Continuing Education Activity

Extreme obesity is a worldwide epidemic. It is the second most common cause of preventable death in the United States, second only to smoking. Bariatric surgery, the surgical management of obesity, has demonstrated a substantial reduction in overall mortality in extremely obese individuals, according to multiple long-term studies. Bariatric surgery was first conducted in the 1960s as the jejunoileal bypass procedure. This procedure showed good weight loss results but involved numerous complications, particularly issues about malabsorption. This activity describes the technique, indications, and complications of laparoscopic band surgery and highlights the role of the interprofessional team in the management of obese patients.

Objectives:

• Describe the indications for laparoscopic band placement.
• Explain the technique for placing a laparoscopic band.
• Summarize the complications of laparoscopic band placement.
• Explain interprofessional team strategies for optimizing care coordination and communication to advance the appropriate and safe use of laparoscopic band surgery and improve clinical outcomes.

Introduction

Extreme obesity is a widely recognized worldwide epidemic. The rates of obesity have exponentially risen in the United States during the last two decades. Accordingly, the prevalence of 30.5% has escalated to 41.9%. Similarly, the mortality rates of this disorder increased. It is the second most common cause of preventable death in the United States after smoking.[1] Bariatric surgery, the surgical management of obesity, has demonstrated a substantial reduction in overall mortality in extremely obese individuals, according to multiple long-term studies.[2]

Bariatric surgery was first conducted in the 1960s as the jejunoileal bypass procedure. This procedure showed good weight loss results that involved numerous complications, especially malabsorption.[3] Over time, surgeons worked to develop techniques with limited complications. The Roux-en-Y gastric bypass was introduced in 1977 and became the procedure of choice by the 1980s. The nonadjustable gastric band procedure was introduced in the late 1970s with poor results, but the first adjustable gastric band was placed in 1985. The results of the adjustable band were released in 1986. They demonstrated improved weight loss with decreased complications compared to nonadjustable gastric banding. The first laparoscopically-placed adjustable gastric band (LAGB) was placed in 1993. Due to its technical ease, it became one of the more popular weight loss surgeries in Europe and Australia in the late 1990s. Laparoscopic adjustable gastric banding was approved in the United States in 2001. Its popularity grew annually until 2008, then began to decline rapidly. The decrease in its use is attributable to the introduction of sleeve gastrectomy. The laparoscopic sleeve gastrectomy was introduced in 1999. Its long-term results as a stand-alone procedure became apparent in the late 2000s. In 2008 the indications for laparoscopic sleeve gastrectomy were published. By 2016 it had become the most commonly performed bariatric surgery in the United States. By 2015, laparoscopically adjusted gastric banding constituted only 5.7% of all bariatric procedures performed in the United States. It is rarely done.[4][5][3]

The two primary mechanisms bariatric surgery allows a patient to lose weight are restriction and malabsorption. Restriction refers to achieving weight loss by limiting the intake of calories. Malabsorption refers to altering the intestinal tract to bypass a certain length of the small intestine. This bypass results in a decrease in the absorption of ingested nutrients. Some procedures change bodily hormonal concentrations, leading to weight loss and resolution of co-morbidities. The laparoscopic adjusted gastric bypass is strictly a restrictive procedure, which may explain why its long-term results are inferior to other bariatric surgeries.[6] It should be noted that bariatric surgeries were originally categorized into three main subgroups a. restrictive, b. malabsorptive, or c. restrictive-malabsorptive procedures. However, it has been demonstrated that all the anatomical alterations in bariatric surgeries would result in either transient or permanent physiological changes.[7]

Although the performance of this procedure is rare in the modern era, many patients may continue to have adjustable gastric bands. Therefore, it is necessary to educate clinicians on the laparoscopic adjusted gastric banding technique to diagnose and treat any potential complications safely and promptly.

Anatomy and Physiology

Gross Anatomy

The stomach begins at the diaphragmatic hiatus, the lower esophageal sphincter, and ends as it continues as the first portion of the duodenum. The divisions of the stomach include the cardia, which is just distal to the gastroesophageal junction, the fundus, which abuts the left diaphragm; the body, the antrum; and the pylorus, which is the most distal portion entering the duodenum. The lesser curvature lies beneath the medial segments of the liver. It contains the incisura angularis, which is the junction of the vertical and horizontal parts of the lesser curvature that marks the transition of the body to the antrum. The greater curvature is the long left lateral edge of the stomach from the fundus to the pylorus, which connects to the greater omentum. The left border of the intraabdominal esophagus and the fundus meet at an acute angle called the angle of His. 

