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

Video Type: CVideo
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Author: Collin Creange
Published:
Specialties: Endoscopy, General Surgery
Schools: New York University Medical Center
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Basic Info

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

Advanced

Procedure

Single incision laparoscopic surgical placement of an adjustable gastric band.

Indications

Morbid obesity with a BMI of >40kg/m2 or >30kg/m2 with significant obesity-related comorbidities.

Contraindications

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.

Instrumentation

Setup

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.

Preoperative Workup

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.

Anatomy and Landmarks

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 30���° 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-BAND���¢���¢ (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 Prolene���® (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/Disadvantages

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.

Complications/Risks

Major complications of gastric banding including gastric prolapse (slip), pouch dilatation, band erosion, port and tubing problems and band intolerance.

Disclosure of Conflicts

Major complications of gastric banding including gastric prolapse (slip), pouch dilatation, band erosion, port and tubing problems and band intolerance.

Acknowledgements

N/A

References

1.Chakravartty S, Murgatroyd B, Ashton D, Patel A. Single and multiple incision laparoscopic adjustable gastric banding: a matched comparison. Obes Surg. 2012;22(11):1695-700.
2.de la Torre RA, Satgunam S, Morales MP, Dwyer CL, Scott JS. Transumbilical single-port laparoscopic adjustable gastric band placement with liver suture retractor. Obes Surg. 2009;19(12):1707-10.
3.Huang CK, Tsai JC, Lo CH, Houng JY, Chen YS, Chi SC, et al. Preliminary surgical results of single-incision transumbilical laparoscopic bariatric surgery. Obes Surg. 2011;21(3):391-6.
4.Osborne AJ, Clancy R, Clark GW, Wong C. Single incision laparoscopic adjustable gastric band: technique, feasibility, safety and learning curve. Ann R Coll Surg Engl. 2013;95(2):131-3.
5.Park K, Afthinos JN, Razi SS, Chan E, Lee DY, Teixeira JA. Laparoendoscopic single-site surgery for the placement of an adjustable gastric band: a large cohort comparison. Surg Obes Relat Dis. 2013;9(5):686-91.
6.Ren CJ, Fielding GA. Laparoscopic adjustable gastric banding: surgical technique. J Laparoendosc Adv Surg Tech A. 2003;13(4):257-63.
7.Saber AA, El-Ghazaly TH, Elain A, Dewoolkar AV. Single-incision laparoscopic placement of an adjustable gastric band versus conventional multiport laparoscopic gastric banding: a comparative study. Am Surg. 2010;76(12):1328-32.
8.Tacchino RM, Greco F, Matera D. Laparoscopic gastric banding without visible scar: a short series with intraumbilical SILS. Obes Surg. 2010;20(2):236-9.

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