Laparoscopic Adjustable Gastric Banding: Bariatric Surgery

Introduction
Laparoscopic adjustable gastric banding (LAGB) is a bariatric procedure that involves placing an inflatable silicone band around the upper part of the stomach to create a small pouch. The band is connected to a subcutaneous port, allowing for adjustments to control the tightness of the band. While LAGB gained popularity due to its safety and simplicity, its use has declined in recent years due to higher rates of long-term complications and reoperations compared to other bariatric procedures.

Background and Patient Selection
LAGB is suitable for patients with a BMI ≥40 kg/m² or ≥35 kg/m² with obesity-related comorbidities. However, it is not recommended for patients with severe gastroesophageal reflux disease (GERD) or those who have undergone previous upper gastric surgeries, such as Nissen fundoplication, as these conditions may interfere with proper band placement or worsen symptoms. Two primary types of bands have been used: the Lap-Band and the Realize Band (formerly the Swedish Band). The Realize Band is no longer manufactured, but both bands function similarly, with differences in their port systems and attachment mechanisms.

Surgical Technique

1. Patient Positioning:
   • Place the patient in a reverse Trendelenburg position to facilitate access to the upper abdomen.
2. Port Placement:
   • Insert ports for the surgeon’s hands, assistant, telescope, and liver retractor.
   • Typically, two ports for the surgeon, one or two for the assistant, and one for the telescope are used.
3. Exposure and Dissection:
   • Divide the peritoneum at the angle of His and the gastrohepatic ligament in its avascular area (pars flaccida) to expose the right crus of the diaphragm.
   • Repair any hiatal hernia if present using a standard posterior esophageal dissection and suture repair.
4. Band Placement:
   • Pass a grasper from the right crus to the angle of His to create a tunnel behind the stomach.
   • Pull the band through this tunnel, ensuring it is positioned just below the gastroesophageal junction.
   • Lock the band into place using its self-locking mechanism.
5. Anterior Imbrication:
   • Secure the band by imbricating the anterior stomach wall over it with several sutures to prevent slippage.
6. Port Placement:
   • Bring the tubing of the band system out through a trocar site near the upper abdomen or xiphoid region.
   • Secure the port to the rectus sheath for easy access during adjustments.
7. Completion:
   • Ensure the band is initially empty, except for priming fluid.
   • Confirm proper placement and secure all ports.

Procedure-Specific Complications

1. Gastric Prolapse or Band Slippage:
   • Most common emergent complication, presenting with acute pain, dysphagia, and vomiting.
   • Diagnosed via plain radiograph (horizontal band position) or upper gastrointestinal (UGI) series.
   • Initial treatment involves removing fluid from the band. If symptoms persist, laparoscopic revision is required.
2. Band Erosion:
   • Occurs in 1–2% of cases, often presenting with port site infection or systemic fever.
   • Diagnosed via endoscopy or CT scan showing free air.
   • Requires laparoscopic band removal and repair of gastric perforation.
3. Port and Tubing Complications:
   • Includes port flipping, tubing leaks, or kinking, occurring in 5–15% of cases.
   • Repaired under local anesthesia by realigning or replacing the port/tubing system.
4. Weight Loss Failure:
   • Higher rates of insufficient weight loss compared to other bariatric procedures.
   • Band removal rates increase over time, with studies reporting up to 40.9% removal after 10 years.

Postoperative Management
LAGB requires ongoing follow-up and adjustments to achieve optimal results:

1. Band Adjustments:
   • Performed by injecting or aspirating saline through the subcutaneous port using a Huber needle.
   • Aim to reach the “sweet spot” of appetite control without causing obstruction.
2. Multidisciplinary Support:
   • Regular consultations with specialists to assess eating habits and provide dietary and behavioral support.
   • Monthly follow-ups during the first year, with adjustments as needed.
3. Nutritional Monitoring:
   • Unlike malabsorptive procedures, LAGB does not cause significant nutritional deficiencies.
   • Focus on healthy eating habits and portion control.

Mechanism of Action
LAGB works primarily by creating a small gastric pouch, which restricts food intake and promotes early satiety. The mechanism is believed to involve vagal nerve signaling, reducing hunger and appetite. Unlike other bariatric procedures, it does not alter the digestive process or nutrient absorption.

Conclusion
Laparoscopic adjustable gastric banding is a minimally invasive bariatric procedure with a favorable safety profile but higher long-term complication and reoperation rates. Proper patient selection, meticulous surgical technique, and lifelong follow-up are essential for success. While it has declined in popularity, it remains an option for select patients who can commit to regular adjustments and multidisciplinary support.