Attention is then turned to placing the band. The lesser omentum is incised over the caudate lobe of the liver. The right crus always disappears into a small fat pad, where it meets the left crus. The point of dissection is right at that fat pad. A small incision is made there with the hook. There is a beautiful plane behind the esophagus starting at that point. It is essential for the assistant to maintain the sweeping retraction of the fundus. The surgeon’s left hand grasper is then gently inserted into the small incision and passed behind the esophagus, to emerge in front of the left crus (Fig. 3), often going behind the spleen. There should be no resistance at all when the grasper is passed. If there is, it’s usually that the fundus is being inadequately retracted, or that it has not been adequately mobilized off the left crus. The key maneuver is for the surgeon to keep their left hand grasper completely horizontal. There is a natural tendency for the tip of the grasper to slide anteriorly, a tendency that should be avoided.

The tubing of the band is brought up and grasped, then drawn behind the esophagus (Fig. 4). The band is locked (Fig. 5). The end of the tubing should come across in front of the liver like a spear, going easily into its socket. The key to locking the band is to do it gently, keeping the parts in the same plane. Any rotation will cause the silicon to lock.

There are two schools of thought about band fixation, either none at all or to use gastrogastric sutures.

Martin Fried, from Prague, has advocated using no sutures. From January to September 2006, he randomized 100 patients undergoing banding to group 1 (n = 50, ≥2 imbrication sutures) or group 2 (n = 50, no imbrication sutures).

The 3-year EWL was 55.7 % ± 3.4 % and 58.1 % ± 4.1 % for groups 1 and 2, respectively. The body mass index at 3 years was 34.0 ± 5.8 kg/m² and 30.3 ± 6.4 kg/m² (range 1.2–6.2) for groups 1 and 2, respectively (P < 0.01). He found that slippage occurred in 1 patient (2.2 %) and 1 patient (2.0 %) and migration in 1 patient (2.2 %) and 1 patient (2.0 %) in groups 1 and 2, respectively (P = NS). Martin concluded that the band is effective and safe with and without imbrication sutures.

Paul Super, from Birmingham, England, has taken the opposite view. Between April 2003 and June 2007, he performed banding in 1,140 consecutive patients. He used a gastropexy suture in addition to the two routine gastro-gastro tunnel sutures in all cases. The gastropexy picks up four bites of fundus and brings it to the diaphragm near the left crus. Excess percent BMI loss in these patients at 36 months was 58.9 %. Slippage with urgent readmission occurred in one patient (0.08 %) at 5 months. Two partial slippages were noticed at 12 and 18 months, respectively.

Both these approaches have delivered great results. Our choice has been to incorporate what Paul Super does by using a 2-0 Prolene to do a gastropexy, then another to do a running gastrogastric suture over the band, stopping 1 cm from the buckle (Fig. 6). I then add another gastropexy below the band, the Patterson stitch, devised by Emma Patterson, of Portland, Oregon. It’s definitely belt and braces, but if it helps reduce slip, it’s worth it.

The tubing is then brought out through the 15 mm port and attached to the port. A small disk of mesh is sutured to the back of the port. The port is then placed on the deep fascia, where the mesh sticks and fixes the port in position.