664 Obesity Surgery, 16, 2006 © FD-Communications Inc. Obesity Surgery, 16, 664-666 Laparoscopic vertical banded gastroplasty (LVGB), is a safe and efficient bariatric operation, with low intra- operative complications. We report an unusual cause of conversion of a LVGB to an open procedure due to the fracture of the spike of the circular stapler during gastric penetration. Key words: Laparoscopic vertical banded gastroplasty, morbid obesity, conversion, circular stapler adverse event Introduction Laparoscopic vertical banded gastroplasty is per- formed with the same principles as the open proce- dure reported by Mason 1 and modified by MacLean 2 . The learning curve of the procedure as reported by advanced experienced laparoscopic sur- geons is low, with only a few operations necessary to achieve satisfactory results. Reported conversion rates from the laparoscopic to open procedure are very low, with low complication rates. The surgeon should be familiar with the use of lin- ear and circular staplers, because failure of those sta- plers could lead to conversion or postoperative com- plications. Technology in medical instruments is constantly improving, and even the most skilled and experienced surgeons need to be occasionally retrained. Moreover, even the most used and familiar surgical instruments may surprise the surgeon and cause unexpected change of the surgical strategy. We report an unusual case of stapler failure, in which breakage of the spike of the circular stapler during gastric penetration, resulted in conversion to laparotomy for the conclusion of the procedure. Case Report A 23-year-old female with intractable morbid obesi- ty and body mass index (BMI) 42.5 was scheduled for laparoscopic vertical banded gastroplasty (LVBG). She was operated under general anesthesia. After establishment of the pneumoperitoneum by the open (Hassan) technique and the insertion of a 30˚ camera, 4 additional ports were inserted under direct visualization (Figure 1). The next step was creation of a retrogastric opening with the use of 10-mm ves- sel sealing system (Ligasure Atlas, Valleylab, Boulder, CO, USA) into the lesser sac. A 32-F bougie was inserted orally to assist in creation of the gastric channel. We use the right approach through the 12-mm right subcostal port following a posterior- to-anterior gastric route to create the transgastric cir- Case Report Fracture of the Spike of the Circular Stapler: an Unexpected Cause of Conversion of a Laparoscopic Vertical Banded Gastroplasty Evangelos Menenakos, MD, PhD; Emmanuel Lagoudianakis, MD; Dimitrios Dardamanis, MD; Dimitrios Theodorou, MD, FACS; Emmanuel Leandros, MD, PhD; John Bramis, MD, PhD First Department of Propaedeutic Surgery, Hippocrateion Hospital, Athens Medical School, Athens, Greece Reprint requests to: Emmanuel Lagoudianakis, MD, First Department of Propaedeutic Surgery, Resident in General Surgery, Athens Medical School, Hippocrateion Hospital, Q. Sophia 114, 11527 Athens, Greece. Fax: +30 2107707574; e-mail: emlag@med.uoa.gr ARTICLES-MAY 4/26/06 12:12 PM Page 664