Laparoscopic Conversion of Sleeve Gastrectomy to One Anastomosis Gastric Bypass in a Hostile Abdomen

Purpose Failure of weight loss is the most common indication for revisional surgery following sleeve gastrectomy (SG) as reported by Guan et al. (Obes Surg. 2019; 29:1965-1975). Recent evidence suggests that the revision rates for SG can be up to 10% when patients are followed up for more than 3 years and as high as 22% after 10 years as reported by Guan et al. (Obes Surg. 2019; 29:1965-1975). Options for revisional surgery following a SG include Roux-en-Y gastric bypass (RYGB), one anastomosis gastric bypass (OAGB), and re-sleeve as the commonest procedures. There is good evidence supporting revisional surgery following failure of weight loss post-primary surgery as reported by Guan et al. (Obes Surg. 2019; 29:1965-1975); Cheung et al. (Obes Surg. 2014; 24:1757-1763); Shimizu et al. (Obes Surg. 2013; 23:1766-1773); and Mora Oliver et al. (Cirugia Espanola. 2019; 97:568-574). However, at the same time, retrospective studies suggest higher complication rates following revisional surgery with a major complication rate up to 10% as reported by Yilmaz et al. (Obes Surg. 2017; 27:2855-2860); Fulton et al. (Can J Surg J Can Chir. 2017; 60:205-211); and Abdelgawad et al. (Obes Surg. 2016; 26:2144-2149). Additionally, the durability of weight loss and morbidity reduction in re-operated patients is still debated and overall high-quality evidence in the field is lacking as discussed by Abdelgawad et al. (Obes Surg. 2016; 26:2144-2149). Aim of this educational video is to demonstrate a revisional bariatric procedure which was technically difficult due to extensive intra-abdominal adhesions and explain the available surgical options and the decision-making process adopted by the surgeons. Materials and Methods The video describes a laparoscopic conversion of a SG to OAGB in a 37-year-old female patient due to weight regain. Her primary bariatric procedure was planned to be a RYGB but due to extensive intra-abdominal adhesions discovered at the time of primary surgery, a SG was performed. Pre-primary procedure weight was 134kg with a BMI of 52.3kg/m(2). After SG, the patient lost a maximum of 50kg (71.4% excess BMI loss) within the first 18 months before she started regaining weight. Her BMI was 45.4kg/m(2) when she was referred for revisional surgery. During the procedure, dense small bowel adhesions were encountered and required meticulous dissection in order to free adequate small bowel to allow a safe, effective, and tension-free anastomosis. One hundred fifty centimeters of small bowel was the maximum length that could be safely dissected starting from the ligament of Treitz. An OAGB was preferred to RYGB as it is routine practice in our unit to bypass 200cm of small bowel for revisional RYGB procedures (50-cm biliopancreatic limb and 150-cm alimentary limb), whilst all OAGB's (primary and revisional) have an afferent limb of 150cm. A re-sleeve was also considered as a viable alternative. Results Extensive adhesiolysis followed by OAGB were performed successfully with an uneventful post-operative course. The patient was discharged on the second post-operative day. Excess BMI loss was 58% at 1-year follow-up. Conclusion Revisional surgery can be a challenging especially in the context of extensive surgical history. OAGB can be used as an alternative to RYGB.