Lap Band® Procedure

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How it Works

The Lap-Band® is an adjustable band that is laparoscopically placed around a specific part of the upper stomach to create a small pouch that restricts the size of the meal.  The pouch is usually about the size of a chicken egg.  The device we use is of one of four used around the world but it is the only adjustable gastric band that has been FDA approved for use in the United States.  Since its approval in 2001, it has become a reliable alternative to the Roux-en-Y gastric bypass.  In Europe and Australia, the Lap Band® procedure is the most common operation performed for weight loss.  In the U.S., the Lap Band® appears to be gaining popularity because of its safety profile.  The Lap-Band® is a silicone ring lined with an adjustable internal balloon attached to tubing that connects to a port implanted under the abdominal wall at the top of the abdomen.

The Lap Band® Procedure

The Lap Band® is laparoscopically placed around the upper portion of the stomach just below the junction of the stomach to the esophagus. The band comes in two sizes; the 10cm and the larger VanGard®. As it comes out of the package, the band is like a belt with a buckle on one end. Using 5 to 6 small incisions, the liver is elevated out of the way and a path is created around the stomach to accommodate the band. Fatty tissue around the stomach must be removed and trimmed back to allow ample space for the band. The band is introduced into the abdomen and the band tubing is tunneled behind the upper stomach and used to pull the band around the upper stomach. The end of the tubing is then brought through the buckle until the band closes to form a circle. The upper part of the stomach is then sutured over the band to the left side of the pouch to fix the band in place and prevent it from slipping. Most patients are discharged on the day of surgery, however some may require overnight hospitalization if they live far away or they need closer monitoring of medical conditions. All patients receive a limited upper GI series prior to discharge to assure the band is in a proper positioning and is functioning normally.

Benefits of Surgery

The absence of a malabsorptive component in the Lap Band® procedure is extremely beneficial as this is the only current weight loss operation that carries no significant risk of vitamin or nutrient deficiency. Unlike RYGBP and DS patients, Lap Banders require a single daily multivitamin. They have no extra requirements for iron, calcium or B12. Their risks or osteoporosis and anemia are the same as other individuals of similar age and status.

Many skeptics of the Lap Band® predicted early on that although patients may loose weight, they will continue to have sustained problems from their associated diabetes, hypertension and other comorbidities. While most long-term Lap Band® studies were developed in Australia and Europe, the United States lagged behind because of delayed FDA approval of this device in the U.S.

Dr. Jamie Ponce, from Georgia published data on his first 402 Lap Band® patients in 2004. This publication established not only significant weight loss in an unselected group of patients, but fairly striking effects on those patients with diabetes and hypertension.
 

Advantages

While weight loss with the Lap-Band® is slower than with other more invasive procedures, the primary advantages of the Lap-Band® are its minimally invasive approach, reversibility, lower cost, and overall safety. Nutritional deficiencies are rarely seen with the Lap-Band® as there is no alteration in the path of ingested food and no bypassed segments of intestine.

• Lap Band® surgery is minimally invasive. The procedure lasts 45 to 60 minutes and 90% of patients are discharged home on the day of surgery. Most patients are able to drive in 1 to 2 days and are back to work within a week. The Lap Band® allows anonymity. It is the only weight loss procedure that allows patients to return to work quickly without friends or co-workers knowing about the surgery.
• Complications are rare and easily managed. There are no staple lines or areas for potential leaks. The procedure is safe and well-tolerated.
• Weight loss is gradual allowing excess skin more time to retract and potentially avoid reconstructive surgery later.
• Nutrient deficiencies are rare. The procedure works by decreasing food intake. However, there is no malabsorption as with other procedures. No additional supplements are required other than a daily multivitamin.
• The procedure is entirely reversible. If pharmaceutical companies develop effective weight loss medications, the procedure may become obsolete and the band may be removed with little consequence. That is not the case with other procedures.
• As third party payers become increasingly reluctant to cover weight loss surgery, many patients are either switching insurance coverage or paying all costs outright.
 

Complications of Surgery

Surgical complications of Lap Band® surgery are rare. There are no staple lines, no rerouting of intestines, and limited anesthesia time. The risks associated with Lap Band® surgery are the same as laparoscopic surgery in general. Bleeding may occur during the operation, which may require transfusion or reoperation through an open incision.

