Laparoscopic gastric banding and individual bariatric surgery

Different factors (strategic, anatomical, instrumental, etc.) can cause difficult surgical situations, especially in bariatric surgery. In a difficult surgical situation, the surgeon faces a dilemma as to whether to continue the intended operation "at all costs" or to deviate from the initially planned surgical procedure to some alternative technique or procedure. The dilemmatic nature of the difficult surgical situation in bariatric surgery has motivated us to discuss the following aspects because they all contribute to the problem: standards in bariatric surgery, deviation from standards, the role of experts, and the focus of research. We also propose to classify bariatric patients according to intraoperative difficulty (I to IV) as: (I) ideal cases (i.e., easy to operate, no problems), (II) not quite ideal cases (some minor difficulties may occur), (III) problematic cases (difficult to operate, some operative techniques are considerably more difficult than others), and (IV) very difficult cases (every operative step is difficult). We discuss the establishment of a registry of difficult surgical situations including the possibilities of deviating from the standard. Scientific analyses of such registries should focus on patients with apparent modifications in treatment (process deviations), but might also look at those with surprisingly good or bad results (outcome deviations). The technical steps of laparoscopic adjustable gastric banding (LAGB) have been chosen to illustrate this concept.