Plate 46

A surgeon may select the use of a gastric band to restrict the gastric size. The same selection criteria used for the Roux-en-Y gastric bypass apply.

Preoperative preparation and anesthetic considerations are similar to the gastric bypass.

Prophylactic antibiotics and venous thromboembolism prophylaxis are employed. A Foley catheter is not inserted into the bladder because of the short duration of the procedure.

The patient is positioned in a modified lithotomy position. The surgeon is positioned between the legs and the assistant to the patient's left. The room setup is shown in Figure 1.

The port placement is similar to that of a Roux-en-Y gastric bypass, with the exception of a left subcostal 15-mm port that is used to introduce the gastric band (Figure 2). Fewer ports may be used in some patients. The patient is placed in the reverse Trendelenberg position. The GE junction is exposed by retracting the liver proximally (Figure 3). Blunt dissection is used to create a retrogastric tunnel as shown in (Figure 4). Retraction of the stomach inferiorly facilitates exposure of the greater curve side of the GE junction. The retrogastric dissection is minimal and the goal should be to create a narrow tunnel that will act to prevent slippage of the device. The tunnel is created superior to the left gastric artery. The orogastric tube placed by anesthesia is removed and a calibration balloon inserted and inflated with 15 mL of saline. The band is placed into the abdomen using an insertion device (Figures 5 and 6). It is placed through a 15-mm port or passed directly through the abdominal wall (Figure 6). An atraumatic grasper is used to advance the gastric band from the opening along the greater curvature near the angle of His to the previously made opening in the soft tissue along the lesser curvature (Figure 7). The band is placed around the stomach just below the intragastric balloon (Figure 8). The balloon is deflated and the band is buckled close (Figure 9). The orogastric sizing balloon is removed. The final position of the band is shown in Figure 9. Several interrupted nonabsorbable sutures (2-0) are used to imbricate the stomach over the band in order to prevent slippage (Figure 10). The distal tubing is retrieved through a left paramedian incision at the 15-mm port site (Figure 2). A subcutaneous pocket is made for the port used to adjust the band. The port is tacked to the anterior rectus sheath with four 0 nonabsorbable sutures (Figure 11).

Closure follows the same procedures outlined for the laparoscopic Roux-en-Y gastric bypass.

The patient is permitted clear liquids the night of surgery and advanced to an initial diet on postoperative day 1. The patient is discharged within 23 hours of surgery if the initial diet is tolerated. A contrast study to determine band position is not necessary prior to discharge. Adjustment of the band is not performed for 6 weeks. The initial adjustment is performed under fluoroscopic guidance.