Swelling in the stomach wall inside the band due to a hematoma may create a temporary obstruction. This complication has been virtually eliminated as all patients receive a limited upper GI prior to discharge from the hospital.

Infections and hernias in the trocar site incisions are rare and inconsequential.

Patients who are morbidly obese are more likely to suffer consequences of their underlying health issues such as sleep apnea and diabetes with the resulting cardiac illness. The stress of anesthesia and laparoscopic surgery may precipitate a heart attack or rhythm disturbances related to underlying heart disease.


Port & tubing 5%
Obstruction 3%
Slippage 2%
Band erosion <1%
Removal <1%
Esophageal dilatation <1%
Mortality 0.1%

The most common complications the can occur with this procedure are related to the port and the adjacent tubing which are located under the skin. Monthly access of the port requires piercing the skin with a needle. This can drag bacteria that normally live in the skin down to the port and because it is a foreign body, can become infected. Most infections can be resolved with antibiotics, however port removal may be required if the infection is severe. The port may be quite deep in some individuals. This creates an increased potential for the needle to miss the port. Rarely, if the needle punctures the tubing, a leak can occur allowing the balloon to decompress and the patient looses all restriction as the balloon deflates. In this circumstance, the port and tubing must be replaced under local anesthesia. Remember, these can be a nuisance but are considered minor complications.

Complications related to the band itself are rare however; they may require urgent surgical intervention, as they can be the most serious. In certain circumstances, the pouch may enlarge through constant overeating and retching. A portion of the stomach below the band may actually be pulled up through the band and create incessant vomiting. This is called a slippage. It can be dangerous because the blood supply to the enlarged pouch can become closed off and the slipped portion of the stomach can rupture. A slippage is usually heralded by incessant vomiting and usually requires urgent treatment. An upper GI test often demonstrates the enlarged gastric pouch. Once discovered, the treatment is urgent decompression of the balloon and surgical repair of the slippage or temporary removal of the band.
 

Erosion of the band into the stomach occurs in less than 1% of patients. This complication may have more to do with placement of the buckle close to the wrapped portion of the stomach than erosion based on the band being too tight. Nevertheless, surgical intervention is usually required to remove the band laparoscopically or in some cases, the eroded band can be removed with an endoscope, thereby avoiding surgery altogether. Although this might be expected to be a disastrous complication, most patients who develop erosion of the band are not aware it has occurred.

During surgery great effort is taken to assure the loose fit of the band at initial placement. Removing the fat pad around the outside of the stomach is an essential part of the procedure to allow proper fitting of the band. Swelling after surgery is a normal occurrence, so a band that is placed loosely should be tolerated. If the band is ‘snug’ or there is excessive bleeding in the wall of the stomach creating a hematoma, then the band may actually be too tight from the onset and the patient will experience obstruction, the inability to tolerate even liquids without vomiting. This complication is avoided by making sure the band is placed loosely around the stomach at the time of surgery. We have elected to perform routine limited upper GI studies on all patients immediately after surgery before they are discharged home to assure proper positioning of the band and free flow of liquid contrast through the band.

Rarely, the elevated pressure in the pouch may be transmitted up to the esophagus and create esophageal dilatation. New onset heartburn or GERD months into successful weight loss is often the first sign of esophageal dilatation. A limited upper GI study readily identifies this condition which is easily reversible by letting the saline out of the balloon for 3 to 4 weeks and allowing the esophagus to contract back down to its normal diameter.

Overall, the risks associated with the Lap Band® are significantly less frequent and less serious as those with the other current surgical options for weight loss. It is important to remember that unlike gastric bypass and duodenal switch surgery, there are no staple lines, no cutting through tissues, and no rerouting of the stream of food flow through the digestive tract. The mortalities associated with Lap Band® procedures are mainly associated with pulmonary embolism, not by the band itself. This procedure is 9 times safer that the duodenal switch.
 

Lap Band® Fills

The Lap Band® is initially placed with the balloon empty. The first addition of saline to the balloon occurs no sooner than 4 weeks after surgery. Subsequent fills will be scheduled at 4-week intervals until you have reached satisfactory restriction. Any fill that occurs within 90 days after the date of surgery is covered in the cost of the procedure (90 day global period). After 90 days, Lap Band® fills will be charged to your insurance company, however, you will ultimately be financially responsible for the balance of the fee. Patients who finance their procedure will receive free fills for one year. After one year, they will be charged a standard fee for each fill.

