Since 1995, thousands of Australians have undergone laparoscopic gastric banding. Complications necessitate revision surgery, and I have been performing laparoscopic Roux Y Gastric Bypass since 2000. Iterative improvements in technique have occurred.
The FlexDex needleholder is an 8 mm laparoscopic instrument with an articulated wrist similar to a robotic instrument.
The steps of the operation are to locate and mobilise the buckle of the band, to undo the gastrogastric fusion, to remove the band and divide the stomach to create the new gastric pouch. Resecting the fundus at this time allows better dissection behind the stomach and removes the traumatised portion of stomach.
The new greater curve is oversewn with 2/0 Stratafix and the end of the suture is used to anchor the small bowel loop measured 100 cm from the DJ flexure.
A two layer anastomosis is performed with the posterior layer of Stratafix, then after opening the gastric pouch and making a matching enterotomy an inner all layers stitch of preprepared 2/0 PDS loop is made using the Flexdex. The anastomosis is completed with an anterior wall of Stratafix.
The small bowel is divided and the enteroanastomosis created with a single firing of the stapler. The enterotomy is closed in 2 layers using PDS and a 15 cm Stratafix seromuscular layer.
Methylene blue is instilled as a leak test.
The mesenteric and Petersens defects are closed with BioA rectangles and Glubran.
Revision surgery can be a technical challenge. The FlexDex allows more accurate suture placement, and avoids the linear staple line which potentially leaves an island of tissue with doubtful viability. It avoids the expensive and time-consuming setup of the robot, and is more readily available.