Morbid obesity surgery: laparoscopic gastric banding

The description of morbid obesity surgery: laparoscopic gastric banding covers all aspects of the surgical procedure used for the management of morbid obesity. Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: creation of pneumoperitoneum, trocar placement, Instruments, exposure, retrogastric tunnel, dissection/variation, intraoperative complications, band fixation, fixation/reservoir, postoperative period, band calibration. Consequently, this operating technique is well standardized for the management of this condition.

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MORBID   OBESITY   SURGERY:   LAPAROSCOPIC   GASTRIC   BANDING

Authors
Abstract
The description of morbid obesity surgery: laparoscopic gastric banding covers all aspects of the surgical procedure used for the management of morbid obesity.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: creation of pneumoperitoneum, trocar placement, Instruments, exposure, retrogastric tunnel, dissection/variation, intraoperative complications, band fixation, fixation/reservoir, postoperative period, band calibration.
Consequently, this operating technique is well standardized for the management of this condition.
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2001-04
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E-publication
WeBSurg.com, Apr 2001;1(04).
URL: http://www.websurg.com/doi-ot02en174.htm

MORBID   OBESITY   SURGERY:   LAPAROSCOPIC   GASTRIC   BANDING

1. Introduction
Gastric banding is a restrictive procedure (Belachew et al., Surg Endosc 1994;8:1354-6; Cadiere et al., Br J Surg 1994;81:1524; Forsell et al., Obes Surg 1997;7:345-51). It involves the creation of an “hourglass” type partition of the stomach, with a superior portion extremely limited in volume (15 mL).
The open surgical method was simultaneously described by Molina in the United States and by Kolle in Norway. Kuzmak, in New Jersey, developed a gastric band adjustable by insufflation.
In the early nineties, two gastric banding systems adapted for the laparoscopic technique were developed:
- the “Adjustable Silicone Gastric Banding System” (ASGBS);
- the “Swedish Adjustable Gastric Banding” (SAGB).
2. Anatomy
• Dissection principles
The adjustable gastric band is placed around the superior portion of the stomach, near the esophageal hiatus, leaving a 15 mL pouch.
Gastric serosa:
Dissection is performed in contact with the gastric serosa. It is begun in the pars condensa of the lesser omentum and continues in the loose fatty tissue behind the stomach. This creates a retrogastric tunnel that opens at the medial aspect of the gastrophrenic ligament.

Crura:
Dissection is performed in contact with the crura. It is begun right after the opening of the inferior part of the lesser omentum by incision of the peritoneum anterior to the right crus. A tunnel is created in contact with the crura, thereby allowing for a posterior gastric pathway.
1. Lesser omentum
2. Voluminous liver
3. Esophageal hiatus
4. Diaphragm
5. Spleen
6. Right crus
7. Left crus
8. Inflatable gastric band
• Posterior dissection
1. Gastrophrenic ligament
2. Loose areolar retrogastric tissue
3. Omental bursa
4. Retrogastric tunnel
3. Indications
Indications
- Body Mass Index (BMI: weight in kg/height in m2) greater than 40;
- BMI between 35 and 40 associated with severe comorbidity (high blood pressure, diabetes mellitus, rheumatoid pathology) according to the National Institute of Health Consensus Conference, 1991.

Absolute contraindications
- BMI less than 35;
- unable to tolerate general anesthesia;
- pregnancy;
- severe mental illness.

Relative contraindications
- previous upper abdominal laparotomy;
- hiatal hernia.
4. Preop period
Blood test
- full blood count;
- thyroid hormones;
- serum cortisol;
- serum cholesterol;
- serum triglycerides.

Contrast swallow:
- search for evidence of a hiatal hernia, which, if voluminous, could contraindicate the placement of a gastric band

Ultrasound of the abdomen:
- search for cholelithiasis, which may necessitate cholecystectomy along with the placement of a gastric band

Cardiovascular assessment:
- exclude any contraindication to anesthesia.

Psychiatric assessment:
- exclude abnormalities that would be a contraindication to limited food intake

Endocrine assessment:
- exclude endocrine abnormalities leading to morbid obesity

