Optimization of access-port placement for the lap-band system

The technical aspects of access-port (AP) placement are not generally described in Lap-Band series.

From November 2000 to April 2002, we performed Lap-Band procedures laparoscopically on 180 patients. A retrospective review was conducted of 3 consecutive AP-placement techniques in nonselected and demographically identical groups. In Group A (n=48, Nov. 2000 to July 2001), the AP was placed at the left subcostal margin. In Group B (n=23, Aug. 2001 to Sept. 2001), the AP was tunneled over the subcostal fascia towards the subxiphoid area. In Group C (n=109, Oct. 2001 to Apr. 2002), the AP tubing was tunneled over the subcostal fascia and connected to the AP, which was inserted through a 3-cm subxiphoid incision.

AP-related problems occurred within the first few months following surgery. In Group A, 24 of the APs (50%) were tilted, and 14 (29%) were completely flipped over. 11 APs (23%) were found to be broken. 19 patients (40%) underwent an additional AP-related procedure. In group B, 12 APs (52%) were tilted and 1 patient required surgery to turn the AP. In Group C, 8 APs (7%) were turned slightly. 1 AP was found to be broken and required surgery to replace it. In this group, all APs were accessible for adjustment in the office.

Tunneling the AP along the left subcostal area is an important technique to protect the AP system from breakage, by changing AP-tube position from vertical to horizontal in relation to abdominal wall movement. This technique also keeps the AP-tube connection over the fascia and protects it from "wear and tear" forces. The addition of fixation at the subxiphoid location helps maintain a straight orientation of the AP for easier adjustments.