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1 Positioning of the patient
The patient lies supine, thighs fully abducted and slightly bent. The operating table has a 30º reversed Trendelenburg tilt. The surgeon stands between the patient's legs, the first assistant on the patient's left side and the second assistant on the right.
2 Insufflation
A long Verres needle is introduced. Intraperitoneal insufflation is carried out through the initial 10 mm cannula site placed on the xyphoumbelical line 6 finger breadths below the xyphoid. Intra abdominal pressure is monitored at 15 mm Hg.
3 Placement of trocars and instrumentation
Five trocars are placed in the following sequence:
1.-a 10 mm trocar for a 30 optical system 6 finger breadths below
2.-a 10 mm trocar for the liver retractor (sub-xyphoid)
3.-a 10 mm trocar for the grasping forceps and the Lap-Band Closure Tool (in R upper quadrant)
4.-a 5 mm trocar for the cautery hook, needle holder and grasping forceps (in L upper quadrant)
5.-10 mm trocar for the atraumatic grasping forceps for band introduction and reservoir placement (on the L anterior axillary line below the costal margin).
4 Initial dissection
The anaesthetist introduces the balloon tipped naso gastric tube inside the stomach.The anaesthetist insufflates 25 cc of fluid in the intragastric balloon and pulls back the balloon which 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 dissection on the lesser curvature begins at the equateur of the calibration balloon. Once decided, this level is marked by scoring the peritoneum on the lesser curvature with the coagulating hook.
5 Dissection of the lesser curvature
The lesser curvature is then dissected with the coagulating hook about 2 cm caudal from the cardia. The grasping forceps coming from the R upper quadrant grasps the gastrohepatic ligament while another grasping forcep coming from the most lateral trocar grasps the gastric wall. This puts the peritoneum on the lesser curvature under tension. The dissection should be undertaken as close as possible to the gastric wall, care being taken not to damage it, and should preserve the nerve of Latarjet. Under direct vision the full thickness of the hepato-gastric ligament is dissected from the gastric wall so as to make a narrow and limited opening. The posterior gastric wall is clearly recognizable. The dissection has to be of the same size as the band or even less in order to prevent the band from slipping.
6 Two ways are possible
a) Above the peritoneal reflection of the bursa omentalis shown as a blue arrow in the figure, or,
b) Below the peritoneal reflection of the bursa omentalis shown as a yellow arrow in the figure.
7 Dissection of the phrenogastric ligament
The gastric fundus is pulled caudally by the grasper with the most lateral 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.
8 Retrogastric tunnel
An Endograsp Roticulator or an Articulating Dissector is introduced into the right upper quadrant trocar and is advanced into the retrogastric tunnel under direct vision. The instrument is then curved and its extremity becomes visible in the dissection area of the phreno-gastric 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.
9 Introduction and placement of the LAP-BAND
In the path of the most lateral 10 mm trocar a LAP-BAND (BioEnterics Corporation, Carpinteria, California) with its tubing is introduced intraperitoneally, grasped by the endograsp Roticulator 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.
10 Tightening
The anaesthetist reinsufflates 15 cc in the oral gastric calibration tube and again pulls it back until it hits the GE junction. The surgeon can now be ascertained of the correct positioning of the band. A specific tool for tightening of the band is now introduced through the right upper quadrant trocar and the band is tightened and locked.
11 Calibration of the LAP-BAND
The tip of the oral gastric calibration tube contains pressure sensors. Saline solution is injected into the inflatable balloon of the LAP-BAND with a syringe connected to the end of the non-kinking tube outside the abdominal cavity. This will displace the sequential lights on a Gastrotonometer Electronic Sensor to the right till the fourth light is reached. The fourth light corresponds to a 12 mm stoma. This calibration is usually achieved with 2-4 ml of saline. The tube is double-clamped with rubber-shod clamps, and the redundant part is cut and removed.
12 Suture stabilisation of the LAP-BAND
Four to five stitches are placed between the serosa of the stomach just proximal and distal to the band to avoid slipping.
Finally, a posterior fixation is performed after opening the pars flaccida of the gastro hepatic ligament, only if the band has been placed below the peritoneal reflection of the bursa omentalis.
13 Placement of the Access Port
The most lateral L port is removed, the non-kinking tube is cut to an appropriate lenght and connected to the injection reservoir.
The reservoir, is fixed with four stitches to the abdominal fascia in the L hypocondrium.
Thanks to this reservoir, the size of the gastric stoma can be adjusted by inflating the gastric band.
14 LAP-BAND Adjustment
This adjustment is performed in the X-ray department postoperatively. Stoma size will be adjusted depending on patient's needs, on the weight loss curve and on the X-ray picture.
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