Surgical complications

There are intraoperative (during surgery) and postoperative complications, which in turn can be differentiated into early (up to the 3rd week) and late complications.

Intraoperative complications

a) Switching to upper-abdominal laparotomy

(Open technique with stomach incision)

The migration rate is less than 5%. The main reason for switching is previous operations performed in open upper-abdomen technique (laparotomy).

Mandatory reasons:

Impaired view due to anatomical circumstances. There is a heightened risk for the android fat types (fat-tissue concentrated in the abdominal area) with extreme obesity (super obesity, BMI > 50). The instruments may be too short due to long distances (the trocars may be too far away from the operation area), an extremely aggrandised fatty liver may not be held far enough to the side, or the pneumoperitoneum (inflation of the abdominal cavity with gas (CO2) during the laparotomy) may not hold up. Even in the super-obese this occurs very rarely (< 1%). However, compromises are generally not acceptable when it comes to safety. If in doubt, the open method must be selected.
Intraoperative complications (during the operation): Injuries to stomach and neighbouring organs that may not be treated safely enough with a laparotomy.
Equipment problems (very seldom since replacing an instrument is almost always possible).

Promoting factors:

Prior surgeries of the abdominal cavity (often the upper-abdominal area) where operations on the upper abdomen or the middle abdomen to the right allow application of the laparoscopic technique.

Disadvantages of open techniques as opposed to laparoscopy:

More severe postoperative pain; although it is easily treated.
Occurrence of incisional hernias and wound healing complications. Incisional hernias must be treated surgically most of the time, possibly combined with plastic abdominal wall augmentation at the fatty apron.
Hematoma (bruising) and wound infections in the abdominal wall (rare) due to larger wound surfaces.
Cosmetically less desirable result.

b) Organ injuries

As with other laparoscopic techniques organ injuries may occur. Massive organ injuries happen very rarely and usually do not require a switch to open techniques.

When creating the pneumoperitoneum (inflating the abdominal cavity):

Puncturing organs with a specially designed needle (Veres). Since this needle is very small in diameter and several safety checks ensure fast detection of such unwanted puncturing, it is usually of no consequence and at times in not noticed at all. Additional measures like evacuating the stomach by suction can reduce the risk of such injuries.
If prior operations were performed and cicatrisation can be expected, CO2 gas can inserted by utilising a small opening into the abdominal cavity to minimise risks.

When placing trocars:

(canulae for the device entrance openings)

Often occurs when placing the first trocar (if not inserted openly) since further insertions need to be created with impaired view. Avoidable by using suitable techniques (incision point, protective mechanisms which are part of the trocars themselves).

When preparing the stomach:

To place the band, a tunnel is created at the rear wall to the stomach entrance (cardia), through which the band will be pulled. This may result in injury to the stomach wall. This is a typical complication for this particular surgical technique. One cause for this is "aggressive preparation" of this area with impaired view. In addition, the literature also describes secondary flow damage to this area. According to this literature (Kunath, 1996) an injury of this type may be fatal if undetected. Thus, detecting such an injury is of utmost importance since an LAP-band may still be inserted if a secure suture is applied to the stomach wall.

Oesophageal injuries:

Occur very rarely when exiting the prescribed operational area. This has been described in the literature (Pier, 1998).

Injury to neighbouring organs:

The left liver lobe is prone to injury by the hepatic retractor (a device designed to hold the liver to the side when operating) and other instruments and trocars. Due to the heightened vulnerability of the liver in obese patients caused by accumulation of fat and growth (often reaching the spleen in the left upper abdomen), the liver must be held to the side during the entire operation. Smaller surface injuries to the capsule of the liver are common even if very careful handling of the retractor is practised, but these injuries are clinically unimportant. Injuries to the spleen may be caused directly by instruments or indirectly by pulling on concrescences. Though possible in theory due to gastric banding, injuries to the small bowel are very rare. If such a lesion should occur it must be closed and the operational area must be rinsed out thoroughly due to the heightened risk of infection to the implant. Under normal and even difficult anatomical circumstances, massive organ injuries due to concrescence after operations or infections are very rare.

c) Bleeding

Abnormal bleeding occurs very rarely (< 1%), and if it does occur, does not require the use of blood units and can be safely controlled during the operation. Despite these facts, heavy bleeding cannot be ruled out completely. Thus patients need to be informed about the possibility of blood or blood product transfusions. Possible sources of such bleeding are larger blood vessels in the stomach, liver and spleen.

d) Damage to the gastric band, material failure

The lap band may be damaged by sharp instruments or needles mainly in the area of the fillable inner membrane during the operation. This can cause the system to leak in this area. If this is noticed during the operation, the band can be exchanged immediately. Otherwise, a second operation is necessary to exchange the band. Unidentified material failures by the manufacturer ("LAP-Band") are also very rare.

e) Primary band position failure

Once the commonly accepted learning curve for introducing the laparoscopic band insertion has been overcome, this should not occur. Common position failure is a band placed too far down the stomach. Position failures are caused by surgeon error. It is normally ruled out by postoperative x-ray examinations. Symptoms are equivalent to those of a pouch dilatation. A new surgery is unavoidable in this instance.