Evolution of laparoscopic adjustable gastric banding and insertion of trocar

The earliest LAGB-the BioEnterics Lap-Band system (Inamed Health, Santa Barbara, CA, USA)-was developed from the ASGB, making it easier to place and adjust under laparoscopy.

The closure of the straps has changed from sewing to an automatic locking buckle.

The inner balloon expands to almost cover the entire inner circumference, while the initial length of the device is fixed at 9.75 cm or 10 cm when measured from the inner surface.

There are now many commercial brands of LAGB available for application.

However, only two of these brands have had their safety and effectiveness confirmed by the literature.

The BioEnterics Lap-Band system was one of the earliest devices designed for laparoscopic surgery, and there is a large body of literature supporting its safety and effectiveness.

The Swedish adjustable gastric band was originally used in open surgery and is now also used in laparoscopic surgery, but the device has not been modified in any way, and there is relatively little literature on its safety and effectiveness.

We only use Lap-Band, so this chapter will only discuss devices from that brand.

Dr. Mitiku Belachew of Centre Hospitalier Hutois in Belgium performed the first surgery using the Lap-Band system in September 1993.

Since mid-1994, surgeons who have been trained in this procedure have been able to perform this surgical procedure in clinical settings.

Subsequently, the device was rapidly and widely adopted in Europe and many developed countries, including South America, Mexico, Australia, New Zealand, Israel, and Saudi Arabia.

In June 2001, Lap-Band was approved for use in the United States, which greatly contributed to its global promotion.

Since its inception in 1993, the technique of placing gastric bandages has evolved into many important methods.

Although the technology is becoming increasingly convenient, more attention to detail is needed to achieve the desired results and prevent late-stage complications.

The techniques described in this chapter are the methods we used in 2004.

We will elaborate on the basic techniques and give special emphasis to key elements or requirements.

Laparoscopic placement

LAGB is specifically designed for laparoscopic placement; however, it is occasionally necessary to place it via open surgery, mainly because the liver is large and fragile, or there is excessive fat in the abdominal cavity.

Of the 1,400 patients we performed surgery on, 3 required conversion to open surgery.

Our data and observations suggest that laparoscopic placement provides a better field of vision, resulting in more accurate placement and fixation, and significantly fewer perioperative complications. Therefore, we do not recommend open surgery.

The surgery requires good laparoscopic skills and experience in advanced laparoscopic surgical procedures, and should be performed by a physician who is very confident in performing the surgery laparoscopically.

Patient position

The surgeon can stand between the patient's legs or on the patient's right side.

We recommend the former because it allows the surgeon to operate the instruments with both hands in a straight line.

The patient should maintain a head-down, feet-up position, tilted at approximately 25°.

A cushion is placed under the buttocks and secured to the operating table to prevent the patient's body from sliding.

The lower legs are placed on a leg rest that provides firm support and is easy to adjust.

Number of puncture cannulas and insertion method

Even if surgeons perform the procedure in almost identical ways and place the bandage in exactly the same position, there can be significant differences in the insertion of the trocar. Therefore, the accurate insertion of the trocar does not determine the clinical outcome but depends entirely on the surgeon's preference.

Factors influencing their preference mainly include prior experience with laparoscopic surgery, especially laparoscopic antireflux surgery, in inserting trocars, preferred instruments and trocars, and the surgeon's position, such as standing on the patient's right side or between their legs.

We used 6 puncture cannulas, as shown in Figure 20.1-1.

The number of puncture cannulas is not very important.

Generally, adding or removing a 5mm puncture cannula is insignificant, and of course, the safety and comfort of the procedure should not be sacrificed for such an issue.

The procedure can be performed with only four trocars, but there is no reason to increase the risk and difficulty of the procedure just to achieve such a vague goal as reducing the number of trocars by one.

1 puncture cannula

The first puncture cannula was placed 6 cm lateral to the midline below the right costal margin.

This is a puncture cannula with an inner diameter of 5mm and a length of 150mm.

All of our 5mm inner diameter trocars are extended, allowing us to insert them at a very small acute angle to the abdominal wall, with the trocar pointing almost directly towards the esophagogastric junction.

This method ensures that there is no tension between the operator's hand and the instrument when the instrument is pointed at the target area.

The trocar entered the abdominal cavity from the lower edge of the lateral ligament of the left lobe of the liver.

It is primarily used by surgeons in their left hand to hold long grasping forceps and left-hand instruments during suturing.

2-point cannula

A 5mm inner diameter trocar is inserted vertically into the abdominal cavity directly below the xiphoid process to create a passage.

Then the puncture cannula is removed, and a Nathanson liver retractor is inserted along the established channel to retract the liver.

Exposing the liver is very important, and this liver traction method is the most effective and cheapest method to date.