A step-by-step guide to placement of the LAP-BAND adjustable gastric banding system

The early promise of laparoscopic adjustable gastric banding was tempered by reports of high rates of gastric herniation or prolapse. These complications are a function of the operative technique used early on. At the time, in the early 1990s, the LAP-BAND device (INAMED Health, Santa Barbara, CA) was placed lower on the stomach, near the first short gastric vessel. The required perigastric dissection was difficult and variable in its extent, depending on the width of the stomach and where the surgeon began the dissection. To combat these problems, a new surgical method for placement of the band has evolved. Called the pars flaccida technique, it emphasizes minimal dissection and placement of the LAP-BAND out of the lesser sac. This leads to a higher position of the band, away from the body of the stomach. The technique serves to make band placement simple, safe, reproducible, and easily teachable, as well as to decrease the rate of gastric herniation or prolapse. Keeping the band out of the lesser sac, away from the peristalsing stomach, minimizing dissection of the attachments to the stomach, paying strict attention to gastric-to-gastric suturing, and leaving all fluid out of the band until at least 6 weeks after surgery appear to be the most important factors in reducing the incidence of this complication.