DOI:10.2214/AJR.07.2528
AJR 2008; 190:W128-W129
© American Roentgen Ray Society
Adjustment of Laparoscopic Banding Device with the Aid of an Angiographic Compression Device
Colin K. F. Tan1,2 and
Graham D. Walker1,2
1 Radiology Department and the Wesley Medical Centre, The Wesley Hospital,
Auchenflower, Queensland 4066, Australia.
2 Present address: Southern Xray Clinics, The Wesley Hospital, Chasely St.,
Auchenflower, Queensland 4066, Australia.
Received May 8, 2007;
accepted after revision September 9, 2007.
Address correspondence to G. D. Walker.
WEB
This is a Web exclusive article.
Abstract
OBJECTIVE. Adjustable laparoscopic gastric banding has been used as
a surgical means of weight reduction. Percutaneous access of the port for
adjustment can be difficult even if imaging guidance is used. We present a
novel use of an angiographic compression device to stabilize the port and
facilitate the adjustment procedure.
CONCLUSION. This technique has limited the need for multiple
puncture attempts, allowed more efficient access to the port, and reduced
radiation dose to the patient and operator.
Keywords: bariatric surgery • gastric banding • interventional radiology • port access
Adjustable laparoscopic gastric banding is used as a minimally invasive
surgical means of achieving weight loss in patients with morbid obesity
[1]. The technique is a
restrictive surgical procedure that is designed to limit food consumption and
thus promote weight loss. It relies on a silicone band that is
laparoscopically implanted around the proximal stomach above the lesser
omentum. The band functions to form a small fundal pouch also known as the
"neostomach." The band contains an inflatable inner cuff connected
by silicone tubing to a subcutaneously implanted port (Figs.
1A and
1B). The tightness of the cuff
is adjustable with injection or aspiration of fluid through percutaneous
access of the port. The port is usually secured to the rectus abdominis muscle
with sutures, and its depth therefore depends on the amount of subcutaneous
fat [2].
View larger version (110K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B — Photographs of adjustable laparoscopic gastric band
(Lapband, Inamed Health). Image of laparoscopic gastric band in position in
model stomach. Port that allows adjustment of band tightness is secured in
rectus abdominis muscle.
|
|
After an initial period of weight loss, there is usually a plateau period
during which the cuff requires further inflation to tighten the band. Most
devices are accessed by clinicians, often with the patient sitting, which
helps stabilize the port. However, an estimated 5% of ports are difficult to
access because the port is not palpable, the port does not lie perpendicular
to the skin surface, or the patient is needle-phobic. In these cases,
radiologic guidance is used to adjust the size of the cuff
[3–5].
Even with fluoroscopy, technical difficulties from the abundance of
subcutaneous fat can make access difficult. The port may also be tilted or may
tip if the access needle does not puncture the center of the membrane at right
angles to the face of the port.
Techniques that have been described to locate and puncture the port include
sonography, the use of a C-arm unit to line up an orthogonal approach to the
port, or traction of the skin to straighten an oblique port
[5,
6]. All of these approaches
have been used at our institution. Sonography usually gives the operator an
oblique angle to the face of the port and C-arm positioning without
compression does nothing to limit the mobility of the port in the abundant
soft tissue.
We present a simple technique that has been used at our institution to
stabilize the port before puncture.
The patient lies in a supine position and the port is localized with
digital palpation. An angiographic compression device (Compressar Universal
System, Instromedix), used to aid hemostasis after femoral artery puncture, is
placed over the port. The device consists of a base plate; a shaft; and a
movable, lockable arm slide (Fig.
2). The device measures 55 cm in height and the base plate
measures 34 cm wide. There are graduated centimeter markings on the shaft.
When lying supine, all of our patients have been able to fit between the arm
slide and base plate. Compression is applied with the vice mechanism on the
slide arm, stabilizing the port in the patient's subcutaneous tissue
(Fig. 3). A notch on the
plastic end plate of the compression device is visible on fluoroscopy and is
positioned over the port to facilitate a vertical needle approach
(Fig. 4A). Intermittent
fluoroscopy allows an easily adjusted hands-out-of-beam approach to the center
of the port, which is trapped by the compression, and the consistent firm
pressure of the device is well tolerated by patients. Once needle puncture is
successful, the cuff size can be adjusted accordingly by injecting small
quantities of water into the port. The tightness of the cuff is tested by the
patient swallowing water and ensuring that there is no immediate obstruction.
If cuff tightness is satisfactory, the slide arm is then released. This allows
loosening of the band if the cuff is too tight.
View larger version (121K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 4A — Anterior views of compression arm and end plate. Image of
compression arm and end plate over port on fluoroscopy (anteroposterior
view) in 40-year-old man. Swedish lap band port (Sagaband, Obtech
Medical) lies under compression device (Compressar Universal System,
Instromedix) with access point under notch. Needle is placed obliquely for
illustration, but more vertical approach is usually easier.
|
|
We have used this technique successfully for more than 5 years with more
than 200 procedures in patients weighing up to 200 kg, which is the weight
limit of our table. The main issues that we have encountered and needed to
overcome include multiple puncture attempts, inverted ports requiring surgical
intervention, and mobile ports. The technique is excellent in reducing port
mobility. Tilted ports are flattened by the compression, and our failures have
been in those few ports that have inverted, requiring surgical repositioning.
We have found that this technique has limited the need for multiple puncture
attempts, allowed more efficient access to the port, and reduced radiation
dose to the patient and operator.
References
- Hainaux B, Coppens E, Sattari A, Vertruyen M, Hubloux G, Cadiere
GB. Laparoscopic adjustable silicone gastric banding: radiological appearance
of a new surgical treatment for morbid obesity. Abdom
Imaging 1999; 24:533
–537[CrossRef][Medline]
- Szucs RA, Turner MA, Kellum JM, DeMaria EJ, Sugerman HJ. Adjustable
laparoscopic gastric band for the treatment of morbid obesity: radiologic
evaluation. AJR 1998;170
: 993–996[Abstract/Free Full Text]
- Pretolesi F, Camerini G, Bonifacino E, et al. Radiology of
adjustable silicone gastric banding for morbid obesity. Br J
Radiol 1998; 71:717
–722[Abstract]
- Wiesner W, Schob O, Hauser RS, Hauser M. Adjustable laparoscopic
gastric banding in patients with morbid obesity: radiographic management,
results, and postoperative complications. Radiology2000; 216:389
–394[Abstract/Free Full Text]
- Korenkov M, Sauerland S, Yucel N, et al. Port function after
laparoscopic adjustable banding for morbid obesity. Surg
Endosc 2003; 17:1068
–1071[CrossRef][Medline]
- Roy-Choudhury SH, Nelson WM, El Cast J, et al. Technical aspects
and complications of laparoscopic banding for morbid obesity: a radiological
perspective. Clin Radiol 2004;59
: 227–236[CrossRef][Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Abstract
References
