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nique. The disadvantage is that it requires the hand to be inserted into the abdomen, just inferior to the xiphoid, thereby necessitating a larger incision. This creates a risk of incisional hernia at the site. Two or three other ports are used—a supraumbilical camera port and one to two left subcostal working ports (Figs. 8.3 and 8.4). The initial experience with this technique is quite small.

Another variation of the LVBG is Cagigas' "no punch" technique (Fig. 8.5). His group does not create a gastric window. Instead they use a cutting, reticulating linear stapler to create the gastric pouch by starting at the angle of His. At the base of the pouch, they place a Gore-Tex band. The stoma size is calibrated around a gastric tube that is placed prior to the division of the gastric pouch. The advantage of this method is that the procedure can be performed through 10 mm and 12 mm ports, since the large circular stapler is no longer required (Fig. 8.6). A disadvantage is that

Fig. 8.5. A schematic representation of the "no punch" technique laparoscopic VBG described by Cagigas.

the stomach must be divided placing the patient at risk for peritonitis should he have a staple line dehiscence. The preliminary results have yet to be reported.

Outcomes

The reported series of the LVBG and HLVBG have small group numbers and do not have long term follow-up. Gerhart reported his results of a small series of 26 patients who underwent HLVBG with follow-up ranging 3 to 18 months. The %EWL at 12 months was 52.7%, which is lower than the %EWL seen in the open procedure at one year. So far he has experienced three minor wound infections, two patients with clinically significant atelectasis, three incisional hernias, one leak, one pouch outlet obstruction, and one staple line dehiscence. The rate of complications is 42% and rate of reoperation is 24%. Gerhart results are similar to those seen with the VBG.

Bleier reported his initial experience with the HLVBG in 46 patients. He compared them with 46 historical controls (VBG) and found that the HLVBG patients ambulated and ate earlier. The operation was quicker, and ICU stay was shorter. Pulmonary and wound complications were reduced compared to the open group. Pain was more easily managed within the HLVBG group. The one significant difference was three gastric leaks (6.5%) in the HLVBG group but none in the open group. Two of the leaks were managed conservatively and resolved spontaneously. The third required laparotomy and repair. This patient remained in hospital for 96 days. Excluding this patient from the average hospital length of stay (LOS), the HLVBG group had a significantly shorter LOS, 4.3 versus 7.7 days. Overall, the patients faired better in the HLVBG group although the rates of gastric leak were increased. These results are the expected benefit of the laparoscopic technique. The only concern is the high rate of gastric leak. With Bleier's divided gastric pouch. Staple line disruption has been seen in up to 40% of cases with non-divided gastric pouches. This becomes a greater concern in cases where the pouch is divided.

The experience with the LVBG is somewhat more extensive than with the HLVBG. The initial results are as expected. Lonroth attempted 38 LVBG's and successfully completed 35. Three of the patients had to be reoperated for a retained and transected gastric tube, another for a staple line leak, and the last for persistent fever with a subphrenic fluid collection. On the other hand, the LVBG group faired better than the open controls in that they had less pain, quicker mobilization and

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