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Fig. 27.11 Vagotomy. Hill-Barker’s procedure
21927 Minimally Invasive Surgery for Treatment of Complications …
Fig. 27.9 Finney U-shaped pyloroplasty
4. Jaboulay gastroduodenostomy (Fig. 27.10)
In this case, a longitudinal incision is made in the proxi-
mal duodenum and an independent incision in the distal
antrum, leaving the pylorus intact. Then, a gastroduode-
nal anastomosis is performed.
5. Vagotomy
Three types of vagotomy are recommended in these cases:
1. Tronchular vagotomy: Anterior and posterior vagus
are dissected in the wall of the abdominal oesophagus, and both of the vagus are clipped and resected.
2. Supraselective vagotomy: All branches of the vagus
are clipped and sectioned in the lesser curvature.
3. Hill-Barker’s procedure (Fig. 27.11): Posterior trun-
cal vagotomy with anterior highly selective vagotomy.
1. Gastroenteroanastomosis
Two possible types of gastroenteroanastomosis are
described in this chapter:
Fig. 27.10 Jaboulay gastroduodenostomy
220 J. A. Ramírez et al.
1. Antecolic gastroenteroanastomosis: After greater
omentum has been sectioned, jejunal limb is selected to
perform a side-to-side gastrojejunal anastomosis with manual or mechanical sutures.
2. Retrocolic gastroenteroanastomosis: After transver-
sus mesocolon has been opened a jejunal limb is ascended
through mesocolon’s hole. Then a side-to-side gastrojejunal anastomosis is performed with manual or mechanical
sutures.
References
1. Mouret P, Francois Y, Vignal J, et al. Laparoscopic treatment of perforated peptic ulcer. Br J Surg. 1990;77(9):1006.
2. Søreide K, Thorsen K, Harrison EM, et al. Perforated peptic ulcer. Lancet. 2015;386:1288–98. https://doi.org/10.1016/
S0140-6736(15)00276-7.
3. Byrge N, Barton RG, Enniss TM, et al. Laparoscopic versus open
repair of perforated gastroduodenal ulcer: a National Surgical
Quality Improvement Program analysis. Am J Surg. 2013;206:957–
62. https://doi.org/10.1016/j.amjsurg.2013.08.014 (Epub 2013 Oct
8).
4. Bertleff MJ, Lange JF. Laparoscopic correction of perforated
peptic ulcer: first choice? A Review of Literature Surg Endosc.
2010;24:1231–9. https://doi.org/10.1007/s00464-009-0765-z (Epub
2009 Dec 24).
5. Konaté I, Diao ML, Cissé M, et al. The surgical treatment results
of ulcerous pyloro-duodenal stenosis: about 160 cases. Mali Med.
2010;25:18–21.
6. Fadil A, Moumen M, Bellakhdar A et al. Pyloroduodenal
stenosis of ulcer origin. Apropos of 260 cases. J Chir
(Paris). 1992;129:27–30.
Laparoscopic Adjustable Gastric Band
Jaime Ponce
28
28.1 Introduction
Laparoscopic adjustable gastric banding (LAGB) was one
of the most used bariatric surgery procedures in the world
with acceptable outcomes in weight loss and remission of
comorbidities. It was described at the first time by Hallberg
and Forsell in 1985. One year later, Kuzmak implanted a
silastic band with an inflatable small diameter inner balloon.
In 1990s, Catona and Broadbent in Australia implanted
nonadjustable gastric bands laparoscopically. Posteriorly
Belachew described the first laparoscopic placement of an
adjustable band in 1993, using the perigastric technique,
and Forsell in 1996 used the pars flaccida dissection to
avoid some of the complications experienced in nonadjustable banding like gastric prolapse. A third approach combining these techniques was described by Weiner in 2000.
Patients after gastric banding require monthly visits during the first year to assess the need for band adjustment to
avoid over distension of the lower esophageal contractile
segment above the band. This follow-up includes explorations with fluoroscopy and contrast swallow on a routine
basis to assess the anatomy and band position [1].
Outcomes of this technique are good. The weight loss is
slow and gradual. Reported medium and long-term outcomes
show a great variation in weight loss results from 25 to 70%
of excess weight [2]. There have been two prospective multicenter FDA-monitored clinical trials in the United States.
