Step 1: Surgical Anatomy
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The gastric band is placed at the upper portion of the stomach just distal to the gastroesophageal junction, at around the level of the first or second vein on the lesser curve of the stomach.
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In order to access this area of the abdomen, the left lobe of the liver must be retracted anteriorly throughout the procedure.
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The base of the crura can be identified by opening the clear area of the gastrohepatic omentum and retracting the lesser curve of the stomach laterally.
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The angle of His can be identified along the left crus. The omental fat at the fundus of the stomach is retracted caudally, and the fundus is retracted medially to identify the angle and the left crus.
Step 2: Preoperative Considerations
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The patient’s height and weight should be measured accurately in the office by the surgeon to determine the patient’s body mass index (BMI). The patient’s BMI should fall within the NIH guidelines for weight loss surgery. The BMI should be greater than 40 kg/m 2 or ≤35 kg/m 2 with a comorbidity.
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Patients should undergo psychologic evaluation to rule out a binge eating disorder. The psychologist/psychiatrist can also help assess the patient’s readiness for surgery and determine if the patient has realistic expectations from the surgery. The patient should have a nutritional evaluation and a thorough medical evaluation prior to surgery.
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All patients should be asked to stop smoking prior to any weight loss procedure. Smoking will impede healing and increase the risk of perioperative pulmonary complications. Furthermore, smoking is currently the number one cause of preventable death. There is no indication to correct the second cause, obesity, if the first one will already result in early mortality.
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The patient should be well educated about the dietary and lifestyle changes that will be required for successful, sustained weight loss. The patient should know and prepare for the modified diet he or she will follow after the surgery. Patients are counseled on how to incorporate exercise into his or her daily schedules to achieve 1 hour of exercise 5 to 7 days per week.
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It is helpful to advise the patient to lose weight prior to surgery to help facilitate the operative procedure. One option is to require patients to lose 10 lbs and to place them on a liquid diet for 2 weeks prior to the surgery. This helps to shrink the visceral fat and particularly the fatty deposits within the liver.
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The patient should be evaluated for the presence of a hiatal hernia preoperatively to adequately prepare for the procedure. If a moderate to large hiatal hernia (>2 cm) is present, consider repairing it at the time of placement of the band.
Step 3: Operative Steps
1.
Room Setup ( Figure 21-1 )
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The patient is positioned supine on the bed. The feet are secured to a footboard, and both arms are left out. Care should be taken to be sure the arms are well padded to avoid a brachial plexus injury. The feet should be positioned flat on the footboard and secured so that they cannot supinate or pronate.
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The surgeon stands to the right side of the patient. The assistant stands to the left of the patient and will also operate the camera.
2.
Port Placement ( Figure 21-1 )
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The patient’s prior surgical history should be assessed prior to port placement. If the patient has no prior history of surgery in the left upper quadrant, then this area is used as the point of initial entry. An optical trocar is used to enter the peritoneal cavity under direct visualization. Due to the thickness of the abdominal wall, a direct Hasson approach with a cut-down may be challenging.
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Measurement is made 12 cm from the xiphoid process in the midline and the point lateral to this, and just medial to the midclavicular line in the left upper quadrant is used for the initial 10-mm port. A #11 blade is used to make a 1-cm incision, and the trocar is inserted. The abdomen is then insufflated with CO 2 to 15 mm Hg.
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Three additional trocars are placed. A 15-mm bladeless trocar is placed under direct visualization just to the right of midline lateral to the previously marked point 12 cm below the xiphoid. This trocar is placed at an angle so that it comes through the base of the falciform ligament.
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The remaining two trocars are 5 mm. One is placed in the anterior axillary line just below the left costal margin for the assistant. The other is placed in the right upper quadrant off of the tip of the right lobe of the liver for the surgeon’s left hand. This port may need to be placed slightly more medially depending on the size of the patient. This positioning of the trocar will be in direct line of the dissection plane posterior to the stomach. The graspers should be able to reach the left upper quadrant comfortably. Both are placed under direct visualization after anesthetizing the area with 0.5% bupivacaine (Marcaine). ( Figure 21-1 )
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Finally a Nathanson retractor is placed to elevate the left lobe of the liver and expose the gastroesophageal junction. A small incision is made just to the left of xiphoid, and the obturator for a 5-mm trocar is placed perpendicular to the skin toward the level of the peritoneum but not through the peritoneum. Then, through the same tract, the Nathanson retractor is passed and manipulated into place below the left lobe of the liver. This retractor is held in place using a self-retaining mechanical arm affixed to the left side of the patient’s bed. ( Figure 21-2 )