Echocardiography:
- assess left ventricle ejection fraction

Dental assessment:
Gastric banding does not permit the intake of unchewed food, and therefore requires a dentition in perfect condition. In addition, a dental abscess can lead to the development of band infection.
5. Operating room set-up
• Patient
- supine position with both legs abducted;
- thighs slightly bent at the hips in order to have the patient in a “half-standing” position;
- both arms at right angles;
- reverse Trendelenburg position: to be prevented from slipping, the patient must be attached to the table using adhesive strips combined with a mechanical device supporting the perineum (45° tilt test);
- foot rests are required;
- the various contact zones are carefully checked and padded to avoid nerve and arterial compression or pressure sores.
1. Perineal support
2. Adhesive strips
3. Contact zones
4. Tilt test
• Team
1. The surgeon stands between the patient’s legs.
2. The first assistant stands on the patient’s right.
3. The second assistant sits on the patient’s left holding the video camera.
4. The scrub nurse stands on the surgeon’s right.
• Equipment
1. Operating table: conventional operating tables can accommodate a weight of 140 to 170 kg. Beyond this, a special wider table must be used.
2. Anesthetic equipment
3. Laparoscopic video unit
4. Two high-resolution monitors
5. Electrocautery device
6. Creation/pneumoperitoneum
• Pneumoperitoneum
The thickness of the subcutaneous fat and the weight of the abdominal wall make the peritoneal cavity difficult to enter. The first trocar should be introduced under direct vision before insufflation. The optical trocar is the first one, which is introduced a hand’s breadth below the xiphoid process.
Some authors use either the Veress needle, either the Palmer needle introduced in a blind fashion in different places of the abdominal cavity.
1. Veress needle
• Trocar introduction
A hand’s breadth below the xiphoid process:
We choose to introduce it a hand’s breadth below the xiphoid process where the optical trocar will be introduced.
The main difficulty in this region is the presence of a large, fatty, well-vascularized round ligament.
Note: An open laparoscopic approach is difficult due to the thickness of the subcutaneous fat. It is possible, but a large skin incision will be needed.
1. Xiphoid process
• Insufflation technique
When insufflation is done with a Veress or Palmer needle, the insufflation pressure is increased at the beginning of the procedure from 14 to 16 mm Hg and the abdominal wall is pulled up in order to enable the penetration of gas.
The anesthesiologist is warned against the increase in inflation pressure and monitors the capnograph. When a stable pneumoperitoneum is obtained, the first trocar (i.e. optical trocar) can be introduced. At this stage, pressure is decreased to between 12 and 14 mm Hg.
1. Placement of optical trocar
• Variation 1
Other approach: via the umbilicus
This site is often used in laparoscopy. The risk of hernia is very high. This site also allows for extensive stretching, thus making it possible to retract the wall as far as possible from the organs.
1. Umbilicus
• Variation 2
Other approach: in the left quadrant
This is also a favored site in laparoscopy.
Safety maneuvers (air injection, aspiration, infusion of saline) are impaired in obese patients either by the presence of an often fatty omentum or by an enlarged left lobe of the liver.
1. Left quadrant
7. Trocar placement
• Trocar placement
• Principles
Trocar placement is of paramount importance in the procedure due to the thickness of the abdominal wall and the depth of the surgical field.
This technique is usually performed with 5 trocars.
A: 12 mm optical
B: 5 mm operating
C: 5 mm operating
D: 5 mm liver retractor
E: 5 mm stomach retractor
• Insertion angle
The trocar insertion angle is critical. The trocar must be directed toward the hiatal region.
In very obese patients, correct insertion of the trocar is especially important. If the trocar is poorly aligned, the thickness of the abdominal wall exerts a force, which prevents the surgeon from rectifying its direction and results in a constant struggle.
• Optical
The position of the umbilicus varies depending on the patient’s degree of obesity. Therefore, the position of the optical trocar is chosen with the xiphoid process as the anatomical landmark.
This first trocar is placed a hand’s breadth below the xiphoid process slightly to the left of the midline to keep from passing through the round ligament.
If the round ligament is entered along its center, a long trocar must be placed in order to avoid soiling the laparoscope each time it is introduced.
1. Round ligament
2. Epigastric vessels
• Reverse Trendelenburg
The patient is then placed in reverse Trendelenburg position, causing the organs to descend and freeing the operative field in the upper part of the abdomen.
• Retractors and operators
The other trocars are then introduced under visual control according to conventional rules: they are placed in a curve with the hiatal region as its center.
D: Liver retractor
E: Stomach retractor
B and C: Operating trocars
• Variation
This technique may be performed using four trocars:
Optical trocar A: 12 mm (a hand’s breadth below the umbilicus)
Operating trocar B: 5 mm (on the right anterior axillary line)
Operating trocar C: 12 mm (on the midclavicular line): scissors, grasper, needle-holder, bipolar grasper, suction device. It will be replaced by an 18 mm trocar, which allows for introduction of the band into the abdominal cavity.
Retractor trocar D: 12 mm (below the xiphoid appendix)
8. Instruments
• Trocar introduction
Early in our experience, we introduced a third operating trocar (F).
A: Laparoscope
B: Grasper
C: Hook dissector, bipolar grasper, scissors, suction-irrigation device
D: Liver retractor
E: Stomach retractor (grasper)
F: Grasper, suction-irrigation device
• Trocar functions
• Optical
A: 12 mm optical trocar for a 0° or 30° laparoscope
1. 0° laparoscope OR… 2. 30° laparoscope
• Operating
B and C: two 5 mm operating trocars for the following instruments:
B: Grasper
C: Hook dissector, scissors, bipolar grasper, suction-irrigation device
1. Grasper
2. Hook dissector
3. Bipolar grasper
4. Suction-irrigation device
5. Scissors
• Retractors
D and E: Two 5 mm retractor trocars for the following instruments:
D: Circular liver retractor OR… fan liver retractor
E: Stomach retractor (grasper)
1. Circular liver retractor OR… fan liver retractor
2. Grasper
• Optional
F: Optional 5 mm trocar for the following instruments:
F: Grasper, suction-irrigation device
1. Grasper
2. Suction-irrigation device
• Operating trocar
Operating trocar for the gastric band:
One of the operating trocars is replaced with a 15 mm trocar after dissection of the retrogastric tunnel, in order to insert the band (all the other non-optical trocars are 5 mm trocars).
1. 5 mm trocar replaced by a 15 mm trocar
9. Major principles
1) Gastric restriction procedure, with preservation of the anatomy
2) Fashioning of a retrogastric tunnel to encircle the stomach with an inflatable silicone band. The tunnel runs either in contact with the gastric wall or immediately anterior to the crura.
3) Partitioning the stomach into two parts: one 15 mL part for food intake and the remaining part for digestive purposes
4) Fixation of the band by suturing stomach over it. The stomach may also be sutured on its left, right, and middle parts to the diaphragm, right crus and stomach respectively.
5) Avoid passage of the band into the omental bursa with the risk of band migration
10. Exposure
• Note
Because of the size of the left lobe of the liver and of the omentum, retraction plays a fundamental role.
The liver is more voluminous in women, and the omentum is more developed in men.
• Retracting the liver
The left lobe of the liver is retracted cephalad and laterally to visualize the hiatal opening.
This must be performed carefully: the contact area of the liver must be large in order to avoid rupture of the liver’s fibrous capsule.
Liver injuries are rarely deep, but the bleeding impairs the visualization of the operative field and absorbs part of the light intensity.
• Greater curvature
The exposure is completed by retracting the upper part of the greater curvature of the stomach using a grasper introduced through trocar E.
11. Retrogastric tunnel
• Dissection
• Principles
The retrogastric tunnel is created using a hook, scissors or grasper. A bipolar grasper should be available.
The retrogastric space is traversed by small blood vessels, which can rapidly flood the operative field in case of injury. Even the slightest hemorrhage makes dissection difficult and increases the danger of damage to the posterior gastric wall.
A grasper is left in the retrogastric tunnel during preparation of the band.
• Start of dissection
Determining where to start dissection:
The anesthesiologist introduces a balloon-tipped gastric tube into the upper stomach.
The balloon is inflated to 25 mL and the tube is pulled back cautiously until it catches at cardia level.

