The case of being in the wrong place at the wrong time: the consequences of undiagnosed anatomic anomalies.

摘要

The number of laparoscopic bariatric surgery procedures is continuing to lise owing to the increasing number of obese patients MfiHing the eligibility criteria [1], We present a case of failed gastric banding with subsequent sleeve gastrectomy owing to the intraoperative finding of unexpected anatomic anomalies. Our patient was a 31-year-old woman who weighed 98 kg and had a body mass index of 47 kg/m~2. Her obesity-associated co-morbidities included type 1 diabetes mellitus and diabetic retinopathy. She also had hypopituitarism and osteoporosis. She had undergone previous liposuction and had failed to achieve sustained weight loss through dietary or pharmaco-logic methods. She was keen to proceed to a laparoscopic gastric band and had fulfilled the national criteria [1]. She was scheduled for surgery in June 2010 (Video 1). Access to the abdomen was achieved by a small, left, upper quadrant incision and passing a 12-mm bladeless trocar loaded with a 0deg, 10-mm laparoscope into the abdominal cavity under laparoscopic vision. A pneumoperitoneum was established to 15-mm Hg pressure with carbon dioxide. A 15-mm trocar was placed at the midline umbilical position. On entering the abdomen through the umbilical port, it became apparent that her anatomy was not in the usual configuration: she had a right-sided stomach and multiple spleens (splenunculi) but with a correctly oriented small bowel. The right lobe of the liver appeared to be enlarged. She also had increased lymphatic tissue along the lesser curve, and the stomach was almost U-bend shaped (Fig. 1). Another two 12-mm trocars were placed in the right upper and lower quadrants.