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Laparoscopic Adjustable Gastric Banding
(LAP-BAND) |
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Surgery Technique |
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1
Positioning of the patient
The patient lies supine, thighs fully abducted and
slightly bent. The operating table has a 30º reversed Trendelenburg
tilt. The surgeon stands between the patient's legs, the first
assistant on the patient's left side and the second assistant on the
right. |
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2
Insufflation
A long Verres needle is introduced.
Intraperitoneal insufflation is carried out through the initial 10
mm cannula site placed on the xyphoumbelical line 6 finger
breadths below the xyphoid. Intra abdominal pressure is monitored
at 15 mm Hg.
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3 Placement of trocars and
instrumentation
Five trocars are placed in the following sequence:
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 a 10 mm
trocar for a 30 optical system 6 finger breadths below the xyphoid |
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 a 10 mm
trocar for the liver retractor (sub-xyphoid) |
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 a 10 mm
trocar for the grasping forceps and the Lap-Band Closure Tool (in R
upper quadrant) |
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 a 5 mm
trocar for the cautery hook, needle holder and grasping forceps (in L
upper quadrant) |
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 10 mm
trocar for the atraumatic grasping forceps for band introduction and
reservoir placement (on the L anterior axillary line below the costal
margin).
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4 Initial dissection
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anaesthetist introduces the balloon tipped naso gastric tube inside
the stomach.The anaesthetist insufflates 25 cc of fluid in the
intragastric balloon and pulls back the balloon which is blocked at
the G.E. junction. The bulge seen on the stomach allows the surgeon to
decide on the level of initial dissection. The dissection on the
lesser curvature begins at the equateur of the calibration balloon.
Once decided, this level is marked by scoring the peritoneum on the
lesser curvature with the coagulating hook.
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5 Dissection of the lesser curvature
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lesser curvature is then dissected with the coagulating hook about 2
cm caudal from the cardia. The grasping forceps coming from the R
upper quadrant grasps the gastrohepatic ligament while another
grasping forcep coming from the most lateral trocar grasps the gastric
wall. This puts the peritoneum on the lesser curvature under tension.
The dissection should be undertaken as close as possible to the
gastric wall, care being taken not to damage it, and should preserve
the nerve of Latarjet. Under direct vision the full thickness of the
hepato-gastric ligament is dissected from the gastric wall so as to
make a narrow and limited opening. The posterior gastric wall is
clearly recognizable. The dissection has to be of the same size as the
band or even less in order to prevent the band from slipping.
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6 Two ways are possible
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Above the peritoneal reflection of the bursa omentalis shown as a blue
arrow in the figure, or, b) Below the
peritoneal reflection of the bursa omentalis shown as a yellow arrow
in the figure.
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7 Dissection of the phrenogastric
ligament
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gastric fundus is pulled caudally by the grasper with the most lateral
trocar, hereby putting the phrenogastric ligament under tension. A
small window is now created in this ligament by using the coagulation
hook. Location of this second window is usually half way between the
upper pole of the spleen and the esophagus or the left side of the
left crus.
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8 Retrogastric tunnel
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Endograsp Roticulator or an Articulating Dissector is introduced into
the right upper quadrant trocar and is advanced into the retrogastric
tunnel under direct vision. The instrument is then curved and its
extremity becomes visible in the dissection area of the phreno-gastric
ligament. The coagulating hook can deal with the remaining fibrous
strings and the endograsp is advanced until it emerges above the
spleen where the diaphragm is grasped.
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9 Introduction and placement of the
LAP-BAND
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path of the most lateral 10 mm trocar a LAP-BAND (BioEnterics
Corporation, Carpinteria, California) with its tubing is introduced
intraperitoneally, grasped by the endograsp Roticulator and looped
around the stomach at the level of dissection. The tip of the tubing
is introduced in the locking area of the band. The silicone band is
tightened around the stomach.
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10 Tightening
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anaesthetist reinsufflates 15 cc in the oral gastric calibration tube
and again pulls it back until it hits the GE junction. The surgeon can
now be ascertained of the correct positioning of the band. A specific
tool for tightening of the band is now introduced through the right
upper quadrant trocar and the band is tightened and locked.
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11 Calibration of the LAP-BAND
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tip of the oral gastric calibration tube contains pressure sensors.
Saline solution is injected into the inflatable balloon of the
LAP-BAND with a syringe connected to the end of the non-kinking tube
outside the abdominal cavity. This will displace the sequential lights
on a Gastrotonometer Electronic Sensor to the right till the fourth
light is reached. The fourth light corresponds to a 12 mm stoma. This
calibration is usually achieved with 2-4 ml of saline. The tube is
double-clamped with rubber-shod clamps, and the redundant part is cut
and removed.
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12 Suture stabilisation of the LAP-BAND
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to five stitches are placed between the serosa of the stomach just
proximal and distal to the band to avoid slipping.
Finally, a posterior fixation is performed after
opening the pars flaccida of the gastro hepatic ligament, only if the
band has been placed below the peritoneal reflection of the bursa
omentalis.
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13 Placement of the Access Port
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The most lateral L port is removed, the non-kinking
tube is cut to an appropriate lenght and connected to the
injection reservoir. |
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The reservoir, is fixed with four stitches to the abdominal fascia
in the L hypocondrium. |
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Thanks to this reservoir, the size of the gastric
stoma can be adjusted by inflating the gastric band.
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14 LAP-BAND Adjustment
This adjustment is performed in the X-ray department
postoperatively. Stoma size will be adjusted depending on patient's
needs, on the weight loss curve and on the X-ray picture.
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