Eric J. DeMaria and Rifat Latifi Background
Gastric banding has been promoted as a treatment for obesity by many surgeons over recent decades. Advantages included technical ease of performing the procedure and no intestinal anastomosis with the added risks of anastomotic leak. The most popular banding procedure is the vertical-banded gastroplasty, however this involves creation of a gastric staple line with risks of staple line disruption. Gastric banding involves creating a gastric pouch by encircling the stomach with some type of material such as dacron, silastic, etc. in order to create a narrowed efferent tract. Possible complications of this procedure are erosion of the band material into the stomach lumen and intractable postoperative vomiting, if the patient does not follow dietary recommendations including eating slowly and careful chewing of food before swallowing.
Laparoscopic adjustable silicone gastric banding (LASGB) is a relatively new surgical procedure for the treatment of morbid obesity. The LASGB device (Fig. 7.1) clearly has advantages over other forms of gastric banding since there is a lower risk of eroding the gastric wall and the vomiting is not as prevalent. The device encircles the proximal stomach and is connected by tubing to a reservoir implanted and secured to the abdominal fascia in the patient's upper abdomen which can be accessed via a needle to inflate or deflate the band device. Thus, if vomiting develops as a result of band tightening in pursuit of weight loss, it may be relieved by band deflation should dietary counseling fail to alleviate the symptoms, avoiding reoperation. The LASGB procedure is clearly an easier laparoscopic procedure than laparoscopic gastric bypass.
Patient's Positioning and Trocar Placement
The laparoscopic adjustable band procedure is performed using a variety of techniques that share some common features.
Many surgeons place the patient in lithotomy position and stand between the patient's legs using trocars inserted in the left upper abdomen to perform the procedure. This is facilitated by placing a zero degree viewing laparoscope in a subxiphoid position to visualize the proximal stomach, to avoid the constant instrument
'conflicts' created by a supra-umbilical placement adjacent to the surgeon's working port sites. While ergonomically correct, lithotomy is a difficult and awkward position entailing some risk to the morbidly obese patient.
Subsequent experience performing laparoscopic procedures in the morbidly obese has proven that it is possible to perform such procedures with the patient in a supine position with the surgeon working from the patient's right side with the assistant in the left side. For this we place the patient's right arm to his side with careful padding for protection to allow the surgeon flexibility in his/her positioning. In general, port insertion is similar to that of laparoscopic Nissen fundoplication. Retraction of the of the liver and exposure of the proximal stomach is achieved by Nathanson liver retractor, which is placed through a subxiphoid puncture, and which is anchored to the table using a rigid arm.
Steep reverse Trendelenburg positioning is required in the morbidly obese patient as a significant amount of intra-abdominal fat may obscure visualization of the proximal stomach, particularly omentum hanging from the greater curvature of the stomach. Occasionally we have placed a long suture through the superior-most 'tongue' of fat and brought it out through a left lateral trocar in order to facilitate this retraction. In order to safely tilt the OR table into such steep positions, a foot board must be placed and the legs and feet securely positioned and padded for protection to prevent the disastrous consequences of an obese patient sliding off the end of the table.
The dissection is begun high on the lesser curvature of the stomach. The location of the dissection is critical in order to create an appropriately small proximal gastric pouch above the band. To aid in choosing the appropriate site for dissection, a balloon catheter (BioEnterics, Corp, Carpinteria, California) is advanced into the stomach, inflated with 25 ml of saline, and withdrawn until it becomes lodged at the gastroesophageal junction. The balloon is easily visualized laparoscopically within the gastric lumen. The site for dissection is at the balloon's equator with the goal of creating a 15 ml pouch. Initially, the peritoneum overlying the angle of His above the short gastric vessels is opened. Lesser curvature dissection proceeding behind the proximal stomach is the most difficult part of the procedure. The goal is to create a tunnel behind the stomach without entry into the free retrogastric space of the lesser sac. We believe that positioning of the band within this posterior tissue decreases the risk of posterior gastric herniation through the band, which results if the band is placed lower in the free space. For this reason we fix the band in position posteriorly with sutures in the event the lesser sac is entered during the dissection. The retrogastric tunnel should optimally be slightly larger in diameter than the band device itself. Dissection should follow alongside the shiny white tissue of the posterior stomach until the angle of His is reached laterally. A special retractor or reticulating grasper is then introduced into this retrogastric tunnel from the lesser curvature side of the stomach and extended so that the tip of the instrument is easily visualized laterally.
The band device itself is then placed into the peritoneal cavity through the 15 mm port with the tail of the band device introduced first attached to a grasper. The tubing of the band is then threaded through the port followed ultimately by inserting the inflatable band using a grasper attached to the plastic buckle. The band's tail is grasped internally and delivered to the reticulating instrument that is used to pull the band into position behind the stomach. Care must be taken to avoid tying a knot in the long tubing while the band is delivered into position.
Band closure is accomplished by inserting the band's tail into the buckle and pulling it through until the locking mechanism engages (Fig. 7.2). A closing tool facilitates this maneuver. The band must be correctly positioned at the moment of closure such that an appropriately small gastric pouch is created. A balloon catheter connected to a pressure sensor (Gastrostenometer, BioEnterics, CA) which registered the band closure tension facilitated this placement, but proved to be unnecessary with additional experience. The band is optimally closed against the inferior rim of the inflated 15 ml balloon.
Once the band is closed in position, three to four anterior gastro-gastric sutures are placed in the stomach proximal and distal to the band to secure it anteriorly and decrease the risk of anterior gastric herniation (Fig. 7.3). The band reservoir is left empty to decrease the early postoperative risk of vomiting which may increase the risk of early herniation. The device's tail is removed and the subcutaneous reservoir attached to the tubing, brought out through the left mid abdomen (15 mm port site). The reservoir port is anchored securely to the anterior abdominal fascia of the
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