We are following with interest the news reports today of the Chris Christie lap band surgery. Although we are not participating in his care, some general information on what lap band or laparoscopic gastric banding and typical clinical issues to be considered is detailed below.
Lap band surgery is a commonly performed surgical operation done for the control of morbid obesity. It is best performed by experienced bariatric surgeons and is sometimes referred to as the “mini” weight loss surgery.
However, while the surgery is not as extensive as the roux-en-Y reconfiguring of the gi tract, it is a operation that is always done under general anesthesia and has a well-known complication and morbidity rate. However, the weight loss experienced by patients who undergo this procedure can be considerable ranging up to 25 BMI (kg/m2).
Kuzmak and colleagues are credited with developing the lap band technique in 1981 and its use is widespread in Europe. Generally in experienced hands it has a low operative mortality rate, but a significant complication rate, chiefly due to band migration.
Once the band has been placed, adjustments to the size of the band that obstruct the GE junction are made on an outpatient basis and are done under local anesthesia.
The benefits of lap band surgery are the avoidance of gastric resection and stapling and the ability to reverse the procedure. A disadvantage of the procedure is the high failure rate in patients that are “sweet-eaters”. In patients who consume large amounts of sugary drinks or foods, the weight loss will likely be very small and not sustained
Surgical technique for lap band surgery:
1. The patient is placed under general anesthesia and then positioned in a steep Fowler position (incline of the table with the patients legs spread apart to allow the operating surgeon to stand between the legs)
2. 5-6 trocars sites are selected in an upside down T-configuration with one in the subxiphoid area (under the lower tip of the sternum) and the rest in a horizontal line along the upper abdomen from side-to-side.
3. the trocars placed are 10-11 mm in size
4. occasionally an additional port is placed in theleft lower costal area (near the border of the left rib cage) to allow use of a Babcock grasping forcep to retract fatty tissue away from the gastrosplenic ligament (tissue between the stomach and spleen).
5.A 30 degree laparoscope is always used and is placed in the subxiphoid port
6. Once the trocars have been placed and the laparoscope inserted, the anesthesiologist places a gastric catheter with a 50 mL balloon tip that is inflated in the stomach lumen and then pulled back up to fit against the gastroesophageal junction.
7. The surgeon then scores the equator by burning a very shallow line in the tissue with a bipolar forceps
8. Sponges with radiologic markers are then used to perform blunt dissection on either side of the GE junction to clear away tissue.
9. Dissection is usually begun on the left side of the esophageal hiatus at the angle of His, which sometimes can be difficult to discern if there is a significant hiatal hernia.
10. During this blunt dissection, the assistant pulls the esophagus to the right and inferiorly.
11. The short gastric vessels must be visualized and left undisturbed
12. Dissection is continued until the left crus (edge) of the diaphragm is reached and a sponge with radiologic marker is placed to “hold” this space.
13. Traction is placed to pull the GE junction to the left and inferiorly to expose the right GE juntion
14. The gastrohepatic omentum (fatty tissue between the stomach and liver is then incised in an avascular plane (avoiding blood vessles)
15. Dissection level is best at 1.5 to 2 cm below the GE juntion but just above the left gastric artery.
16. Car emust be taken to avoid dissection in the area of any previously completed anti-reflex surgery.
17. When the right crus of the diaphragm is seen it is grasped and pulled to the surgeon’s right by an assistant and then a 2nd assistant pulls the stomach upwards and towards the liver.
18. If the free posterior gastric wall is seen this is an indication of a too low dissection plane and placement of a gastric band here will lead to band migration, an unwanted development. The optimal dissection area is the retrogastric area and not the lesser sac.
19. As the surgeon is working through the dissection in the left gastroesophageal area, periodic inspection of the sponge in the previously dissected angle of His should be used to “get a bead” on the level and direction of the dissection in the left area. This will prevent dissection too low or too high leading to entering the mediastinum.
20. Patients with large hiatal hernias or chronic esophagitis will require a cautious and gentle dissection technique while dissecting in the left GE junction area.
21. After the dissection is complete, one of the left trocars is enlarged to 18 mm and a Swedish adjustable gastric band is carefully introduced.
22. One end is then fed through the just fashioned tissue tunnel so that it can fully circle the GE junction and the SAGB is secured through its locking mechanism.
23. The locked gastric band is then tacked to the surround tissue with 5-6 sutures of 2-0 non-absorbable suture.
24. The band is left uninflated at this point and the anesthesiologist injects fluid into the esophagus to look for inadvertent lacerations or punctures of the esophagus, stomach, or GE junction.
25. The surgical site is inspected for bleeding and hemostasis is performed.
26. Typically, a small amount of topical anesthestic such as bupivacaine is placed on the surgical area to lessen post-operative pain
27. One end of the band is then grasped and pulled toward the area where the reservoir is to be formed to inflating and deflating the band, sometimes positioned at the trocar site that was expanded to facilitate introduction of the balloon
28. The reservoir is then sutured to the fascial plane using 4 stitches of 2-0 material.
29. The reservoir should produce a capacity of 15 mL minimum to effect optimal weight loss.
Leave a Reply