Part IV – Internal View of Gastric Lap Band Placement Text

September 21, 2011

OBGYN.net Broadcasting presents Part IV of a series of presentations on Weight Loss Surgery. This project is unique in that we follow the patient from pre-op to one year post-op.

 

This is the initial view of the abdomen upon entering. The stomach is present as the grayish structure in the middle of the screen, and the pulsating movement is because the aorta lies beneath all the abdominal structures here. The very first thing that is done is to mark the stomach and omentum, which is the fatty tissue, with a single unipolar coagulation mark. As the procedure proceeds, structures are moved around, and this insures that the proper place is marked for later dissection. A nasogastric tube was placed prior to placing the initial trocars at the beginning of the surgery. Next the 15 cc bulb on the nasogastric tube is moved down into the lower portion of the stomach in order to allow more access to the area for dissection. This omentum, or the layer of fatty tissue over the stomach, is opened and the dissection is carried down to the right crura of the diaphragm. At this time further blunt dissection is performed in a very gentle manner, and unipolar electrosurgery is utilized on a limited basis. This dissection is carried down beneath the right crura of the diaphragm which in turn mobilizes the stomach and esophagus from its connections in this region. Note the gentle and blunt dissection technique which is relatively bloodless. 

Dissection is now initiated on the left side of the esophagus and stomach, and the underlying diaphragm is approached from this side. There is a small hiatal hernia here which makes the dissection slightly more difficult. Note the left crura of the diaphragm is initially visualized, and then the dissection is carried down which mobilizes the left aspect of the esophagus and stomach from the left crura of the diaphragm. Again, blunt dissection was primarily utilized with selected but limited use of unipolar electrosurgery. 

Once the stomach has been mobilized, Dr. Weiner's instrument is then placed into the right area of dissection. This is the surgical instrument manufactured by Wolf Instruments that was designed by Dr. Weiner and was discussed in the beginning of the tape. With its hinged design, the instrument then can be curved and tented so that the leading arm moves behind the stomach and esophagus. The leading edge then will traverse behind the stomach and re-appear down in the area of dissection along the left crura. 

Notice the instrument is hinged so that it can more easily be manipulated behind the stomach and esophagus. This dramatically reduces the chances of gastric perforation, which is a recognized complication in this procedure. It is manipulated until it is exactly in the proper position, and the leading tip of the instrument will be visible down in the dissection beneath the left crura. The step was actually a little more difficult than usual because of the presence of the small hiatal hernia 

As the tip of the instrument is visualized, further gentle dissection is performed so that the instrument now completely encircles the upper fundal region of the stomach. Now the entire BioEnterics gastric band is introduced through the large trocar, and the distal end of the tube to the band is placed into the leading edge of the dissection instrument. The instrument is now slowly withdrawn and the band is pulled behind the stomach so that it completely encircles the posterior or dorsal portion of the upper fundus and esophagus. 

At this point, more dissection of the adipose tissue over the stomach is undertaken. This is primarily around the upper fundal region of the stomach for better application of the band and closer approximation of the band to the gastric wall itself. Note this dissection is initiated at the location that was previously marked at the initiation of the surgery. This dissection determines the position of the band on the stomach, and is crucial because proper placement and positioning is critical to the success of the procedure. 

Note that good surgical technique is employed with traction and tension placed on the tissue to be dissected. This results in more accurate dissection in the proper planes with reduced chances of error. Again, this is a hallmark of good surgical technique, and ultimately important to the success of the entire procedure. 

Here Dr. Weiner continues to separate the area of adipose or fatty tissue from the stomach. Gentle and blunt dissection is continued as has been employed through the entire procedure. 

Once the area has been dissected, Dr. Weiner's instrument is placed through this dissected area and its leading tip visualized. Again, use of the hinged blunt instrument reduces the chances of perforation. Once the tip is clear, the distal end of the gastric band is placed in the instrument and pulled through this dissection plane. This results in a more complete encircling of the fundus of the stomach in the region to be banded. 

The entire gastric band is then pulled behind the stomach until the portion of the band that is to encircle the stomach is moved into place behind the stomach. 

Again, note the gentle dissection and movements of the surgeon. 

As the flange on the band is somewhat larger than the rest of the apparatus (which is required to lock the closure of the band), it requires some gentle dissection to move it through the dissected canal. The dissected canal is kept small intentionally so as to minimize damage to the blood supply and surrounding tissue. The less devascularized tissue that is left, the less chance of infection. In addition, the smaller the canal, the less chance of slippage.

Once accomplished, the proper location and position of the band is verified.

At this point, the distal tip of the band is placed through the hole in the proximal end of the band and, by pulling it through the opening, the band is seated into proper placement around the upper portion of fundal region of the stomach. 

The areas are cleaned, the bulb of the nasogastric tube is checked and then the band is locked in place at the appropriate level and in the appropriate position on the stomach. The bulb on the nasogastric tube is exactly the size (15 cc) of the optimal gastric pouch being formed at the upper end of the stomach, and thus having the bulb here facilitates its development.

The band is checked as for its proper location, and note the bulb of the nasogastric tube is above the region of the band thereby demarcating the 15 cc pouch.

At this point sutures are placed in the gastric wall. This is to secure the band in its proper location and avoid slippage. Slippage of the band is another one of the common complications and primary reasons for failure of the procedure. However, with proper placement of these sutures, the incidence of post operative slippage of the band has been nearly totally eliminated.

Several sutures are placed sewing the gastric wall both above and below the band together. Note the intracorporeal suture tying and how skillful Dr. Weiner is at performing it. Many surgeons are not able to tie knots in this manner because it is a difficult technique to master. The sutures are tied securely, thus securing the band in place to avoid slippage. 

The band is continually checked between placement of each suture to insure continued proper placement and location of the band. Approximately five or six sutures are placed for proper securing of the band. As each successive suture is placed, note the progressive overlapping of the sutured gastric wall over the band to insure the immobility of the band and to avoid any chance of slippage.

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At this time, three years post-op, Roberta is satisfied with the outcome of her surgery and hopes you have found her story helpful in your search for answers. Please direct any questions about LAP BAND surgery to your personal physician, or email the product makers directly at: http://www.inamed.com/contact/bio_patient.cgi.  Due to time restraints Roberta Speyer and the OBGYN.net team cannot respond to personal emails. See Professor Rudolf Weiner's website about Weight Loss Surgery to see if this option is right for you. Visit www.profweiner.com.