How to Place an Adjustable Gastric Band

Column Editors: Raul J. Rosenthal, MD, FACS, FASMBS, and Daniel B. Jones, MD, MS, FACS

This month’s technique: Adjustable Gastric Banding: Part 1—How to Place an Adjustable Gastric Band

This Month’s Featured Experts:

Jaime Ponce, MD, FACS, FASMBS, Director of Bariatric Surgery, Hamilton Medical Center, Dalton, Georgia; Co-Director of Bariatric Surgery, Memorial Hospital, Chattanooga, Tennesee

Co-Author
Brooke Lindsey, RN, CBN, Bariatric Surgery Clinical Coordinator, Dalton Surgical Group, Dalton, Georgia

Introduction
History. Dr. Mitiku Belachew1 from Belgium described the first laparoscopic placement of an adjustable band in 1993. Belachew used the perigastric technique, and in 1996, Dr. Peter Forsell1 used the pars flaccida dissection. A third approach, the “two-step” (pars flaccida to perigastric progression) described in 2000 by Dr. Rudolf Weiner from Germany combined these techniques for use with an extremely large fat pad. Use of the pars flaccida technique has been shown to reduce the incidence of gastric prolapse,[1,2] and it is the most widely accepted dissection for band placement.

Technique
Patient position and trocar placement. In our approach, a five-port technique is used, with four 5mm ports and one 15mm port. The patient is placed in supine with the arms extended, in the modified lithotomy position, with the surgeon standing between the patient’s legs and all extremities well padded. An oro-gastric tube is used for gastric decompression.

A 5mm optical trocar is used to access the abdominal cavity in the left subcostal region. The position of the trocars is as follows: Trocar 1 is inserted subxiphoid in a mid-epigastric position; trocar 2, used for liver retraction, is inserted at the patient’s right subcostal margin in the mid-clavicular line; trocars 3 and 4, in an arc extending from trocar 2 toward the patient’s left; and trocar 5, laterally on the left subcostal margin (Figure 1). The aim of liver retraction is to elevate the liver away from the gastroesophageal angle and spleen, which allows safe dissection at the angle of His.

Angle of His dissection. The omentum covering the angle of His is gently swept to the side to facilitate exposure during the creation of a small incision lateral on the left side of the gastroesophageal junction within the gastrophrenic ligament; this small “window” initiates the plane of dissection for the retrocardial tunnel. Care must be taken to preserve the gastrophrenic attachments to help secure the band and maintain stability of the fundus. Fat pads surrounding the gastroesophageal junction can be excised, if needed, to expose the stomach wall or identify and repair a crural defect or hiatal hernia.

Pars flaccida dissection. In the lesser omentum (“pars flaccida”) dissection at the lesser curvature, the pars flaccida is stretched to make an incision and expose the right crus. If a large aberrant hepatic artery emanates from the left gastric artery, the “two-step” dissection can be used by creating an additional perigastric passage above the aberrant hepatic vessel and next to the lesser curvature.

The point of dissection is along the anterior border of the right crus, at its most lower aspect. This is the point of confluence of the right and left pillars of the right crus. The peritoneum is incised and an articulating blunt dissector is introduced, inserted at the incision at the right crus, and gently advanced to emerge at the angle of His incision (Figure 2). The dissector comes through the right-sided port and passes gently into this area of dissection without any torque. It then passes a very short distance behind the gastroesophageal junction to emerge into the already dissected angle of His. This critical step requires no force at all. Any resistance encountered means that the point of dissection at the right crus is too high and that the dissector is pushing into the esophagus or stomach or there is a possibility of a hiatal hernia with a posterior sliding component. In this case, the dissector should be gently withdrawn and inserted caudal to follow a new course behind the gastroesophageal junction. Once the dissector comes through the pars flaccida tunnel, it is ready to hold the band by its tubing or suture loop to pull it through.