The Lap-Band trial A [3] recruited 259 patients from 1995
to 1998 with band implanted laparoscopically by perigastric
dissection. The average percent excess weight loss (%EWL)
was 34.5% at first year, 37.8% at second year, and 36.2% at
third year after surgery. The Swedish Band clinical study [4]
recruited 276 patients in 2003 with laparoscopic pars flaccida
technique. The mean %EWL at 3 years was 41.1%.
In comparison with other techniques, Angrisani et al.
[5] randomized 51 patients and allocated them to undergo
either banding (n = 27) or gastric bypass (n = 24). At
5 years after the procedure, the band patients had an average %EWL of 47.5% versus 66.6% for the gastric bypass
group. Nguyen et al. [6] randomized and followed 86
patients with gastric banding and 111 with gastric bypass,
obtaining similar results. Buchwald et al. [7] published
a meta-analysis and systematic review that included 136
studies with 3,873 LAGB patients. The mean %EWL was
47.5%, with 2 years or less follow-up reported. O’Brien
et al. [8] analyzed 4,456 band patients with good results:
%EWL at 1, 3, 5, and 8 years were 42.6, 57.5, 54, and
59.3%, respectively. In summary, the median weight loss
for the LAGB studies with more or equal than 10-year
follow-up is 48% EWL with a range of 33–60% [9] and a
wide variability of revisions or reversals (8–60%) [9].
LAGB is proving to be an acceptable form of bariatric
surgery because of its safety, effectiveness, long-term weight
loss, and reversibility. Weight loss is variable ranging from
36 to 56% of the excess body weight at 3–5 years and an
average of 48% at long-term follow-up (>10 years) with a
wide range of revisions and removals. Lately, there has been
some discouragement with band intolerance, weight regain
and other clinical issues requiring band explantation and in
some cases, conversion to other procedure.
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_28) contains
supplementary material, which is available to authorized users.
J. Ponce (*)
CHI Memorial Hospital, Chattanooga, TN, USA
e-mail: jponcemd@gmail.com
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_28
28.2 Description of the Surgical Technique
(Video 28.1)
1. Patient and trocar position
The correct position to perform this technique is a
lithotomy supine position with arms extended, surgeon
221
222 J. Ponce
Fig. 28.1 Position of patient and trocar’s placement. Real (a) and schematic view (b)
Fig. 28.2 Dissection of the angle of His. Close (a, b) and schematic view (c)
standing between the patient’s legs, camera holder on the
5. Hiatal crura repair (Fig. 28.5)
left and assistant on the left of the surgeon (Fig. 28.1).
Five ports are used: 4 of 5 mm and 1 of 15 mm.
2. Dissection of the angle of His (Fig. 28.2)
After placement of the liver retractor, a small incision is performed on the left side of the gastroesophageal junction within the gastrophrenic ligament. Then
6. Creation of a retroesophageal window (Fig. 28.6)
a minimal blunt dissection of the angle of His is necessary by means of the articulated dissector type
“Goldfinger”, preserving the gastrophrenic ligament.
3. Pars flaccida dissection (Fig. 28.3)
7. Introduction of the band device
In this step, it’s necessary to open the pars flaccida to
expose the right crus.
4. Hiatal dissection (Fig. 28.4)
A correct dissection from the anterior border of the right
crus at its most lower aspect (hiatal “V”: confluence of the
right and left pillars of the right crus) must be realized.
If laxity of the right crus posteriorly, this is repaired
by approximating both pillars by means of EndoStich
(R) or standard stitches. All sliding hiatal hernias are
reduced with full mobilization of the distal esophagus,
followed by repair.
By blunt dissection by means of an articulated
dissector-type Goldfinger, a retroesophageal window is
created in direction to the angle of His.
The band is introduced into the abdomen using the
15 mm trocar (Fig. 28.7). The end of the tube is pulled
through the retroesophageal tunnel from the His to the
right (Fig. 28.8). The whole tube has to pass in order to
place the band properly.
