Laparoscopic Lap Band Placement 

Obesity is caused by a combination of genetics, environmental issues, and behavioral factors.^{[1, 2, 3]} Consumption of high-calorie foods, consumption of too much food, and a sedentary lifestyle all work together to create this condition. Obesity is associated with the development of diabetes mellitus, hypertension, dyslipidemia, arthritis, sleep apnea, cholelithiasis, cardiovascular disease, and cancer.

More than 100 million Americans (65% of the adult population) are overweight.^[2] Obesity is the second-leading cause of preventable death in the United States after smoking. Obesity-related diseases account for 400,000 premature deaths each year.^[2]

Obesity can be treated medically and surgically. Medical treatment for obesity is difficult, because the amount of weight lost is small and patients tend to regain most of the weight.^[1] A 2010 prospective, randomized controlled trial in 50 adolescents demonstrated that a greater percentage of patients achieved a loss of 50% of excess weight with laparoscopic gastric banding than with lifestyle intervention.^[4] Operations that are designed to cause significant and long-lasting weight loss in patients who are severely obese are termed bariatric surgery. The term bariatric surgery is derived from the Greek words baros (weight) and iatreia (medical treatment). Laparoscopic lap band placement, described here, is one such surgery. For information on gastric bypass (another form of bariatric surgery), see eMedicine article Laparoscopic Gastric Bypass.

Body mass index (BMI) describes relative weight for height and correlates significantly with an individual’s total body fat.^[3] BMI is based on height and weight and applies to adults of both sexes. BMI is calculated as follows: BMI equals weight in kg/height in m² or weight in lb/height in square inches.^{[5, 2]}

In 1991, the National Institutes of Health (NIH) provided a consensus statement for selecting bariatric surgery candidates.^[5] Patients were considered candidates for surgery if they met one of the following criteria:

• Body mass index (BMI) >40
• BMI of 35-40 plus one of the following obesity-associated comorbidities:

  • Severe diabetes mellitus
  • Pickwickian syndrome
  • Obesity-related cardiomyopathy
  • Severe sleep apnea
  • Osteoarthritis interfering with lifestyle

To be candidates for bariatric surgery, patients should have attempted, without success, to lose an appropriate amount of weight through supervised diet changes.^[1] Patients must also comply with postoperative diet and exercise.

• History of substance abuse
• An active major psychiatric disorder
• End-stage organ disease (eg, cardiac, liver, pulmonary)

• General anesthesia is required for this procedure.

Laparoscopic instrument tray that includes the following:

• Grasper
• Dissector
• Lap-band device
• Sutures
• Different length and sizes of trocars
• Nathanson liver retractor

• Patient is placed in the lithotomy position with all of the stress points comfortably padded.

Preparation

• The patient is placed in the lithotomy position. The surgeon stands between the patient’s legs or on the patient’s right side, and the first assistant stands on the left side of the patient and holds the camera.
• The surgeon should be standing comfortably with arms and elbows in an abducted position. Prior to starting the case, the surgeon should adjust the monitors to eye level.
• The trocars should be positioned at least a fist length apart. This allows the surgeon to comfortably use both hands.
• Check the balloon of the lap band prior to placing it to avoid placing a defective band.
• The gastrogastric sutures are over the band to hold it in position.

Technique

• The patient is placed in lithotomy position with the trocars as shown.
• The abdomen is entered under direct visualization by placing a 5-mm port with a 30-degree lens.
• A 15-mm trocar and a 10-mm trocar are placed as working points.
• A 5-mm first assistant port and a Nathanson retractor to elevate the left lateral segment of liver are placed as shown.
• The dissection begins with a gentle blunt release of gastrophrenic attachments at the angle of His.
• The gastrohepatic window is entered, and dissection at the right crus is performed to create a retrogastric tunnel.
• A lap band of appropriate size is introduced through the 15-mm trocar. The tubing is grasped by the grasper, retracted through the retrogastric tunnel, and is locked into position anteriorly.
• Three gastrogastric sutures are placed to create a sleeve around the band.
• An additional gastrogastric suture is placed below the band.
• The tubing is exteriorized and connected to a port, which is secured to the abdominal wall fascia.
• The Nathanson retractor and the trocars are removed, and incisions are closed in standard fashion, as shown below.

  Technique for laparoscopic lap band placement.

• A preoperative liquid diet seems to help decrease the size of the liver.

• Infection
• Bleeding
• Pouch enlargement
• Band slippage
• Band erosion
• Dilated esophagus
• Vomiting
• Heartburn
• Perforation of stomach
• Injury to spleen
• Mechanical device failure
• Mortality rate of 0.08%