Adjustable gastric banding

Published on 09/04/2015 by admin

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Last modified 09/04/2015

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CHAPTER 26 Adjustable gastric banding

Step 1. Surgical anatomy

Adjustable gastric banding was first introduced in 1993. Initially the Lap-Band was the only band available, now we have two types: the Lap-Band System by Allergan Health (Figure 26-1) and the Realize Band by Ethicon Endo-Surgery (Figure 26-2).

The first landmarks to establish are the location of the gastroesophageal junction and the angle of His. Often there will be a large gastroesophageal fat pad, which obscures the location of the gastroesophageal junction. The fat pad will need to be dissected away to identify the gastric serosa.

Once the gastroesophageal junction is identified, then the presence of a hiatal hernia can be determined. If present, a hiatal hernia will need to be repaired to avoid future dysphagia and failure of the band.

The hepatogastric ligament, which is part of the lesser omentum, connects the liver with the lesser curve of the stomach. It consists of a caudal flaccid portion known as the “pars flaccida,” which is usually transparent and contains no vessels. The right-sided dissection begins here, and there is usually no need to dissect in the more cranial portion of the hepatogastric ligament known as the “pars densa.” The pars densa should be avoided when possible because it contains the hepatic branch of the vagus nerve and an associated artery. If there is a replaced left hepatic artery, it will be located in this region and must be considered while dissecting in this region because it is often obscured by overlying fat.

Once the pars flaccida is opened, the right diaphragmatic crus can be exposed. Proper identification of the right crus is critical to ensure safe dissection into the retrogastric space. Proper technique and placement of band will help the surgeon to avoid entering the lesser sac.

A perigastric dissection occurs along the lesser curve of the stomach and requires meticulous tissue dissection. This approach may be utilized in cases when there is excess fat along the lesser curve, large accessory or replaced vessels, and poor visibility of the right crus.

Step 2. Preoperative considerations