Fig. 28.3 Dissection of the pars flaccida and right crus. Close (a, b) and schematic view (c)
22328 Laparoscopic Adjustable Gastric Band
Fig. 28.4 Hiatal dissection. Close (a, b) and schematic view (c)
Fig. 28.5 Hiatal crura repair. Close (a, b) and schematic view (c)
224 J. Ponce
Fig. 28.6 Creation of a retroesophageal window. Close (a, b) and schematic view (c)
8. Band locked
The locked band should not be tight on the cardias
(Fig. 28.9). Once the band is correctly placed around
the cardias, the band is locked (Fig. 28.10). The band
should rotate freely around the cardias. Otherwise the
band needs to be unbuckled and more perigastric fat
must be excised.
9. Anterior (superior) gastro-gastric fixation of the
band (Fig. 28.11)
Anteriorly, a plication of the fundus below the band to
the upper gastric pouch is performed (2 stitches).
10. Inferior fixation of the band (Fig. 28.12)
With one stich, from the fundus to the high lesser curvature, the band is inferiorly fixed.
11. Placed the port subcutaneously (Fig. 28.13)
The distal tube is exteriorized through an abdominal opening to assemble this end with the adjustment
access port. With four cardinal stitches the pouch
is fixed to the anterior fascia of the anterior rectus
muscle. The pouch is placed subcutaneously, not to
superficial. The port is fixed to the anterior rectus fascia
by four cardinal stitches.
12. Accessing the port and adjustment of the band
(Fig. 28.14)
Injecting saline through the access port of the band
will tight it around the upper stomach. In this way the
passage of food from the esophagus to the stomach is
Fig. 28.7 Introduction of the band device into the abdomen
reduced.
Fig. 28.8 Passing the
band tubing. Close (a) and
schematic view (b)
22528 Laparoscopic Adjustable Gastric Band
Fig. 28.9 Locking the band. Close (a, b) and schematic view (c)
226 J. Ponce
Fig. 28.10 The band is locked
Fig. 28.11 Anterior-superior gastro-gastric fixation of the band. Close (a, b) and schematic view (c)
Fig. 28.12 Inferior fixation
of the band. Close (a) and
schematic view (b)
22728 Laparoscopic Adjustable Gastric Band
Fig. 28.13 Placed the port subcutaneously. Close (a) and schematic view (b, c)
References
1. Ponce J. Laparoscopic adjustable gastric banding: technique and
outcomes. In: Nguyen NT, Blackstone RP, Morton JM, Ponce J,
Rosenthal RJ, editors. The ASMBS Textbook of Bariatric Surgery.
New York: Springer; 2015. p. 193–204.
2. Ponce J, Dixon JB. 2004 ASBS consensus conference.
Laparoscopic adjustable gastric banding. Surg Obes Relat Dis.
2005;1:310–6.
3. Ren CJ, Horgan S, Ponce J. U.S. experience with the lap-band sys-
tem. Am J Surg. 2002;184:46S – 50.
4. Phillips E, Ponce J, Cunneen SA, Bhoyrul S, Gomez E, Ikramuddin
S, et al. Safety and effectiveness of realize adjustable gastric band:
3-year prospective study in the United States. Surg Obes Relat Dis.
2009;5:588–97.
5. Angrisani L, Lorenzo M, Borelli V. Laparoscopic adjustable gastric
banding versus roux-en-y gastric bypass: 5-year results of a prospective randomized trial. Surg Obes Relat Dis. 2007;3:127–33.
6. Nguyen NT, Slone JA, Nguyen XM, Hartman JS, Hoyt DB. A
pro-spective randomized trial of laparoscopic gastric bypass versus
laparo-scopic adjustable gastric banding for the treatment of morbid
obesity. Outcomes, quality of life, and costs. Ann Surg. 2009;250:
631–41.
7. Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W,
Fig. 28.14 Accessing the port and adjustment of the band.
Schematic view
Fahrbach K, et al. Bariatric surgery. A systematic review and
meta-analysis. JAMA. 2004;292(14):1724–37.
228 J. Ponce
8. O’Brien PE, McPhail T, Chaston TB, Dixon JB. Systematic review
of medium-term weight loss after bariatric operations. Obes Surg.
2006;16:1032–40.
9. O’Brien PE, McDonald L, Anderson M, Brown WA. Long term outcomes after bariatric surgery: fifteen year follow up of adjustable
gastric banding and a systematic review of the bariatric surgical literature. Ann Surg. 2013;257(1):87–94.