The First Fill
The balloon is left empty when the band is first placed because the mere presence of the Lap Band® creates a sensation of satiety that can last up to 2-3 weeks after surgery. After Lap Band® placement, patients return to the office periodically for “adjustments” to gradually inflate the balloon and begin the process of restricting the outlet of the pouch. The first adjustment occurs 4 weeks after surgery. At that time, the doctor and the patient assess the patient’s progress and if appropriate, the patient will receive the first Lap Band® ‘fill.’

With the patient lying flat, the port is located and the skin over the port is cleansed with iodine and a small amount of local anesthetic is injected under the skin. A special non-coring needle is advanced into the port and a little over 1cc of saline is injected into the port. At this point, the patient sits up and is asked to drink a few sips of water to assess the effect of the added saline on swallowing. As the patient is sipping water, we are assessing whether or not the water is actually passing through the band or whether it is backing up into the esophagus. Pain or fullness in the area of the neck suggests the band is too tight and a small amount of saline is removed. More saline may be added if the swallowing test suggests inadequate restriction. After the patient is able to comfortably drink water feeling only a slight amount of restriction, the needle is removed from the port and the patient may leave.

Subsequent Fills
The effect of the first fill tends to wear off so it is not unusual for patients to report feeling restriction for 2 to 3 weeks after the first fill followed by the ability to tolerate larger portions and greater food volume. It is very important to have already scheduled your second fill appointment at the time you leave the office from your first fill. Those who fail to return within 4 to 6 weeks after their first or second fill can actually slow their weight loss or even gain weight depending on what and how much they are able to eat. Fills are sequenced at 4 week intervals until optimal restriction is reached.

Remember, the ultimate goal with the Lap Band® is to be limited to eating a ½ cup portion of solid food and feeling full or nearly full and staying full for 3 to 4 hours. If a ½ cup portion of solid food fills you but you become hungry again in one hour, then you will likely begin snacking and dramatically slow down your weight loss. If you find yourself wanting to snack 1 to 2 hours after a filling meal, then you may not have enough restriction and you may need to come in for another fill. If you require 1 or 2 cups of food to gain a sense of fullness, then you clearly need more restriction and another fill. You should call schedule an appointment for a fill.

At times, people may find that solid foods are painful or just won’t stay down. If this happens, make sure you are eating slowly, taking small bites, and eating the right kinds of foods. If foods are coming back up and you are eating appropriately, then your band may be too tight and may need saline removed from the balloon. Some people actually try to achieve a state of excessive restriction to enhance their weight loss. This is unwise and may be harmful; it doesn’t work and it can lead to a slipped band requiring emergent surgery and removal of the band and possibly a portion of the stomach. Excessive restriction may lead to poor food choices and paradoxical weight gain.
 

Over the next several months, patients may receive 3-4 fills targeting weight loss of 1 to 2 lbs. per week or 8 to 10 lbs. per month. There may be periods of slow weight loss or plateaus early on as patients adjust to increasing restriction. Some people catch on quickly and learn how to use the Lap Band® as a tool to maximize weight loss. Success comes rapidly to those who embrace the suggested guidelines and avoid eating snacks, chocolates or ice cream. They listen to their pouch, not to their brain. When the pouch says”I’m full!” they stop eating. (The pouch never lies.) Your brain however will lie. It will try to talk you into ‘just on more portion’ or ‘one more bite.’ Patients learn quickly that when their pouch is full it will not accept more food. ‘One more bite’ will get half way down and then burp right back up into their mouths.

It may take several months to learn to break old eating habits that have been learned over a lifetime. For some, taking small bites, chewing carefully, and finishing a meal in 30 minutes are behaviors that were never learned. Learning to slow down during meals and choose healthy foods takes time.

After the 3rd or 4th fill, most patients have grown to understand the mechanics of the band and their small gastric pouch. They have learned that there is life with out milk shakes or chocolate. The concept of using their band as a weight loss tool becomes real. As the weight and inches come off, so do some of the medicines. Sleeping without a CPAP machine or being able to tie ones shoes may seem like small things, but they are really BIG. Playing with grandchildren or going to the mall again become powerful motivators to stay with the program. Over time, saline may diffuse slowly out of the balloon, requiring occasional ‘top offs’ once or twice a year.

