LAP-Band™ (LASGB) Surgical steps
(simplified extensively)
Surgery usually doesn’t take longer than an hour.
Creating the pneumoperitoneum
Using a specially designed needle, the abdominal cavity is filled with CO2 gas, before the patient is placed in the anti-Trendelenburg position, so as to keep the liver from sinking downwards and thus becoming more prone to injury.
Placing trocars
Optimal positioning in the upper abdominal area is necessary. The shortest possible distance and the primary direction selected are of utmost importance as the position along the axis of trocars placed on an adipose abdominal wall can only be modified with great effort. By placing an initial so-called "blunt" trocar, which will have to be inserted blindly, the injury risk is reduced. All subsequent trocar insertions will be guided optically.
Preparing the surgical area
This involves inspection of the abdominal cavity (although obstructed by fat depots), holding back the left liver lobe with the retractor, and shaping the stomach entrance point below the diaphragm gap (cardia, sub-cardial region)
Determining the pouch size
A specific probe (calibration probe) is inserted into the stomach. A balloon is fixed at its tip, which will be filled with 15ml. Then the probe is pulled back under laparoscopic view, until the balloon touches the transition of the oesophagus to the stomach (lower oesophageal sphincter). The optimal position of the gastric band is at the balloon’s vertex, which will be marked. The balloon is then emptied, and the probe pushed forward into the stomach.
Preparing the retrogastric tunnel
A tunnel is formed around the stomach entrance, at a predetermined location, through which the gastric band will subsequently be pulled. This is done under visually clear conditions to avoid injury to the abdominal wall. Opposite the tunnel (HIS-angle) the peritoneum is opened to complete the tunnel.
Inserting the gastric band into the abdominal cavity, retrogastric pull-through, and closure
After the gastric band is prepared (rinsing with NaCl, removing air from the system), it is inserted through the left entrance (extended to 18 or 20mm by switching the 12mm entrance) into the abdominal cavity. The stomach is then circled through the previously created tunnel, under visually clear conditions, with the pull-through instrument, until the tip of the device appears at the HIS-angle. A joint allows the tip to be lifted from the stretched position. The flap at the catheter end of the gastric band is then inserted into the pull-through instrument’s thread eye, the tube is pulled through behind the stomach, and the band is placed. Before closing the band, the pouch size is checked, and any potential necessary adjustments are made. A special device (gastrotensometer) to check the correct positioning of the band by measuring the pressure may be used when closing the band.
Fixating the gastric band
The band is fixated to its position by the tight tunnel around the stomach; thus, fixation sutures need only be applied on the front and sides to keep the stomach wall from slipping below the band.
Connecting and fixating the reservoir system Upon retracting the catheter, the pneumoperitoneum is released, and all trocars are removed. The tube system is then connected to the reservoir via a detachable adapter. The two catheter ends are then secured above the adapter with two sutures. The reservoir is then secured to an efficient abutment such as the left costal arch or the abdominal wall.