Adjustable Gastric Banding
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TechniquePositioning of the patient
The patient lies supine, thighs fully abducted and slightly bent. The operating table has a 30° reversed Trendelenburg tilt. The surgeon stands between the patient's legs, the first assistant to the patient's left and the second assistant to the right.
A long Verres needle is introduced above the umbilicus so as to avoid the fatty hepatic ligament. Intra-abdominal pressure is maintained at 15 mm Hg.
Placement of trocars and instrumentation
Five trocars are placed in the following sequence : a 10 mm trocar for a 30° optical system 6 fingerbreadths below the xiphoid; a 10 mm trocar for the liver retractor (subxiphoid); a 10 mm trocar for a grasping forceps and the Lap-Band Closure Tool (in right upper quadrant); a 5 mm trocar for the cautery hook, needle holder and grasping forceps (in left upper quadrant); and a 10 mm trocar for an atraumatic grasping forceps replaced later on by a 18 mm trocar for band introduction and reservoir placement (on the left anterior axillary line below the costal margin).
The anaesthetist introduces a balloon tipped naso gastric tube inside the stomach.
25 cc of fluid are injected in the intragastric balloon after which the balloon is pulled back until it 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 correct level is the equator of the bulge. This level is then marked by scoring the peritoneum on the lesser curvature with the coagulating hook.
Dissection of the lesser curvature
The lesser curvature is dissected with the coagulating hook about 2 cm distal to the GE junction. The grasping forceps coming from the right upper quadrant grasps the gastrohepatic ligament while another grasping forceps coming from the most lateral trocar grasps the gastric wall. This puts the peritoneum on the lesser curvature under tension. Dissection should be undertaken as close as possible to the gastric wall, with care being taken not to damage it, and should preserve the nerve of Latarjet. Under direct vision the full thickness of the hepatogastric ligament is dissected from the gastric wall so as to make a narrow and limited opening. The way of dissection is above the reflexion of the peritoneal sheet covering the lesser sac.
Dissection of the phrenogastric ligament
The gastric fundus is pulled distally by the grasper in the most lateral left 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.
An gastric forcep is introduced in the right upper quadrant trocar and is advanced in the retrogastric tunnel under direct vision. The instrument is then curved and its tip becomes visible in the dissection area of the phrenogastric 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.
Introduction and placement of the LASGB
The most lateral 10 mm trocar is replaced by an 18 mm cannula. A silicone band (BioEnterics, Carpinteria, California) with its tubing is introduced intraperitoneally, grasped by the grasping forceps 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.
The anaesthetist reinsufflates 15 mL in the balloon tipped nasogastric tube and again pulls it back until it hits the GE junction. The surgeon can now be certain of the correct positioning of the band. The band is tightened and locked.
Suture stabilisation of the LASGB
Four to five stitches are placed between the serosa of the stomach just proximal and distal to the band to avoid slipping.
Placement of the injection reservoir
The 18 mm port is removed, and the nonkinking tube is cut to an appropriate length and connected to the injection reservoir.
The reservoir, is burried, convex side up, and stitched to the anterior thoracic fascia overlying the costal margin to the left.
The reservoir enables adjustments of the fascia stoma by inflating the gastric band.
This adjustment is performed by a radiologist one month after surgery. Stoma size will be established depending on complications (reflux, food intolerance), on the weight loss curve and on the radiograph.