Positioning

Patient in lithotomy – normal bariatric split leg position with arms out 

Ports 

Need 2 x 10mm (including scope) and a 5mm port

Don’t usually need a liver retractor but can put one in epigastric (nathienson’s) or RUQ (diamond flex)

Insufflation with Verress at Palmer’s point

(If previous port sites are in correct position, can be used…but there rarely are. DON’T compromise access!)

Procedure

Divide adhesions around the gastric band to the liver. Normally hook diathermy will suffice.

With the hook, diathermy onto the plastic of gastric band to free it from adhesions to the stomach. 

N.B. Be careful of burning onto stomach wall (ie. underneath the band) and stick to the upper border of the band to stay away from stomach wall. 

You need to free enough of the band for it to rotate freely around the stomach, to have the whole of the locking mechanism free and (ideally) to have opened any gastro-gastric tunnel. 

For dissecting the gastro-gastric tunnel use scissors and traction to show the plane between the 2 stomach walls. You should be aiming to cut through the sutures. 

With the Mid-bands, there are 2 “belt-strap” like thin plastic bits that you cut through. This releases the device. 

With Allergen, you can undo the strap to remove it or just cut through the band with scissors. 

Follow the arrows on the tubing to get as close to the abdominal wall as possible and cut the tubing.

Pull the band in a posterior direction around the back of the stomach and retrieve the band by grabbing the tube and pulling it all out through the 10mm port. If the band doesn’t come out of the retrogastric tunnel easily (particlarly with Allergen bands) consider cutting the band and retrieving in 2 pieces (but you MUST match all the pieces after extraction to make sure its all out)

Divide the fibrous capsule around the stomach by passing a Maryland between the capsule and stomach wall, opening the jaws to create a plane and then cutting with the scissors. Do this until completely across the capsule.

Grab both cut ends of the capsule with Yohans and stretch to make sure the stomach wall is able to expand.

Make a skin incision over the injection port  (if not used for an instrument port already) and cut through the capsule until metal is revealed. Grab this and retrieve it. 

(Make sure the metal bit between the flat part and the tubing is retrieved in a Mid-band)

Check that all the cut parts match each other perfectly, so that no-small parts are left inside.

Close fascia with PDS at accessible 10mm pot sites

3-0 monocryl to skin.

Post-op:

Free fluids overnight

If well the next day, can build up to normal diet. 

Be aware: 

If any doubt about stomach/oesophageal injury, consider an endoscopy or methylene blue test.