The stomach is an organ that requires a rich supply of blood as it is an area that is highly mobile and distensible, is composed of 5 different cell types functioning at high metabolic rates, and has multiple muscle layers to facilitate the stomach waves of brisk peristalsis for the second phase of digestion. The celiac trunk, branching directly anteriorly from the aorta, provides the main arterial blood supply. The trunk supplies the common hepatic artery (CHA), splenic, and left gastric artery (LGA). The less curved side of the stomach is provided proximally by a descending branch of the LGA, with its ascending branch supplying portions of the esophagus. The CHA runs superior to the pancreas, and the right branches off to the gastroduodenal artery (GDA). It continues with the branch that proceeds from the CHA being the proper hepatic artery. The right gastric artery (RGA) then branches from the proper hepatic artery.

The RGA then runs from right to left across the lesser curved portion of the stomach and continues to branch into smaller vessels through the body of the stomach to join the network of smaller arteries supplying the stomach as branches off from the LGA. The posterior superior pancreaticoduodenal artery (PSPDA) branches off of the GDA, which then branches into the anterior superior pancreaticoduodenal artery (ASPDA) and the right gastro-omental (gastroepiploic) artery (RGEA). The RGEA then traverses and supplies from right to left the greater curvature of the stomach. The left gastroepiploic (gastroomental) artery (LGEA) branches from the splenic artery and supplies the greater curvature body portion of the stomach, except beginning on the left side and moving and branching in the right direction. Three to 5 additional smaller arteries also branch from the splenic artery to supply the stomach. The left gastric (coronary) vein and the right gastric and right gastro-omental veins all achieve drainage into different segments of the portal vein. The short gastric veins (also termed the vasa brevia) and the left gastro-omental vein achieve drainage via the splenic vein.

The lymphatic drainage of the stomach can be understood as having four levels. Level 1 includes the perigastric lymph nodes and follows a path of drainage of the right pericardiac and left pericardiac, along with the less curved body portion, the greater curved body portion, supra-pyloric, and infra-pyloric. Level 2 is comprised of drainage along the LGA, along the CHA), along with the celiac axis, at the splenic hilum, and along the splenic artery. Level 3 is characterized by drainage in the hepatoduodenal ligament, posterior to the duodenum and pancreas head, and at the source of the small bowel mesentery. Finally, the fourth level is characterized by mesocolic and paraaortic drainage.

Ligaments

• Gastrohepatic ligament: Continues from the lesser curvature to the medial liver edge and contains the left and right gastric arteries. It may also include a replaced left hepatic artery.
• Gastrophrenic ligament: Extends from the fundus to the left hemidiaphragm.
• Gastrosplenic ligament: Runs from the greater curvature to the spleen, which lies in the left upper quadrant. It contains short gastric vessels.
• Gastrocolic ligament: Extends from the inferior stomach to the transverse colon and is considered part of the greater omentum. It contains the gastroepiploic vessels.

Blood Supply 

The celiac trunk has three branches, including the left gastric, common hepatic, and splenic arteries. The left gastric artery runs along the superior lesser curvature and anastomoses with the right gastric artery. The common hepatic artery gives off the gastroduodenal artery, which runs behind the first portion of the duodenum. The right gastric artery is a branch of the proper hepatic artery. It joins the left gastric artery along the lesser curvature. The right gastroepiploic artery then branches from the gastroduodenal artery and runs in the gastrocolic ligament along the greater curvature. It then joins the left gastroepiploic artery, a distal branch of the splenic artery coursing along the greater curvature from lateral to medial. The splenic artery also gives off three to five short gastric arteries running in the gastrosplenic ligament to the gastric fundus.

Indications

The indications for bariatric surgery were first described in 1991. The classic criteria for a patient to be a candidate for any bariatric surgery include the following:

1. A body mass index of 40 or higher or a body mass index of 35 or higher with at least one obesity-related comorbid condition. Such conditions include hypertension, diabetes mellitus, and severely limiting musculoskeletal issues.
2. Unsuccessful nonoperative weight loss attempts.
3. Mental health clearance without alcohol or illegal substance dependence.
4. No medical contraindications to surgery.

