Overview of Laparoscopic Gastric Band Placement
Obesity has quickly become a major health crisis, not only in the United States, but around the world. Over the last 20 years, the number of obese people in the U.S has significantly grown from 30.5% to 41.9%. This rise in obesity has also led to an increase in deaths linked to obesity, making it the second leading cause of preventable deaths in the country, following smoking. Bariatric surgery is a medical procedure carried out to help obese people lose weight, and studies show that it greatly reduces the risk of death in extremely obese individuals.
The first bariatric surgery was performed in the 1960s and achieved good results in terms of weight loss. However, it caused several complications, particularly malabsorption, which is when the body can’t properly absorb nutrients from food. Over time, surgeons improved the techniques to reduce these complications. In 1977, the Roux-en-Y gastric bypass, a type of weight loss surgery, was introduced and became the favored option by the 1980s. The late 70s also saw the introduction of the gastric band procedure, although the early outcomes were not very good. The first adjustable gastric band was placed in 1985, and it resulted in better weight loss with fewer complications.
The first laparoscopic adjustable gastric band, a surgery in which a band is placed around the upper part of the stomach to create a small pouch to hold food, was placed in 1993. This surgery quickly gained popularity in Europe and Australia due to its simplicity. It was approved in the U.S in 2001 and its use increased every year until 2008, when it started to decrease thanks to the introduction of sleeve gastrectomy. The laparoscopic sleeve gastrectomy was introduced in 1999, and by 2016, it had become the most common weight loss surgery in the U.S.
Bariatric surgeries help patients lose weight by restricting food intake and preventing the body from fully absorbing nutrients from food. Some procedures can also alter hormone levels in the body. The laparoscopic adjustable gastric bypass is purely a restrictive procedure, which could explain why its long-term results are not as good as other types of weight loss surgeries. Bariatric surgeries were initially classified into three groups: restrictive, malabsorptive, or a mix of both. However, it has been found that all types of bariatric surgeries can cause temporary or permanent changes to the physiology of the body. Even though the use of the laparoscopic adjustable gastric band procedures is not as common today, the adjustable bands from past surgeries still remain in many patients. Hence, it’s important for doctors to be educated on how to diagnose and address any possible complications from these bands.
Anatomy and Physiology of Laparoscopic Gastric Band Placement
The stomach is an organ in your body that helps break down the food you eat. It starts at the opening in your diaphragm, which is a sheet of muscle that helps you breathe, and ends where it transforms into the beginning of your small intestine, also known as the duodenum. The stomach is divided into several parts, including the cardia, fundus, body, antrum, and pylorus.
Your stomach has a left lateral edge, known as the greater curvature, extending from the fundus to the pylorus. The point where your esophagus (the tube that carries food from your mouth to your stomach) and the top section of your stomach meet is called the angle of His. The lesser curvature of your stomach is under portions of your liver.
Your stomach has a rich supply of blood, which is needed as it is a highly active organ that needs to stretch and move. The main blood supply comes from the celiac trunk, an artery that branches out from the aorta, the main blood vessel in your body. This artery divides into several smaller arteries that supply blood to different parts of your stomach.
The lymphatic system of your stomach, which helps in fighting infections and transporting white blood cells, drains through various paths known as ‘levels’. For example, lymph fluid drains from the perigastric lymph nodes to various areas in ‘Level 1’.
Your stomach is also connected to various other parts of your body by something called ligaments. These are like strong elastic bands that hold organs in place. For example, there is a gastrohepatic ligament that extends from the lesser curvature of your stomach to the edge of your liver.
Your stomach also has a complex network of veins that drain blood from various segments of the stomach and transport it to the portal vein, a major vein that carries blood to your liver.
Why do People Need Laparoscopic Gastric Band Placement
Bariatric surgery, which is a type of surgery that helps people lose weight, was first brought into practice in 1991. To know if a person is a good candidate for this kind of surgery, there are specific guidelines to follow:
- A person may need this surgery if they have a Body Mass Index (BMI) of 40 or above. BMI is a measure of body fat based on a person’s weight and height.
- Another guideline is a person having a BMI of 35 or above, along with at least one medical condition linked to obesity, like high blood pressure, diabetes, or severe issues with bones and muscles.
- Having tried and failed to lose weight through non-surgical means.
- Not being addicted to alcohol or illegal drugs and having a good mental health condition.
- As long as undergoing a surgery won’t create any additional health risks.
- Newer rules are considering people with a BMI between 30 to 35 who have health issues connected to obesity. They might be suitable for a special type of surgery called laparoscopic adjustable gastric banding.
However, there is some disagreement about the right BMI level that should qualify a person for bariatric surgery. The National Institute of Health suggests that even if a person is healthy, but has a BMI above 40 and has tried to lose weight through diet, exercise, or medicine without success, then bariatric surgery could be an option. Those with health issues like diabetes or sleep apnea could also consider the surgery if their BMI is above 35.
The American Society for Metabolic and Bariatric Surgery also suggests considering this type of surgery for those with a BMI between 30 to 35, who have obesity-related health issues and who haven’t had success with other weight loss methods.
