Laparoscopic Adjustable Gastric Banding for the Obese Teenager
This video presents a Laparoscopic Adjustable Gastric Banding procedure involving an obese teenager. The procedure was performed at the Morgan Stanley Children’s Hospital of New York-Presbyterian.
At the Morgan Stanley Children’s Hospital of NY Presbyterian (MSCHONYP) obese teenagers age 14-18 may be considered for bariatric surgery if they have met the recommended adult criteria set forward by the NIH in 1991.
Laparoscopic adjustable gastric banding (LAGB) is offered since its history of safety, success, and adjustability (as well as reversibility) is believed to provide the best combination for adolescents. Each patient undergoes rigorous screening that includes evaluations by endocrinologists, psychiatrists, nutritionists, nurse practitioners, and surgeons. Even if a patient comes with documented prior trials at weight loss therapy, they need to meet with the team for several months so that a thorough evaluation can be provided and it can be determined what factors (e.g., home environment, eating habits, psychological state) might contribute to or interfere with a successful outcome.
For patients who undergo surgery, they are followed for at least 5 years to monitor their progress and provide whatever is necessary to help them lose weight. The FDA has granted the Morgan Stanley Children’s Hospital of NY Presbyterian approval to implant bands in the 14-17 age group following protocol accepted by them and by Columbia University’s Investigation Review Board.
Prior to surgery, each patient is placed on a liquid protein-based diet for 10-14 days. This reduces the fat present in the liver and can make the procedure easier.
On the day of surgery, the patient is brought to the operating room after voiding and positions himself/herself on the OR table. Venous compression boots are applied. All pressure points are padded. General anesthesia is induced. The patient is then given 2 grams of cefalothin and 5000 units of subq heparin. The patient’s abdomen is prepped with pridone-iodine solution and draped.
All cases are recorded on DVD for review and for teaching purposes.
The abdomen is entered just below the ribs in the left upper abdomen near the middle of a line drawn down from the clavicle. A clear spreading device is used atraumatic port loaded with a 0-degree 5 mm lens to accomplish this. Once in the abdomen, it is insufflated with CO2 to 15 mmHg pressure. The patient is tilted into steep reverse Trendlenberg position (head up). The lens is changed to a 5 mm 30-degree scope. A 5 mm screw-in port is placed in the right upper abdomen approximately mirroring the one on the left. Between the ports and somewhat superiorly and to the left, a small incision is made and the Nathanson liver retractor (usually medium blade) is inserted; this is attached to a stem that is fixed to the operating table at the start of the case. A 3 cm incision is made in the area between the ports and a 15 mm atraumatic port is inserted. A fourth port is placed lateral and below the port in the left upper abdomen.
With the Nathanson blade holding the left lobe of the liver up, the gastroesophageal junction is identified, or more specifically, the fat pad at this location. If prominent, a portion of it may be removed. At this point the scrub nurse is asked to prime the band being used, having made an assessment of the proper size at this point. Following it to the left and posteriorly the left crus of the diaphragm is encountered, the first landmark. Cautery is used to open the peritoneum in this area and expose a small portion of the crus. Then, doctors turn to the right side of the stomach and create a window above the left gastric vessels. The pars flaccida (gastrohepatic ligament) is identified and opened to identify the right crus. Where the crus meets the retroperitoneal fat, a small opening is made with cautery and a long grasper is passed through the right upper abdomen port gently behind the stomach to pass into the space opened on the left.
The primed band is passed through the 15 mm port into the abdomen. The end of the tubing is then passed behind the stomach at the site of dissection and the band is locked in placed upon itself. The fundus of the stomach is then imbricated over the band with nonabsorbable sutures. The tubing is brought out through the 15 mm port, which is removed. The Nathanson retractor is removed. The fat at that wound is opened down to the fascia. The tubing is connected to the primed injection port. Four nonabsorbable heavy sutures are placed into the fascia of the wound (in quadrants) and the port is secured deep into the abdominal wall. The excess tubing is fed back into the abdomen. Doctors look inside to check to see that there are no problems with tubing or bleeding. Remaining ports are removed. The large incision is closed in layers, and all other sites are closed. Dressings are applied.