Prevention and management strategies for complications of laparoscopic adjustable gastric banding

Prevention of complications

gastric perforation

Most cases of gastric perforation that may occur during surgery occur when creating the retrogastric tunnel.

This step can be very difficult for patients with a high BMI, excessive abdominal fat, or especially male patients.

Causes and incidence

The relationship between gastric perforation and surgical procedures is very clear, and it is an indication for emergency surgery.

Most surgeons have reported one or two cases of gastric perforation in the early stages of the learning curve, with an incidence rate ranging from 0.2% to 3.5%.

symptom

The symptoms of gastric perforation are that stomach contents continue to enter the abdominal cavity, similar to the peritonitis caused by gastric perforation.

diagnosis

This complication can be easily detected by injecting methylene blue solution into the stomach when the bandage is passed through the stomach during surgery.

After the straps are placed and secured, methylene blue solution is injected to check for perforations, which are usually undetectable.

Because a complete bandage may fill the perforation, it does not show any leakage.

A routine upper gastrointestinal diatrizoate meglumine contrast radiography on the first day after surgery can show gastric perforation.

How to avoid

There is an area for blind operation when creating the posterior gastric passage.

To avoid this complication, the left diaphragmatic crura can be exposed more extensively, and the lesser curvature can be dissected more extensively.

This could be considered if the perigastric anatomical approach is used.

To avoid damage to the stomach wall, the calibration tube should be removed during dissection. The calibration tube should be placed vertically so as not to damage the thin mediastinum when passing through the esophagus.

We found that articulated anatomical shears were sufficient to avoid damage to the stomach wall.

Excellent surgical techniques, adequate exposure, and appropriate instruments can reduce the incidence of this serious complication.

If a high risk of retrogastric dissection is found, laparoscopic assisted techniques are a better option.

The surgeon's right hand enters the abdominal cavity through a small incision in the abdominal wall.

Using the calibration tube as a reference, perform perigastric anatomy with your fingers.

The articulated anatomical scissors were then placed in place, the small abdominal incision was closed, and the entire surgery was completed laparoscopically.

gastric prolapse

Gastric prolapse refers to the formation of an excessively enlarged gastric sac above the gastric bandage after surgery. It is commonly known as gastric prolapse and is easily confused with gastric sac dilatation. This complication can occur on the anterior or posterior wall.

reason

The most common type is posterior gastric wall slippage.

The bandage pierced the posterior wall of the stomach, causing the gastric pouch to become excessively large on the posterior wall.

The straps were rotated to a vertical position, or even beyond a vertical position and shifted to a position further to the left.

This problem is mainly due to the strap being placed at the top of the gastric pouch, rather than along the tissue above the pouch.

Anterior gastric wall slippage is caused by failure of anterior wall fixation (fixation sutures).

The straps were moved to a horizontal position, and the enlarged proximal gastric pouch covered the left side of the straps.

It may be because the side part (large bend side) of the strap was not secured when the strap was sewn in place.

This could result in the sutures not securing the bandage properly, or the sutures being placed on the fat pad above the bandage instead of on the stomach wall, causing it to tear later.

Expansion of the posterior and anterior walls of the stomach leads to excessive gastric tissue entering the ligament, causing an obstruction between the upper and lower gastric cavities.

Incidence

This is the most common complication of laparoscopic adjustable gastric banding.

Due to a better understanding of the anatomy of the gastroesophageal junction and the evolution of surgical techniques, its incidence has decreased year by year (from as high as 22% to less than 5%).

The report describes three methods for placing the Lap Band: ① perigastric method; ② relaxation area method; ③ method from relaxation area to perigastric region.

Of these techniques, the perigastric technique has the highest slippage rate, possibly because it is more difficult to master.

However, in reality, the slippage rate is very low when the perigastric technique is properly mastered. In our experience, the incidence rate is 10%, of which 1.9% require repeat surgery.

symptom

For patients who are otherwise healthy after surgery, changes in their eating habits should raise suspicion of bandage slippage.

The symptoms of slippage include partial or complete obstruction and fluid retention in the lower esophagus and upper gastric pouch.

These symptoms include: heartburn, vomiting, regurgitation, difficulty swallowing, choking (especially at night), wheezing, and being able to tolerate only liquids.

This complication is usually chronic.

However, patients may develop severe dehydration, electrolyte imbalance, and ischemia in the upper part of the stomach.

Gastric ischemia is usually serious because it can lead to gastric necrosis.

diagnosis

The examination and treatment depend on the severity and intensity of the symptoms.

Patients should not experience the above symptoms after bandaging surgery.

Therefore, if the above symptoms occur, it indicates that the straps have been set too tight or have slipped.

Upper gastrointestinal contrast radiography can aid in diagnosis.

How to prevent gastric prolapse

To avoid this complication, it is very important to correctly select the anatomical location for entering the gastrodiaphragmatic ligament along the lesser curvature.

A reliable anatomical reference point is the horizontal part of the balloon at the diaphragmatic gastrostomy ligament corresponding to the left diaphragmatic crura (inflate the calibration tube with 25 ml of air at the gastroesophageal junction and then withdraw it).

Reference points are also needed when constructing the retrogastric tunnel.

The dissection must be performed vertically and aligned with the left diaphragm.

The omentum should not be included, and the anatomy should reach the diaphragmatic-gastric ligament above the peritoneal reflection of the omentum.

Once the Lap-Band is placed, it is embedded and sutured from the larger curve side to the smaller curve side using fixation sutures.

After these steps are performed, it is unlikely that the bandage or stomach wall will slip off.

Undoubtedly, postoperative gastric prolapse occurs due to the following reasons: ① A "virtual" gastric sac is created, and usually, a small gastric sac cannot stretch the gastric fundus from below the sling; ② The position of the gastric wall fixation suture as the sling is very important; ③ The sling is positioned very high behind the stomach, close to the gastroesophageal junction.

This anatomical tendency of a high posterior wall position is useful in relaxation techniques and relaxation combined with perigastric techniques.

However, surgeons with extensive experience in perigastric techniques also recommend a high posterior wall position.