When a Person Should Avoid Laparoscopic Gastric Band Placement
This procedure might not be suitable for some people for various reasons. These include people who cannot safely go under general anesthesia, which is a type of medicine that helps you sleep during surgery. If a person has a blood disorder that makes it hard to control bleeding, known as uncontrollable coagulopathy, the procedure might be too risky.
There are also certain situations where the procedure isn’t usually recommended, though there might be exceptions. These include people with Prader-Willi syndrome (a genetic condition that creates constant hunger), severe overeating related to cancer (maladaptive hyperphagia), untreated serious mental health issues, pregnant women, people with liver disease who have portal hypertension (high blood pressure in the vein leading to the liver), autoimmune connective tissue disorders (conditions where the immune system attacks tissues), chronic inflammatory conditions, and people who need to take corticosteroids (a type of medication) regularly.
Equipment used for Laparoscopic Gastric Band Placement
The procedure needs basic equipment used for keyhole surgery (laparoscopic equipment), which includes the introduction of a gas (insufflation) with carbon dioxide to help create a viewing and operating space for the surgeon, special drapes, screens to view the procedure, keyhole surgery tools, and a device for cutting or burning tissue (electrocautery).
Unlike typical keyhole surgery procedures, operations on patients undergoing weight loss surgery (bariatric patients) need longer access tubes (trocars) and keyhole surgery tools. This is because these patients have a thicker belly wall.
For a specific type of weight loss surgery called laparoscopic adjustable gastric banding, three 5 mm access tubes, one 15 mm access tube, a tool to move the liver aside (liver retractor), a bendy keyhole camera (angled laparoscope), and a special band that is placed around the upper part of the stomach (gastric band) are required. In the United States, there are two types of bands that are approved for use.
Who is needed to perform Laparoscopic Gastric Band Placement?
The operation needs a team of medical professionals each with a role to play. The team includes an anesthesiologist, who is a doctor responsible for putting you to sleep during the operation so you don’t feel any pain. It also includes a primary surgeon, who is the main doctor responsible for doing the operation. A scrub nurse helps the doctor by giving them tools and making sure everything is clean. The first assistant is another doctor or nurse who helps the surgeon during the operation. Everyone works together to make sure your operation goes smoothly.
Preparing for Laparoscopic Gastric Band Placement
Before starting the surgery, the patient will receive some necessary medications. Antibiotics will be given about half an hour before making the first cut, to help defend against potential infections. Another set of drugs will also be provided to prevent venous thromboembolism, a condition where blood clots form in the veins.
In preparation for the surgery, any hair on the abdomen will be trimmed away while patient is still in the pre-surgery area. The patient will then be carefully placed and secured on the operating table to ensure safety during the procedure.
Once the anesthetic has been given and the patient is asleep, a gentle device, known as an orogastric tube, will be placed inside the stomach. This is done to keep the stomach empty and safe during surgery. The patient is then positioned appropriately with their arms extended.
Next, the skin from the chest area (nipples) right down to the groin area (pubic symphysis) is thoroughly cleaned to reduce the risk of infection on the operative site. Pharmacy, surgery, and nursing teams will then perform a quick pause, or ‘time-out’ before the operation begins. This safety measure is taken to confirm the correct patient, the correct procedure, and the correct site of the operation.
How is Laparoscopic Gastric Band Placement performed
An adjustable gastric band procedure is a technique to promote weight loss by limiting how much a person can eat. Here’s an example of how this procedure is carried out using the pars flaccida technique.
1. The initial procedure is to prepare the abdomen and introduce the trocars (small tubes through which the surgical tools are passed). The surgeon stands between the patient’s legs, the assistant stands on the left side, and access to the abdomen for the operation is achieved via a specific needle. Several small incisions are made in the stomach area under the ribs, the surgeon puts in trocars here that allow for special surgical tools to be inserted.
2. The surgeon then checks the diaphragm area to look for any hernias. If any are present, these should be fixed at the start of the procedure. The surgeon can assess this by inflating a balloon and checking if it moves incorrectly. Minor and non-sliding hernias are repaired from the front, larger or sliding hernias are repaired from behind.
3. The surgeon then prepares the area for inserting the gastric band. They move the stomach to expose a membrane known as the pars flaccida. They then carefully open it wide enough for a special instrument to pass through. This is done without entering a specific cavity in the abdomen as doing so can cause future complications.
4. The gastric band is then brought to the surgical area through the trocar. The band is placed around the upper part of the stomach and locked in place, and it should be loose enough to move freely. If the band is too tight, additional fat is removed from the stomach area to ensure proper band placement.
5. The surgeon then stitches parts of the stomach together to protect the gastric band. The band is then rotated to a specific position.
6. The end of the tube connected to the gastric band is taken out of the body through the trocar. Once the band is in place, the special instruments and trocars are removed, and the air in the abdomen is allowed to escape. The end of the tube is trimmed and connected to a port (a small reservoir that lies beneath the skin), which is secured to the muscle layer beneath the skin.