Updates to these criteria have included patients with a BMI of 30 to 35 with obesity-related comorbidities as an indication for laparoscopic adjusted gastric banding.[8]

There is debate as to the appropriate threshold for bariatric surgery. The National Institute of Health makes the following recommendations: Otherwise, healthy patients with body mass indexes greater than 40 kg/m^2, who have failed at efforts at dieting, exercise, and medications, can be considered. Those with one comorbid condition, such as diabetes mellitus type 2 or obstructive sleep apnea, can be considered if the body mass index is greater than 35 kg/m^2. The American Society for Metabolic and Bariatric Surgery (ASMBS) states. Bariatric surgery should be offered as an option for appropriate individuals with a BMI of 30 to 35 kg/m^2 and obesity-related comorbidities who are unable to achieve lasting weight loss or comorbidity improvement with reasonable nonsurgical methods.

Contraindications

This procedure is contraindicated for patients unable to tolerate general anesthesia. It is also contraindicated for those with uncontrollable coagulopathy or those at a prohibitive operative risk.

Relative contraindications include Prader-Willi syndrome, malignant hyperphagia, untreated severe psychiatric illness, pregnancy, cirrhotics with portal hypertension, autoimmune connective tissue disorders, chronic inflammatory conditions, and the need for chronic corticosteroid use.[8]

Equipment

This operation requires basic laparoscopic equipment, including insufflation with carbon dioxide, drapes, monitors, laparoscopic instruments, and electrocautery. Unlike conventional laparoscopic procedures, bariatric patients require longer trocars and laparoscopic instruments to accommodate the thicker abdominal wall.

Laparoscopic adjusted gastric band procedures specifically require three 5 mm trocars, one 15 mm trocar, a liver retractor, an angled laparoscope, and a gastric band. There are two approved bands in the United States.

Personnel

The operative procedure requires an anesthesiologist, a primary surgeon, a scrub nurse, and a first assistant.

Preparation

The patient will be given preoperative antibiotics 30 minutes before incision and venous thromboembolism prophylaxis. The hair on the abdomen is removed with clippers in the preoperative area. The patient is placed on the operating table and secured well. After the induction of anesthesia, an orogastric tube is positioned within the stomach. The patient is placed in the modified lithotomy position with their arms extended. Routine skin preparation is completed from the nipples to the pubic symphysis. A time-out is performed.

Technique or Treatment

There are many ways to perform a laparoscopic adjustable gastric band procedure. The following example employs the pars flaccida technique.[9]