Hiatal crural repair. The fat pad around the gastroesophageal junction is removed when ‘‘dimpling’’ of the anterior crus is noticed or if there is laxity of the right crus posteriorly. All sliding hiatal hernias are reduced with full mobilization of the distal esophagus, and repaired primarily with posterior nonabsorbable figure-of-eight sutures (Figure 3). Complete crural exposure posteriorly can be obtained with careful dissection staying cranial to the lesser sac. If no sliding component is visualized but a crural defect is noted, the anterior esophagus is mobilized and an anterior crural repair is performed for small defects or posterior dissection and repair for larger defects with elevation of the esophagus to obtain good exposure. If complete dissection of the pillars is performed, the repair will be tension free. Aggressive hiatal crural exploration and repair has been shown to potentially decrease the incidence of band reoperations for intractable reflux, prolapse, and pouch enlargement.[3,4]

Introduction and placement of band. Selection of the band size depends on the thickness of the upper stomach and perigastric fat. Most of the patients can have the smaller size of each band brand available in the United States. In our experience, the patients that usually require a larger band size are men, with higher body mass index that have thicker tissues.

Depending on the band type, preparation on the back table needs to be performed. The Lap-Band AP (Allergan, Irvine, California) requires priming with saline to aspirate the air from the system. The Realize band (Ethicon Endosurgery, Cincinatti, Ohio) only requires aspiration of the air until the balloon is emptied completely.

The band is inserted into the abdomen through the 15mm trocar. After the band is inside the abdomen, the band is pulled through the posterior esophagogastric tunnel (Figure 4). The Lap-Band (Allergan) is pulled from the end of the tubing as opposed to the Realize band (Ethicon Endosurgery), which is pulled from the suture loop attached to the band side. Sometimes the retroperitoneal tissue snags on the band, but usually slides relatively easy.

In order to lock the Lap-Band, the tubing tag is fed through the locking mechanism of the band and the band is locked. The Realize band closure is achieved by inserting the dissector through the band’s buckle opening to grasp the end flap, which is pulled through the buckle. The locked band should not be tight on the stomach but rather should be able to rotate freely around the upper stomach. If the band appears snug or does not rotate easily, the band needs to be unbuckled and more perigastric fat must be excised.

Anteriorly, a plication of the fundus below the band to the upper gastric pouch is needed. Gastrogastric suturing over the band is completed with a permanent suture material (Figure 5). The plication should be without tension to prevent any risk for band erosion. The plication begins at the greater curvature, as far to the left as possible. A curved needle is preferred to ensure secure “bites” of tissue between the seromuscular layer of the fundus and the pouch. These stitches protectively tunnelate the anterior band, except at the location of the buckle, to minimize the risk of tension and possible erosion. The band should lie without tension within the tunnel to allow for filling during the adjustments. Usually the plication can be accomplished with two or three interrupted sutures.

If there is redundant floppy fundus below the band, an additional plication suture can be placed to fix the greater curvature fundus to the more stable lesser curvature below the band. This suture needs to be placed away and below from the band to avoid constriction and tension on the band anterior gastric tunneling. The free end of the band tubing is pulled out through the 15mm port in preparation for fixation of the port system.

Summary
After a period of evolution of technique, the pars flaccida  approach has been established with the creation of a very small upper gastric pouch, primarily anteriorly, and the dissection on the lesser curvature of the stomach including the neurovascular bundle of the lesser omentum. Suture fixation of the anterior wall of the stomach, with gastrogastric sutures, is performed to stabilize the band anteriorly.

References
1.    Ponce J. Surgical implantation and adjustment technique with the Realize band system. Surg Obes Relat Dis. 2009;5:104–110.
2.    O’Brien PE, Dixon JB, Laurie C, Anderson M. A prospective randomized trial of placement of the laparoscopic adjustable gastric band: comparison of the perigastric and pars flaccida pathways. Obes Surg. 2005;15:820–826.
3.    Gulkarov I, Watterau M, Ren CJ, Fielding GA. Hiatal hernia repair at the initial laparoscopic adjustable gastric band operation reduces the need for reoperation. Surg Endosc. 2008;22:1035–1041.
4.    Ponce J, Fromm R, Paynter S. Outcomes after laparoscopic adjustable gastric band repositioning for slippage or pouch dilation. Surg Obes Relat Dis. 2006;2:627–631.

Funding: There was no funding for the preparation of this manuscript.

Disclosures: Dr. Ponce has been a consultant, proctor, and faculty member and has received research support from Allergan and Ethicon Endosurgery, Inc. Ms. Lindsey reports no conflicts of interest relevant to the content of this article.

Category: Past Articles, Surgical Pearls: Techniques in Bariatric Surgery