Laparoscopic Adjustable Gastric Banding
The adjustable gastric band is designed to divide the stomach into a small upper pouch of approximately 15 mL that can empty only gradually into the rest of the stomach. This bariatric surgical procedure is used in selected patients. It has the advantage of reversibility and causes minimal metabolic derangements. Early problems with band erosion, inadequate weight loss, and slippage are gradually being eliminated as the technique evolves.
This chapter presents the basic steps for implantation. Currently, two such devices are in use around the world, and the procedure has some nuances depending upon which device is being used. It is essential to be completely familiar with the device being used, and to follow recommended steps specific for that particular device.
With any bariatric surgery procedure, the surgery is just a small part of the overall care of the patient. Careful patient selection, preoperative preparation, and postoperative care are ideally delivered by a dedicated and experienced bariatric team. References at the end describe these parts of care in greater detail.
SCORE™, the Surgical Council on Resident Education, classified laparoscopic operations for morbid obesity as “COMPLEX” procedures.
STEPS IN PROCEDURE
Position patient with legs spread, reverse Trendelenburg
Access abdomen with Veress needle, left upper quadrant at midclavicular line
Additional trocars along left and right costal margins
Elevate left lobe of liver to expose lesser omentum and hiatus
Grasp stomach and pull it inferiorly and caudally
Identify and grasp Belsey’s fat pad
Incise peritoneum over left crus
Pull stomach to left and caudally
Open lesser omentum at cephalad aspect, where diaphragm and gastrophrenic ligament converge
Dissect plane behind gastroesophageal junction, exiting through opening in the left crural peritoneum
Introduce band passer into laparoscopic field and pass it through tunnel
Select appropriate size band, and similarly pass through tunnel
Have anesthesiologist inflate calibrating balloon with 25 mL of air and withdraw it, pulling stomach up against hiatus
Adjust band
Pass attached tubing through fascia
Secure hemostasis and desufflate abdomen
Place port in subcutaneous location
Secure all trocar sites
HALLMARK ANATOMIC COMPLICATIONS
Injury to esophagus or stomach
Band slippage
Band erosion into stomach
Gastric pouch dilatation
LIST OF STRUCTURES
Stomach
Esophagus
Diaphragm
Left crus
Right crus
Lesser omentum
Pars flaccida
Patient Position and Initial Dissection (Fig. 68.1)
Technical and Anatomic Points
Position the patient with legs spread. Place the operating table in reverse Trendelenburg position. Stand between the patient’s legs so that you are directly facing the operating field (Fig. 68.1A). Note how the operating room setup shown allows the surgeon (S) unobstructed access to the field. The monitors (M) should face surgeon and assistant (A) while the camera operator (CO) stands to the patient’s right side. An instrument table (IT) completes the setup.
Obtain access to the abdomen with a Veress needle inserted in the left upper quadrant at the midclavicular line. This location
generally avoids the thickest part of the pannus as well as the liver (which is often fatty and significantly enlarged in these patients). The lower costal margin helps to provide support as the needle enters the peritoneum, minimizing the chance of visceral injury.
generally avoids the thickest part of the pannus as well as the liver (which is often fatty and significantly enlarged in these patients). The lower costal margin helps to provide support as the needle enters the peritoneum, minimizing the chance of visceral injury.
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