The equator of the balloon is the landmark for starting the dissection of the retrogastric tunnel.
1. Balloon
2. Equator of the balloon
3. Initiation of dissection
• Dissection plane
Determining the dissection plane:
The correct plane of dissection is flush against the stomach wall. The retrogastric tunnel must be made as small as possible.
1. Posterior gastric wall
2. Retrogastric tunnel
• Retrogastric tunnel
Creating the retrogastric tunnel:
The tunnel courses anteriorly and to the left of the left crus of the diaphragm.
Care must be taken when opening the peritoneum on the left in order to avoid splenic injuries. The left part of the gastrophrenic ligament can be dissected initially; this simplifies the opening of the peritoneum.
1. Incision in the lesser omentum
2. Retracting the stomach
3. Pars condensa
4. Left crus
5. Left peritoneum
6. Posterior window
• Dangers
• 1
Passage into the mediastinum
If the tunnel is directed too vertically, the dissecting instrument may enter the hiatal opening and penetrate the mediastinum, with the risk of rupture into the pleural cavity.
1. Correct route
2. Into the mediastinum
• 2
Opening of the omental bursa
If the tunnel is directed too horizontally or too low, the dissecting instrument may enter the omental bursa. Posterior fixation of the band to avoid slippage of the posterior gastric wall through the band is required in this case.
1. Correct route
2. Into the omental bursa
12. Dissection/variation
• Principles
The retrogastric tunnel is created using a hook, scissors or grasper. Bipolar forceps should be available.
The retrogastric space is traversed by small blood vessels, which can rapidly flood the operative field in case of injury. Even the slightest hemorrhage makes dissection difficult and increases the danger of damage to the posterior gastric wall.
A grasper is left in the retrogastric tunnel during preparation of the band.
• Start of dissection
Determining where to start dissection:
Once the inferior part of the lesser omentum has been opened, the right crus is exposed by retracting the stomach to the left. Dissection is begun at the medial and inferior part of the right crus by opening the peritoneum.
1. Right crus
• Retrogastric tunnel
Creating the retrogastric tunnel:
The retrogastric tunnel is created in contact with the crura using two graspers to progressively push away the tissues. The tunnel is continued until the left side of the gastrophrenic ligament is reached. This structure is opened. It may also be dissected and opened prior to creation of the retrogastric tunnel. Dissection should be cautiously performed to avoid splenic injuries when opening the left gastrophrenic ligament. As dissection is performed at a distance of the stomach, there is little risk of opening the omental bursa.
1. Retrogastric tunnel
2. Left window
3. Grasper left in retrogastric tunnel
13. Intraop complications
Hemorrhage:
- in dissecting the retrogastric tunnel;
- injury of the short gastric vessels;
- injury of the spleen.