1. Entrance into the abdomen and trocar placementThe surgeon stands between the patient's legs, and the assistant is on the patient's left side. Entrance into the abdomen is done via Veress needle insufflation. An optically-guided 5 mm trocar is placed in the left subcostal margin at the midclavicular line; this is an assistant camera port. The remaining ports are placed under direct visualization. These include two 5 mm trocars at the left and right mid-abdomen in the bilateral midclavicular lines, which are the surgeon's working ports. A 15 mm trocar is placed more laterally at the left subcostal margin in the anterior axillary line, which is the assistant port. A liver retractor is placed in the subxiphoid position. The patient is then placed in the reverse Trendelenburg position.
2. Assessment of the diaphragmatic hiatusCrural defects and Hiatal hernias should be repaired at the beginning of laparoscopic adjusted gastric band operations. Such defects may not be obvious intraoperatively and not be preoperatively diagnosed. One way to assess them is to place an orogastric calibration tube and inflate the balloon with 15 mL of air or water. A crural repair should be performed if the balloon slips up into the chest past the gastroesophageal junction. Anterior crural repairs can be performed for small non-sliding hernias. This type of repair only requires mobilization of the distal esophagus anteriorly with subsequent suture approximation of the right and left crura. Posterior crural repairs are necessary for larger and sliding hernias. These repairs require full mobilization of the right and left crus and the distal esophagus. While mobilizing the esophagus posteriorly, it is important that the dissection remains superior to the lesser sac, as it must not be entered.
3. Pars flaccida dissection and tunnel creationThe assistant grasps the fat high along the lesser curvature and retracts the stomach to the patient's left side. This exposes the pars flaccida, a clear membrane that covers the caudate lobe and runs between the lesser curvature of the stomach and the liver. The right crus fibers should be visualized and distinguished from the inferior vena cava. This is superior to the left gastric artery and caudal to the gastroesophageal junction. The opening should be wide enough to pass a 5 mm laparoscopic dissector. Care must be taken to stay superior to the lesser sac; entering this space may lead to future complications. A laparoscopic dissector will then be bluntly placed through this opening and passed posterior to the stomach toward the angle of His. The dissector will then traverse the left gastrophrenic ligament at the angle of His with blunt dissection. The angle of His may be incised before this step at the physician's discretion.
4. Introduction and placement of the gastric band The appropriate band size and brand are determined. The lap band balloon is fully deflated on the back table by aspirating the balloon port of the device. The assistant then introduces the device through the 15 mm trocar with either the tube or suture, depending on the brand. The distal portion of the device is grasped with the dissector located at the angle of His. The band or suture loop is pulled through the posterior esophagogastric tunnel. The gastric band is then locked anteriorly, and its mobility on the stomach is evaluated. The locked band should be able to rotate freely around the superior stomach. Otherwise, it is too tight. In this case, the band must be unbuckled, and the perigastric fat must be excised to thin the tissue around which the gastric band is to be placed.
5. Gastro-gastric plication 2-0 permanent sutures approximate the distal fundus of the stomach to the superiorly-located gastric pouch. These sutures create a protective tunnel for the anterior, left-lateral aspect of the band. This approximation should be without tension and typically requires three sutures in the seromuscular plane. The buckle should not be covered with the imbrication and should be lifted to check for underlying tension. Once satisfactory plication is achieved, the buckle is rotated as far as possible to the right toward the lesser curvature.
6. Access port placementThe free end of the gastric band tubing is grasped and removed via the lateral 15 mm port. All ports, instruments, and retractors are removed from the abdomen with the subsequent release of the pneumoperitoneum. The tubing is trimmed and connected to the injection port with care not to shorten the tubing. Tubing long enough to lie loosely within the peritoneal cavity is required. The port is then secured to the anterior fascia in four quadrants with nonabsorbable sutures.
7. ClosureAll wounds are closed with subcuticular absorbable sutures. Sterile dressings are applied.
8. Postoperative carePatients are typically admitted to the general surgical ward and given a non-carbonated, sugar-free clear liquid diet on the day of surgery. Some surgeons discharge these patients home on the day of surgery. If admitted to the hospital, the patient's diet is advanced to full liquids or purees on postoperative day one. As long as the patient tolerates a diet and maintains hydration, they can be discharged. No solid foods are permissible until at least four weeks postoperatively. Some advocate for a barium swallow before discharge, although it is not required. The band is not initially insufflated with fluid. The first band adjustment is offered four to six weeks postoperatively. The first few port infusions should be done under fluoroscopic guidance. Subsequent monthly appointments for adjustment are made for the first year. During the second postoperative year, the patient should be seen two to three times for adjustments. The amount of fluid instilled during these adjustments should be tapered to allow for a weight loss of 0.5 to 1 kg per week. The patient must be able to swallow water without difficulty before leaving the office.[10][11]

Complications

Laparoscopic adjusted gastric banding has the lowest mortality of all the bariatric procedures, ranging from 0.02% to 0.1%.[12] It carries a 3% 30-day morbidity and a 12% rate of late complications, though this varies among the literature.[13][14]

Early Complications

• Deep vein thrombosis: Pulmonary embolism is the leading cause of death following laparoscopic adjusted gastric band surgery in many series.[15] These patients should receive appropriate venous thromboembolism prophylaxis.
• Esophageal or gastric perforation: The most common location for this is the retro gastric space. It is usually associated with an undiagnosed hiatal hernia. If a perforation occurs and is close to where the band will be placed, the procedure should be aborted.
• Esophagogastric obstruction: This can be an immediate postoperative obstruction caused by a tight gastric band. It is not typically seen due to the larger diameter of later band designs. This can be prevented by removing the perigastric fat pads to allow for adequate room for the gastric band.[16]

