Allergan Lap-Band

Adjustable Lap Band Consent Form.pdf

Trocar Placement

Objective: Place 5 ports (3- 5mm trocars, 12mm trocar, 15mm trocar)

Port 1: LUQ 5mm port.  Veress access in L subcostal anterior axillary line.  Following insufflation to 15mm Hg, 5 mm port placed.  Insert 5mm laparoscope to visualize abdominal cavity.

Port 2: L paramedian 15mm port.  Place 1 hand’s breadth inferior to Port 1 and 1-2 cm left of midline.  This port will be used for the laparoscope for most of the case.

Port 3: RUQ 5 mm port.  R subcostal, midclavicular line.

Port 4: R paramedian 12 mm port.  R midclavicular line 1 hand’s breath lateral to Port 2 and inferior to Port 3. 

Port 5: R subcostal, midaxillary line.  5 mm port for liver retractor.  Insert liver retractor through this port and retract the L hepatic lobe. 

Placement of Adjustable Gastric Band

Objectives: 1) Create posterior window behind GE junction.  2) Create a 15cc gastric “pouch” by placing band circumferentially around stomach, 3) Secure band into place.

Once the stomach is visualized, the band is selected.  Most patients will receive an Allergan AP-S (Standard) band but those with a large amount of intraabdominal fat around the stomach will require a larger band (AP-L)

1.      Using long gator in L hand and Harmonic Scalpel in R hand, create a small window at the angle of His.  (Assistant needs to expose the Angle of His and keep scope light cord at 2:00 for optimal visualization)

2.      Clear fat overlying GE junction (gastroesophageal fat pad) with Harmonic to expose the anterior surface of the gastric cardia.

3.      Divide gastrohepatic ligament to identify the R crus.  Expose the R crus as posteriorly as possible.  Incise/dissect with Harmonic to the right of R crus to provide access to a retroesophageal tunnel.  (Assistant will keep the light cord at 10:00 for optimal visualization)

4.      Insert gator in L hand posteriorly into tunnel just created with tips exiting at the angle of His.

5.      Attach band at the buckle to duckbill in R hand.  Pass band into the abdomen through the 15mm port (you will need to use the port converter).

6.      Grab end of band tubing with duckbill in R hand and pass it to the tips of the grasper in your L hand.

7.      Pull the tubing through the retro-gastroesophageal tunnel until the “shoulder” of the band comes through. 

8.      Grab the tip of the tubing with your R hand and thread this through the large hole in the buckle.  Stabilize the buckle with a gator in your L hand.  Assistant will grasp the tubing with his/her gator once you pass it through the hole. Pull tubing until band is locked.

9.      Position the band obliquely approximately 1-2 cm distal to the gastroesophageal fat pad.  Place 2 interrupted 2-0 Surgidac sutures beginning at the greater curvature to secure the band anteriorly. This will create a ~15cc gastric “pouch”.

10.   In order to determine that the band is not too tight, ensure that 1) buckle is not covered, 2) band can turn easily, 3) you can insert a grasper between the band and the stomach.

11.    Remove the liver retractor under direct visualization.

12.  Close 12mm port site with Carter Thompson Device and 0-polysorb suture with figure of eight stitch around the trocar. Secure ends of suture with a snap.

13.     Close 15 mm port site with simple stitch lateral to trocar.  Secure ends of suture with a snap.

14.     Pull end of band tubing through the 15 mm port and remove the 15mm port.  All other ports stay in. 

15.     Deflate the abdomen and turn off gas and light sources.

Placement of Access Port

Objectives: 1) Prepare and prime the access port.  2) Place access port into an accessible subcutaneous pocket. 

1.      After band tubing is brought out of the abdomen, place a blue towel underneath and secure with tonsil. 

2.      Prepare the subcutaneous pocket by extending the 15mm trocar incision towards the right with an 11 blade.  Assistant will retract and perform blunt dissection with Deavers, while surgeon utilizes forceps and electrocautery to expose the anterior rectus sheath fascia.  Clear fascia with a sponge stick.  Do not incise the fascia, just clear an adequate space to place the access port. 

3.      Prepare the access port by trimming a square of prolene mesh to leave a 1 cm margin. Then cut the tube and connect the access port to the band tubing.  Access the port using a non-coring needle attached to a stopcock and syringe with 4 cc saline.  Remove air from band by actively pulling back on syringe.  You may need to close the stopcock & disconnect the syringe from the stopcock to evacuate the air.  Allowing syringe plunger to settle passively will replace the air with prime fluid, usually about 2 ml. 

4.    Orient port with tubing facing the patient’s left side.  Place two 0-prolene sutures through port, mesh, fascia, and through mesh and port again.  Place the access port so that it lies flat, mesh side down on the anterior rectus sheath fascia.  Return excess band tubing back into the abdomen. 

5.      Place a Betadine sponge in the subcutaneous pocket. 

6.      Reinflate the abdomen to check for bleeding, verify correct band placement, and to ensure that the tubing is free of kinks (especially at the 15 mm entry site).  Remove trocars under direct visualization and deflate the abdomen again.

Closing

1.      Tie previously placed fascial sutures at 12 and 15 mm port sites. 

2.      Secure access port into place by placing a few interrupted sutures in the subcutaneous tissue around and above the access port using 3-0 Vicryl. 

3.      Close skin with 4-0 polysorb and place steristrips and primapore dressings. 

Postoperative Care

Night of Surgery:  Similar to gastric bypass patients.  Continuous pulse oximetry, strict NPO, OOB the night of surgery, foley stays in, first postoperative lovenox dose 12 h after preop heparin given in holding area, PCA, Zofran, CPAP (if appropriate), Lopressor + cardiac monitor (if they take it at home). 

POD 1: Patients will have UGI.  If normal, patients will automatically be advanced to Phase 1.  Nurses will also automatically take away PCA and convert to Roxicet, DC foley, DC IVF. If tolerating Phase 1, patients may be discharged in the early afternoon. 

Gina M. Howell, MD and J. Robert Klune, MD