At that time the patient had lost 45 Kg and had a BMI of 25 Kg/m2.
Laparoscopic surgical revision was performed. The patient was placed in the supine position with open legs. The leading surgeon stood between the patient's legs with one assistant on each side. A total of 5 trocars were placed using the scars from the previous bypass. The camera was placed at the 12mm port in the supraumbilical position.
The first step of the procedure was the recognition of the anatomical structures. There were adhesions from the previous surgery. You can see the roux limb and the pouch in contact with the hepatic left lobe. The assistant surgeons performed traction from the roux limb.
The scissors were used for the initial stage of the dissection. The gastric fundus was also individualized. We use the energy devices only when the correct plane is evident. Adhesiolysis between the pouch and the gastric remnant continued, trying to find the Gastro gastric fistula.
Blunt dissection also exposes the avascular planes. Now the strategy is to perform traction from the gastric fundus. The non-dominant hand provides extra exposure and the dominant hand applies blunt dissection. The maneuver is similar to the movements used to build a tunnel behind the stomach in order to create the pouch.
This is the fistulous tract. It had well defined fibrotic walls. The goldfinger was used to ensure that the fistula was completely mobilized.
A beige TriStapler was used to divide it. The final revision was made. No drain was left in.
Surgery was uneventful and took 45 minutes. The patient left hospital on the first post operative day with no complications.
One month after the procedure the patient remains asymptomatic.
