After clearing all adhesions, the gastric band is identified. In some cases with dense anterior adhesions, this may be facilitated by getting into the lesser sac and behind the stomach from the greater curve to first find the band in an area with less fibrosis and scarring. When possible, the gastroplasty vertical staple line is identified as well. A window must then be created into the lesser sac, on the lesser curve side of the stomach and proximal to the gastric band. The lesser curve neurovascular bundle should be preserved, and this window should be created as close to the gastric wall as possible. Once this dissection is complete, a linear stapler with a thick tissue cartridge is fired transversely on the gastric pouch and fundus proximal to the band. An esophageal bougie (38–42 French) is passed until it abuts the newly created proximal transverse staple line. The bougie is maneuvered as close as possible to the lesser curve of the pouch, and a linear stapler is fired multiple times until the new gastric pouch is completely isolated and divided from the remnant stomach. It is important to avoid crossing the original gastroplasty staple line when creating the pouch. By crossing staple lines and incorporating tissue of vastly different thicknesses in the same staple line, the potential for staple line failure increases. There is an additional possibility of leaving a small cuff of stomach on either the remnant stomach or the gastric pouch that does not communicate with either lumen. For this reason, it is mandatory to stay very close to lesser curve bougie and typically resect the fundus of the remnant stomach along with the band and the original staple lines. For open cases, a hand-sewn gastrojejunostomy, using absorbable sutures, was performed. In laparoscopic cases, the gastrojejunostomy is created by passing the anvil to a 25-mm circular stapler (DST Series™ EEA™ OrVil 25-mm device, Covidien, Norwalk, CT) transorally. Several experiences reported the same limb length as in primary LRYGB: a 50-cm biliopancreatic limb and a 100- or 150-cm Roux limb, depending on the patient’s BMI.

After band deflation the first step is to identify the gastric band and its orientation. The fibrous tissue that covers the band is removed, and the port-connection tube is cut and pulled out of the abdomen. Then the band is sectioned, freed by the remaining adhesions, and gently extracted into a port. The gastric bypass can be performed during the same laparoscopic session or after several weeks according to both the surgeons’ experience and patients’ conditions.

The patient is positioned in the reverse Trendelenburg lithotomy position. A closed carbon dioxide pneumoperitoneum is created, and 6 trocars (5 of 12 mm and 1 of 5 mm) are inserted. The balloon gastric bougie (Inamed-Allergan) is placed transorally in the stomach and inflated with 30 mL of a saline solution, and the stomach is retracted backward by the anesthesiologist to reach the cardioesophageal junction. Dissection is started at its equator in the perigastric space between the neurovascular bundle of Latarjet and the lesser curvature of the stomach using the harmonic scalpel (Ultracision, Ethicon Endo-Surgery, Cincinnati, OH). The retrogastric space is entered, and gastric transection performed by multiple linear staples fired in sequence up to the angle of His. The 30–45 Endocutter (Ethicon Endo-Surgery, Cincinnati, OH) and 35-, 45-, and 60-mm Endo GIA (US Surgical, Tyco Healthcare) were used interchangeably when available and as required. The flip-top anvil of a 25-mm circular stapler (CEEA, US Surgical, Tyco Healthcare) is advanced transorally into and through the proximal gastric pouch using a modified nasogastric tube anvil apparatus. The Roux limb is constructed by transecting the small bowel 40–60 cm from the ligament of Treitz. A jejunotomy on the alimentary limb is created, and the circular stapler is introduced transabdominally and advanced into the lumen of the jejunum to create an antecolic, antegastric end-to-side gastrojejunostomy. The jejunotomy is closed with a 60-mm linear stapler. The presence of a gastrojejunostomy leak is tested by injecting 40–60 mL of methylene blue through the nasogastric tube previously positioned into the temporarily clamped alimentary limb. A side-to-side jejunojejunostomy is performed with a 45-mm linear stapler through a jejunotomy 100–150 cm distal to the gastrojejunostomy. The anastomosis is completed using 2-0 polydioxanone continuous suture (LAPRA-TY, Johnson & Johnson, Cincinnati, OH).

The closure of the Peterson space with nonabsorbable stitches is routine. Also, drainage of the gastroenteroanastomosis and enteroenteroanastomosis is done in all cases.

Some authors have described a new technique with band left in situ and the small bowel anastomosed with the stomach above the band.