Late Complications

• Gastric prolapse, or a “slipped band,”: Is characterized by the lower stomach herniating superiorly through the device. It can be classified as an anterior or posterior slippage of the fundus past the band; the anterior is more common. The patient will experience sudden-onset food intolerance or reflux symptoms. Diagnosis begins with a plain abdominal radiograph. Normally the band is oriented diagonally from 2 to 8 o’clock and points towards the left shoulder. A slipped band will appear oriented more horizontally from a 10 to 4 o’clock position and will point towards the left hip. Confirmation is generally done with an esophagram. Treatment should be initial deflation of the band to temporarily alleviate the patient’s symptoms. Definitive management includes a reoperation and one of the following techniques: laparoscopic band repositioning, removal with or without replacement of the band, and conversion to another bariatric procedure such as sleeve gastrectomy or Roux-en-Y gastric bypass.[17] Rarely, gastric ischemia and necrosis may ensue. Gastric prolapse had a much higher prevalence in the 1990s, secondary to the laparoscopic adjusted gastric band procedure done with the perigastric technique. This procedure involved a retro-gastric tunnel that entered the lesser sac, resulting in much more freedom and movement of the stomach. This freedom of movement allowed for posterior fundal herniation through the band. With the advent of the pars flaccida technique, the rate of prolapse has decreased from 15% to 4%.[18]
• Band erosion: The incidence of band erosion into the stomach wall increases with time but remains between 1% and 2% in the literature.[19] These are typically manifested by delayed port site infections, abdominal pain, or failure to suppress the appetite despite band adjustment. The diagnosis is confirmed with endoscopy. Treatment involves an operation, removal of the band, repair of the gastric wall, and drainage. Delayed replacement of the gastric band should be done in three months. 
• Device malfunctions: These can be characterized by various complications, including device leaks leading to failure of band adjustment, tube kinking, port dislodgment, and port site infection. Leaks can occur via tubing disconnection, port puncture, or band puncture. The port may become dislodged from the fascia and flip, rendering the port inaccessible. 
• Band obstruction: This can be secondary to an overinflated band, which is most common, or a low band placement due to technical errors or a missed hiatal hernia. This will lead to a gastric pouch and esophageal dilation with esophagitis that can result in esophageal dysmotility, such as megaesophagus or pseudo-achalasia, in chronic cases.[20] Diagnosis is with an esophagram demonstrating esophageal and gastric pouch dilation. Treatment is the deflation of the band and imaging to monitor for the resolution of the gastroesophageal dilatation. If conservative management fails, an operation to revise or remove the band is required.[21]

Clinical Significance

Long-term outcomes of the laparoscopic adjusted gastric band procedure are incredibly variable. This method was once one of the most popular weight loss procedures. It accounted for 42.3% of all bariatric surgeries worldwide in 2008.[22] With the peak of its popularity gone, laparoscopic adjusted gastric banding accounts for a minority of weight loss procedures. This change is attributed to the publication of long-term results of gastric banding and sleeve gastrectomy procedures. Studies demonstrated a reasonable long-term excess weight loss ranging from 33% to 60%, with still lower percentages than gastric bypass. However, they also showed extremely high long-term reoperation rates requiring gastric band removal, ranging from 8% to 60%.[23][24][25][26][27] 

Surgeons were discouraged from gastric banding due to its poor long-term outcomes and the need for close follow-up for frequent adjustments. It is a low-risk procedure in the perioperative period. However, it is associated with patient frustration and lower compliance rates, leading to poor excess weight loss. Despite this reputation, many publications demonstrate a low risk of reoperation and band removal, ranging from 1.2% to 3.7%, when evaluating long-term data for laparoscopic adjusted gastric banding.[28][29][30][31] These results may be attributed to surgeon experience and advances in techniques that limit complications, such as the pars flaccida technique. The sleeve gastrectomy in meta-analyses has demonstrated excellent long-term results, low complication rates, and technical ease of operation compared to the Roux-en-Y gastric bypass surgery.[32] Sleeve gastrectomy was not recognized as an independent weight-loss procedure until long after gastric banding was established. It was previously the first of two operations for the duodenal switch procedure. However, its success is a clear contributing factor to the decline in the number of laparoscopic adjusted gastric band procedures performed.

Enhancing Healthcare Team Outcomes

For bariatric surgery, the patient must be evaluated by an interprofessional team before being a surgical candidate. This team includes a nutritionist, a psychiatric specialist, the surgical team, the nursing staff, and the primary care clinician. It is recommended but not required to conduct a preoperative esophagogastroduodenoscopy before laparoscopic adjusted gastric band surgery.

A clinician must be familiar with bariatric procedures and their complications. Bariatric surgery has proven highly efficacious in the treatment of obesity. The laparoscopic adjusted gastric band procedure is rarely done. However, many patients have previously undergone this surgery and may present with complications unique to this procedure. These pathologies must be understood, recognized, properly evaluated, and treated promptly.