Laparoscopic gastric banding
Laparoscopic gastric binding:
• Pre-operative interview:
– Age, residence, cardiovascular disease, lung disease, OSA, GERD, DM, smoking hx
– Facial hair, height, weight, BMI, previous surgeries, drug allergies, family history
– PONV, hypertension, neck motility, digital pictures
• Pre-operative medications on the day of surgery:
– Scopolamine patch behind ear
– Pepcid 20 mg and Reglan 10 mg IV
– Bicitra 30 ml po
• Pre-operative considerations:
– Troop elevation pillow, chin higher that chest
– Inflatable transfer mattress
– Extremity padding
– Fresh soda lime
– Modest reverse Trendelenburg
– Versed 2-3 mg and fentanyl 75-100 mcg (to lessen sympathetic response)
– Defasciculation with rocuronium 5 – 7 mg
– Vigorous preoxygenation
– Neuromuscular block monitor on
– Cefazolin 1 gram IV
– Difficult airway equipment – bougee, light wand, ILMA, Levitan, blades, etc.
• Induction:
– Propofol and succinylcholine
– Cricoid pressure
– Twitch diminution
– Secure airway
– Surgeon nearby for tracheotomy if needed
• Maintenance of anesthesia:
– Lidocaine or labetalol prn
– Rocuronium 30 mg
– Desflurane (sevoflurane 2nd choice)
– Mechanical ventilation @ 10 ml/kg and 5-10 ml of water PEEP
– Zofran, Phenergan, Decadron IV
– Placement of gastric tube
– Suction of stomach, esophagus, and pharynx as gastric tube is pulled
– Ketorolac 60 mg IV as case ends
• Emergence:
– Propofol or lidocaine to smooth wakeup
– Full reversal of NMBA’s in all patients
– Following commands at extubation
– Semi-upright positioning during transport
Lap Band Protocol
aparoscopic gastric banding (LGB) is an effective surgery to aid in weight loss and is an acceptable procedure for same-day surgical centers. Although this procedure does not involve bowel anastomosis, it is a major laparoscopic abdominal procedure, carrying with it a set of risks and possible complications. Patients undergoing this procedure are morbidly obese and have a higher proportion of co-morbid health factors than the general public. These factors include obstructive sleep apnea, hypertension, and gastroesophageal reflux disease. Thus, selection of anesthetic agents, airway management, surgical technique, and post-operative care are critical factors is patient safety and success of the procedure.
The following guidelines will apply to all LGB cases at Provo Surgical Center, but will, of course, be altered if necessary to meet the needs of individual patients.
- Acceptable LGB patients – LGB patients will have a body mass index (BMI) of 50 or less and/or they will weigh less than 320 pounds.
- Initial contact with patients –
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- After the surgery is scheduled, an anesthesiologist will contact the patient and discuss health history, surgical history, airway status, height and weight, and will answer pertinent questions. If the patient lives within a reasonable distance of PSC, he or she will be asked to come to PSC for pre-anesthesia airway evaluation with an anesthesiologist. If the patient does not live locally, he or she will be asked to provide the anesthesiologist with digital images of the head and neck for airway evaluation.
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- Scheduling personnel will contact he patient a few days prior to the scheduled surgery date to discuss arrival times, insurance questions, and fasting protocols.
- Preoperative preparations, the day of surgery–
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- Preoperative preparations will be according to establish protocols with the following additions:
– An OR table appropriate for the patients weight will be utilized.
– Patients will be asked to obtain and place a scopolamine SQ patch before arriving at the PSC
– Patients will receive ranitidine 150 mg and metoclopramide 10 mg po upon arrival at PSC. These drugs, along with the scopolamine, will lessen the likelihood of . . . postoperative nausea and vomiting and will also decrease stomach acidity
– The patient will be given 30 cc of sodium citrate shortly before entering the operating room
Pre-induction, in OR
- Patient will be placed on a positioning wedge and placed in moderate reverse Trendelenburg positioning to facilitate tracheal intubation
- Preinduction medications will include versed, fentanyl, and a defasciculating dose of rocuronium in appropriate doses
- Adequate preoxygenation will be provided
- Neuromuscular blockade monitoring will be used on all patients
- Forced air warming devices will be used to help maintain adequate body temperature
- Induction – Routine procedures will be utilized, with appropriate modifications dictated by the patient’s height and weight and medical conditions. Cricoid pressure will be maintained until successful tracheal intubation is achieved
- Maintenance of anesthesia – Routine procedures will be utilized, with appropriate modifications dictated by the patient’s height and weight and medical conditions. Additional medications will be provided to help decrease the likelihood of postoperative nausea and vomiting
- Emergence – In most instances, patients will remain intubated until they are able to follow simple commands and maintain their own airways. Full reversal of neuromuscular blocking agents will be provided in all cases unless there is a contraindication for such
- PACU – Routine procedures will be utilized, with appropriate modifications dictated by the patient’s height and weight and medical conditions
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