Laparoscopic adjustable gastric banding for morbid obesity - Home Study Program

AORN Journal,  May, 2003  by Dorothy Roedel Ferraro

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Laparoscopic gastric banding generally is performed with the patient in a modified lithotomy position (Figure 5). After the anesthesia care provider has induced the patient under general anesthesia, the circulating nurse inserts a Foley catheter and places intermittent pneumatic sequential compression devices on the patient's legs. The circulating nurse and several other surgical team members cooperatively place the patient's legs in well-padded, bootlike, low-lithotomy stirrups. They ensure that the patient's hips and knees are not hyperextended. The anesthesia care provider and circulating nurse either tuck the patient's arms at his or her sides or extend them at less than a 90-degree angle on well-padded OR bed armboards. When positioning patients who are obese, surgical team members take care to ensure that the patient's extremities are adequately supported and secured to prevent nerve injury and movement during the surgical procedure.

[FIGURE 5 OMITTED]

The surgeon stands between the patient's spread legs, and the RN first assistant stands on the patient's left side. Some ORs are equipped with booms suspended from the ceiling that can accommodate the laparoscopic monitor. If these are not available, the circulating nurse positions the monitor as close as possible to the left or right side of the patient's head.

Intra-abdominal access and trocar placements. Laparoscopic intra-abdominal access can be achieved by either an open technique using the Hasson cannula or a closed technique using the Verres needle. The surgeon determines which of the two methods to use to enter the abdominal cavity. One of the more common sites for access is the umbilicus; however, alternate site access and insufflation at the left upper quadrant or left subcostal region is possible. When using a left subcostal approach, as the Verres needle passes through the anterior and posterior fascia and the peritoneum, three distinct clicks should be audible.

It also is imperative to perform a saline drop test, which helps ensure safe passage into the peritoneum without injury to any solid or viscous organs or vascular structures. When the surgeon has inserted the Verres needle using the three-click method, he or she attaches a 10-mL syringe to the Verres needle and aspirates back. Withdrawing any fluid or material, such as blood, intestinal content, stool, or urine indicates that the needle has punctured an organ and requires remedial action. If no fluid or material is withdrawn, the surgeon drops several milliliters of saline into the Verres needle. The saline flowing easily through the needle confirms that it is safely in the peritoneal cavity.

The surgeon achieves pneumoperitoneum to a level of 15 mm Hg. He or she then strategically places five or six trocars that vary in diameter (ie, 5 mm, 10 mm, 12 mm) using laparoscopic vision. One 15-mm trocar also is placed for introduction of the laparoscopic adjustable gastric band into the peritoneal cavity (Figure 6). The site of the 15-mm trocar usually is the largest incision so the surgeon can place the laparoscopic adjustable gastric banding system access port subcutaneously and anchor it to the anterior rectus fascia.