Single Incision Laparoscopic Surgical (SILS) Placement of an Adjustable Gastric Band

Contributors: Melissa Beitner and George Fielding

This video shows a single incision laparoscopic surgical placement of an adjustable gastric band.

DOI: https://doi.org/10.17797/jdzx4zu6s8

Single incision laparoscopic surgical placement of an adjustable gastric band.
Morbid obesity with a BMI of >40kg/m2 or >30kg/m2 with significant obesity-related comorbidities.
Patients unable to tolerate general anesthesia, significant history of open abdominal surgery, previous ventral hernia repair with mesh, severe portal hypertension, previous fundoplication and patients who do not meet NIH criteria for bariatric surgery.
The patient is placed supine on the operating room table with both arms out. Pressure points are padded. Sequential compression boots are placed and subcutaneous heparin and antibiotics are administered prophylactically. An orogastric tube is placed for gastric decompression. The surgeon stands on the patient���¢s right and first assistant on the left. Prior to commencement, the tubing of the band is primed with saline and Marlex mesh is sutured to the access port.
Patient must meet NIH criteria for bariatric surgery. Patients are required to attend a multidisciplinary educational workshop preoperatively. They are educated and screened with preoperative medical, psychological and nutritional assessments. Patients are placed on a calorie-restricted high-protein liquid diet for two weeks preoperatively.
A 3 cm intraumbilical incision is made and the abdomen is entered under direct vision via a periumbilical 12mm trocar using the Hasson technique. The band is then inserted directly into the abdomen. Pneumoperitoneum is established with carbon dioxide to a pressure of 15mmHg. A 10mm 30Ã��Ã�° scope is introduced via the 12mm trocar. A 5mm trocar is placed on either side of the 12mm trocar. A liver retractor is introduced in the subxiphoid region percutaneously and used to retract the liver superiorly to expose the gastric fundus. Swording (crossing) can be reduced by grasping the tissue further away from the target than normal. With the fundus retracted laterally, dissection begins at the angle of His with division of the phrenoesophageal ligament using electrocautery. Next, the gastrohepatic ligament (pars flaccida) is divided to expose the right crus. The peritoneum over the right crus is divided to allow a flexible blunt grasper to be passed posterior to the esophagus and exit at the angle of His. The tubing of a prepped LAP-BANDÃ��Ã�¢Ã��Ã�¢ (Apollo Endosurgery Inc, TX, USA) is placed into the grasper and the band is pulled through and positioned around the superior-most portion of the stomach, 2 cm below the esophagus. The band is locked and secured anteriorly with a continuous 2-0 ProleneÃ��Ã�® (Ethicon, NJ, USA) gastro-gastric plication stitch. Ensure that the esophagus is not incorporated instead of the stomach and that no stomach covers the buckle of the band, as this can predispose to band erosion. Ascertain that the band is not be too tight around the stomach and take care to avoid injury to the band with the needle. The tubing is retrieved out of the abdomen through the left umbilical trocar. All trocars and the liver retractor are removed. The umbilical fascia is closed with 0 VicrylÃ��Ã�® (Ethicon, NJ, USA). The band tubing is attached to the access port and all redundant tubing is gently replaced into the abdomen. The port is laid flat on top of the anterior rectus muscle within a subcutaneous pocket but not sutured. No fluid is placed in the band. Skin is reapproximated with 4-0 Monocryl® (Ethicon, NJ, USA) subcuticular sutures and local anesthetic is infiltrated into the wounds.
Advantages: ���¢���¢Of the SILS approach - superior cosmetic outcome; decreased postoperative pain; decreased use of oral analgesics; improved patient satisfaction; improved safety profile by decreasing the number of ports used and thereby reducing the risk of port-related complications, namely, bleeding, infection and hernia; avoids lateral placement of trocars which eliminates the risk of injuring the epigastric vessels; the same technique is used for band placement as the conventional multiport laparoscopic approach. ���¢���¢Of the adjustable gastric band - favorable safety profile, effective weight loss and improvement in comorbidities, adjustability, reversibility. Disadvantages: ���¢���¢Of the SILS approach - slightly longer operative time; increased operative cost if standard reusable laparoscopic instruments are not used; crowding, clashing and swording (crossing) of instruments; lack of triangulation.
Major complications of gastric banding including gastric prolapse (slip), pouch dilatation, band erosion, port and tubing problems and band intolerance.

Major complications of gastric banding including gastric prolapse (slip), pouch dilatation, band erosion, port and tubing problems and band intolerance.
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Review Single Incision Laparoscopic Surgical (SILS) Placement of an Adjustable Gastric Band.

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