Laparoscopic Gastric Banding
Preparation for surgery
Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient have been formulated by the American Society for Metabolic and Bariatric Surgery. [16] A preoperative low-calorie diet seems to help decrease the size of the liver. Care should be taken to ensure that the patient is kept well hydrated.
Operative details
The abdomen is entered under direct visualization by placing a 5-mm port with a 30º lens. A 15-mm trocar and a 5-mm trocar are placed as working points. A 5-mm first assistant port and a Nathanson retractor to elevate the left lateral section of the liver are placed (see the video below). The trocars should be positioned at least a fist-length apart; this allows the surgeon to use both hands comfortably.
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 band of appropriate size is introduced through the 15-mm trocar. Before insertion, the balloon of the device should be checked to avoid placement of a defective band. When the band is in place, the tubing is grasped by the grasper, retracted through the retrogastric tunnel, and locked into position anteriorly. Three gastrogastric sutures are placed to create a gastrogastric plication around the band and hold it in position. 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 under direct visualization, and incisions are closed in standard fashion.
Complications
Complications of laparoscopic gastric banding include the following:
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Infection
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Bleeding
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Pouch enlargement
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Band slippage [17]
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Band erosion [18]
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Dilated esophagus
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Vomiting
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Heartburn
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Perforation of stomach
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Injury to spleen
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Mechanical device failure
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Mortality of 0.08%
A systematic review and meta-analysis by Majdoubeh et al suggested that symptomatic hiatal hernia could be a direct complication of gastric banding; further research would be required to confirm a causal relation and define the mechanism. [19]
In a retrospective review of 156 patients who underwent laparoscopic adjustable gastric banding over a 4-year period, Papadimitriou et al reported an overall complication rate of 15.4% and a major complication rate of 3.2%. [20] The authors noted that the procedure carried certain complications even when performed by a surgeon experienced in laparoscopic surgery. Subset analysis suggested that the learning curve for laparoscopic gastric banding is at least 50 procedures.
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Technique for laparoscopic gastric banding.