Gastric perforation:
- dissection of the stomach wall.
14. Band fixation
• Material
1. Syringe and saline
2. Stopper
3. Balloon
4. Reservoir and fixation suture
• Band preparation
• Technique
The band is prepared by flushing air from the balloon and the catheter. When the system is flushed, a stopper is inserted in the tip of the catheter to obstruct it and allow for easy handling of the device when introducing it in the retrogastric tunnel.
A 15 mm trocar replaces trocar C. The band is inserted into the abdominal cavity via this trocar.
1. Flushing
2. Stopper
• Positioning the band
The tip of the catheter is drawn into the retrogastric tunnel, whereafter the whole of the band is slipped through this tunnel. The band is then loosely closed (closure on position 1).
1. Closure on position 1
• Pouch calibration
The balloon of the gastric tube is once again inflated, but to only 15 mL. It is positioned just below the cardia, creating a 15 mL upper gastric pouch.
The band is closed completely, below the balloon. Closure of the band can be performed using specific ancillary instrumentation, requiring the introduction of a 10 mm trocar in the right upper quadrant, or using two atraumatic graspers.
• Band fixation
The band is fixed with 3 or 4 stitches, approximating the stomach wall below and above the band. This fixation prevents slippage of the stomach wall through the band.
1. Gastric muff
• Variation
The band may be fixed using three stitches:
- one stitch fixing the stomach to the left diaphragm;
- one stitch fixing the stomach to the right crus;
- one gastro-gastric stitch.
1. Fixation to the right crus
2. Fixation to the left diaphragm
3. Gastric muff
15. Fixation/reservoir
• Note
When the band is encircled by its gastric muff, the liver retractor and the trocars are removed under visual control. The remaining operative steps are performed without laparoscopy.
As illustrated, the reservoir should now be fixed to the fascia.
1. Catheter
2. Reservoir
3. Closure of the opening
• Fixation of the reservoir
The tip of the catheter is removed from the abdominal cavity via the 15 mm trocar opening.
The stopper initially used to block the catheter is removed.
The reservoir is fixed onto the catheter, taking care not to introduce air into the device.
1. Catheter
2. Reservoir
3. Fixation sutures
• Subcutaneous positioning
Subcutaneous positioning of the reservoir:
The 15 mm trocar opening is enlarged at the level of the skin incision to allow for the positioning of the reservoir.
1. Reservoir
• Fascial fixation
Fixation of the reservoir with four fascial stitches must be done carefully to avoid a rotation, which would preclude puncture of the reservoir, requiring re-operation to fix it again.
Ideally, trocar openings of over 5 mm should be sutured at the level of the aponeurosis. This is difficult in obese patients, however.
1. External oblique aponeurosis
2. Sutured aponeurosis
3. Fixation sutures
16. Postop period
A nasogastric tube can be left in place for the first 24 hours to prevent acute gastric dilatation, which may induce gastric necrosis. This can be difficult to diagnose.

The day after the procedure, a water-soluble contrast examination is performed to confirm:
- good band position;
- absence of gastric perforation.

Once this examination has been performed, the patient can progressively return to normal drinking and eating. For the first few days, food is mixed with fluids to prevent early bolus obstruction. The patient can then resume a normal diet, with the recommendation to chew adequately.

The patient usually leaves the hospital 48 to 72 hours after the procedure.

Follow-up is performed at one week, when sutures are also removed.
17. Band calibration
• Calibration
Band calibration must not be performed until the third postoperative week to allow for proper healing of the entire cardia region. The scarring process ensures firm positioning of the band and prevents any slippage of the stomach through the band.
1. Saline
2. Reservoir
• Adjustment
Adjustment of the band is performed under radiological control to monitor the passage of contrast through the band as it varies depending on the band’s degree of insufflation.
This adjustment is performed each time the patient mentions a decrease in the feeling of satiety.
1. Non-calibrated band
2. Calibrated band
3. Contrast agent
4. Feeling of non-satiety
5. Feeling of satiety