Laparoscopic adjustable gastric banding for morbid obesity - Home Study Program

AORN Journal, May, 2003 by Dorothy Roedel Ferraro

* restrictive lung disease,

* fatty infiltration of the liver and cholelithiasis, and

* hiatal hernia and gastroesophageal reflux disease.

Based on the health history and physical examination findings, tests such as polysomnography, nuclear stress testing, echocardiography, and endoscopy may be indicated. Cardiac, pulmonary, and endocrine consultations should be requested based on individual patient needs. Esophageal manometry and pH monitoring also may be considered when alteration in esophageal motility is suspected.

PERIOPERATIVE CONSIDERATION

Patients undergoing bariatric surgery need special consideration perioperatively. Their large body habitus and associated serious comorbidities make patients who are morbidly obese high-risk surgical candidates who require careful planning and implementation of patient care.

Equipment Facilities in which surgical procedures for the treatment of morbid obesity are performed must have equipment that can accommodate patients who weigh more than 350 lbs (159 kg). The OR bed and stretchers must have the capacity to accommodate patients who are super obese (eg, up to 770 lbs [350 kg]) and be able to rotate and tilt to gain adequate exposure. Most standard hospital beds, OR beds, commodes, scales, and wheelchairs are not adequate; however, there are a number of companies from whom these pieces of equipment can be purchased or rented. Extra-large patient gowns and blood pressure cuffs require a small investment by the hospital and should be stocked routinely. In addition to the standard equipment required for a laparoscopic procedure, a high-flow insufflator (ie, 20 L per min), extra-long trocars, and a retractor strong enough to atraumatically retract a large, heavy liver should be available. (37)

Positioning the patient is challenging, so additional padded safety belts, gel or foam pads, and large elastic bandages are needed to prevent injury and movement of the extremities during surgery. This patient population has a higher incidence of venous stasis disease, placing them at increased risk for deep vein thrombosis, and they should have proper-fitting pneumatic sequential compression devices applied in the OR.

Anesthesia. The preoperative anesthesia assessment should include

* a review of the patient's medical history;

* careful physical examination;

* laboratory screening;

* evaluation of cardiac size, lung pathology, medications; and

* a detailed assessment of the upper airway.

Rapid sequence induction with crycoid pressure is the preferred method for intubation. (38) Sodium citrate and [H.sub.2] antagonists are given preoperatively to increase gastric pH and block acid production. These are administered because of the increased incidence of gastroesophageal reflux disease and hiatal hernia in this patient population, which places them at higher than normal risk for aspiration pneumonitis.

Positioning the patient and surgical team. Favorable outcomes for laparoscopic procedures are dependent on a well-organized surgical team. Proper patient positioning can either facilitate the procedure or increase the level of difficulty.