7. After the procedure is finished, the incisions are stitched up, and bandages are placed on the wounds.
After surgery, the patient usually stays in the hospital and starts on a clear liquid diet. Depending on how the patient is feeling after surgery, they might be discharged the same day. Solid foods are not permitted until at least four weeks later.
The adjustable band around the stomach isn’t immediately filled with fluid. 4 to 6 weeks after surgery, the band is adjusted – filled with fluid – for the first time to limit how much food the stomach can hold. This is typically done under x-ray guidance. The patient will have follow-up appointments roughly monthly for the first year, and 2-3 times in the second postoperative year, to adjust the band and monitor their process. The aim is to encourage weight loss of about 0.5 to 1 kg (roughly 1 to 2 lbs) per week.
Possible Complications of Laparoscopic Gastric Band Placement
Gastric banding surgery, a type of weight loss procedure, generally has very low risk. The chances of dying from this surgery are very low, between 0.02% to 0.1%. There’s a 3% chance of having issues within the first 30 days after surgery, and a 12% chance of having problems later on. These figures can vary based on the source of information.
There can be a few complications that might happen soon after the surgery. These include blood clots, which can cause serious problems like blocking blood flow to the lungs, tearing of the esophagus or stomach (usually connected with an undiagnosed hiatus hernia), and obstruction caused by the gastric band being too tight. Doctors give patients medications to lower the risk of blood clots. Any tears found near where the band was placed might mean the surgery needs to stop, and if the band is too tight, it can be prevented by removing fat pads around the stomach.
Later on, complications can occur like the stomach moving upward through the device, referred to as “gastric prolapse” or a “slipped band”. This may result in sudden food intolerance or heartburn-like symptoms. Usually, the lower part of the stomach moves forward or backward past the band device; the forward movement is more common. Doctors can identify this problem by analyzing abdominal X-rays and then confirming with another type of X-ray where you drink a special liquid (barium) that coats your throat and stomach to make them show up more clearly on the X-ray. The immediate treatment is to deflate the band which can relieve symptoms. Then, a decision needs to be made about a repeat operation, and this could involve re-adjusting the band, removing it with or without replacement, or changing the bariatric procedure to another type like gastric sleeve or bypass.
Rarely, the stomach may not get enough blood leading to tissue damage and death (necrosis). The slip risk was more common in 1990s due to a different surgical technique that allows more stomach movement.
Another issue can be band erosion, when the band rubs against and wears down the stomach wall. This happens less often, between 1% and 2% of folks who’ve gotten gastric banding. These people might have delayed infections, stomach pain, or not feeling full even after the band is adjusted. Doctors usually find this problem using a special tool to look at the stomach (endoscopy). The treatment is surgery to remove the band and fix the stomach wall. The band can be replaced after 3 months.
Other complications can occur through device malfunctions, like leaks leading to a non-adjustable band, twisted tube, dislodged port, and port site infection. Leaks can happen through tubing disconnection, port puncturing or band puncturing. The port might dislodge from the tissue and flip, making it inaccessible.
Lastly, band obstruction can happen, mostly due to an overly inflated band, or a band placed too low due to technical mistakes or a missed hiatus hernia. This can lead to swelling of the outlet of the stomach and food pipe which can then result in difficulty swallowing. Long term, it can affect food pipe movement, leading to wider than normal esophagus or mimic narrowing of the lower end of the esophagus (achalasia). Finding the problem requires another special type of X-ray where you drink a barium liquid. The treatment is deflating the band and monitoring to make sure the dilated areas return to normal. If less invasive management doesn’t work, surgery to fix or remove the band might be required.
What Else Should I Know About Laparoscopic Gastric Band Placement?
The process of weight loss through a surgical operation called laparoscopic adjustable gastric banding is known to have widely different results. This procedure, which involves placing a band around the upper part of the stomach to create a small pouch for food, was one of the most commonly performed weight loss surgeries. In fact, in 2008, it made up over 40% of all weight loss surgeries across the globe.
Nowadays, fewer people opt for this surgery due to the revealing of long-term outcomes. Studies have shown that while this surgery can result in a significant weight loss between 33% to 60% of excessive weight, it doesn’t perform as well as gastric bypass surgery. Additionally, there’s a high likelihood of having to undergo another surgery to remove the gastric band, which ranges from 8% to 60%.
Surgeons suggest less use of gastric banding because of its unsatisfying long-term results coupled with the requirement for regular adjustments. Despite it being a low-risk procedure shortly after the operation, it can lead to patient dissatisfaction and low levels of sticking to the program, thus resulting in not so great weight loss outcomes. That said, some studies show that the risk of needing another surgery and removing the band is actually pretty low, from 1.2% to 3.7%, when looking at the long-term data.
This may be down to improvements to the surgery and better skills and expertise of the surgeon. There are other surgical procedures like sleeve gastrectomy (a surgery to remove a large portion of the stomach), which yield excellent long-term results, have low complications rates, and are relatively easy to perform. This could be compared to Roux-en-Y gastric bypass surgery, which is more complex. Before sleeve gastrectomy became popular, gastric banding was the go-to surgery for weight loss. Now, successful outcomes from sleeve gastrectomy likely contributed to the decrease in gastric band surgeries.