After-Fill Instructions
Patients are advised NOT to eat a meal just before a fill. If the fill is in the morning, you may drink liquids; tea, coffee, milk or a protein drink. Do not eat a solid breakfast. If the fill is scheduled for the afternoon, a small breakfast is advisable but do not eat lunch before the fill. We want your pouch empty before we add saline to the balloon.

Immediately after a fill, the stomach wall swells slightly inside the band that lasts 1 to 2 days. For this reason, we ask that you stay on liquids for two days after a fill. For example, if your fill is on a Thursday, you should stay on liquids all day Thursday and all day Friday. Two days later (Saturday), you may start on soft foods. Soft foods are those through which a fork easily pushes through like scrambled eggs, mashed potatoes, and cream of wheat or yogurt.

The third day after a fill (Sunday), you may have solid foods. Avoid bread, beef and pork for a week after a fill. These are foods that do not go through your band initially. This is the time to begin new eating habits. Serve yourself smaller portions, take small bites, chew your food 27 times, and slow down! No ‘drive-through’ meals.
 

Problem Foods

Any food that is not fully chewed, consumed too quickly, or too large a bite is a problem food.
Dry or leftover meat
Pork and roast beef (even if moist)
Steaks
Shrimp
Untoasted or doughy bread
Asparagus, celery, dried fruits
Pasta and sticky rice
Citrus fruits
Potato salad
Hot dogs, kielbasa, brats, sausage (remove skin)
ABSOLUTELY NO chewy candy (it gets caught in the band) like Carmel Chews, Mentos, Bits o’ Honey, Gummie Bears, Rolos, Tootsie Rolls, taffy.
 

Eating Tips

Fill up on proteins first. Some people imagine their pouch as if it were a funnel. As saline fills the balloon over time, the bottom of the funnel becomes narrower and the sensation of fullness occurs with less food. That is the basic strategy used by restrictive procedures. The more solid the meal, the longer the pouch stays full. Longer periods of satiety lead to fewer calories ingested and greater weight loss over time. Lap Band® patients learn quickly that softer foods like mashed potatoes, macaroni and cheese, and ice cream pass through the band easily. They may fall into unhealthy eating habits that override the benefit of the band called the “soft calorie syndrome.” One easy way to avoid the soft calorie syndrome is to fill up on protein first. That means fill up on chicken, fish or vegetables before you eat the mashed potatoes. Proteins like beef, fish, and chicken are healthier food choices anyway.

Avoid drinking during meals. The same principle applies to keeping the pouch full as long as possible. All patients who undergo weight loss surgery need to drink 36 ounces of water daily; the trick is to get your liquids in ½ hour before the meal and stop drinking around the meal to avoid washing the meal out of the pouch.

Chew your food 27 times. Take small bites and chew slowly and deliberately. Certain meats, especially beef and pork are very dry and may be difficult to digest initially. The more chewing you do on the front end, the more comfortable you will be after the meal.

Slow down. Eating with family or friends at work requires skill and focus. Why? Because when we eat with others, we tend to take larger bites and chew less. The average meal in this country lasts 12.5 minutes! Lap Band patients simply cannot eat that quickly any more. Drive-through window meals are no longer compatible with the new eating habits needed to have successful weight loss.
While sitting down to a meal, look at your watch and make more deliberate plans to finish the meal in 30 minutes.

Exercise. Most people begin feeling better after loosing only 20 or 30 pounds. They experience greater energy, they sleep better and their mood brightens. This is the time to seriously look at developing new habits. Getting into the habit of walking daily or spending 30 minutes at the gym pays huge benefits to your long-term success and longevity. Running a marathon is not necessary, exercising to a sweat improves your cardiovascular efficiency and protects your body from muscle wasting and improves tone.

Vomiting. Most people experience ‘productive burping’ or P-Bing occasionally and some more than others. P-Bing is the same as regurgitation and little force around the band is required for P-Bing. Vomiting however requires a forceful contraction of the stomach that propels food out of the pouch, up the esophagus and out of the mouth. Vomiting is an undesirable event for those with Lap Bands®. Repeated vomiting may create a band slip that is considered an emergency. Therefore, it is advised that patients who experience persistent vomiting call us at 615 284-2400. Vomiting is the enemy of this procedure. Most vomiting is temporary, however we recommend that patients who experience vomiting begin drinking liquids for 48 hours to allow time for any swelling inside the band to diminish.