Novel Method for Port Implantation in Lap-Band Surgery—Transumbilical Subfascial Port Implantation

Introduction

Laparoscopic adjustable gastric banding (LAGB) is a minimally invasive operation that is being performed increasingly since it was introduced in the early 1990s. In Asia, LAGB is still the most frequently performed bariatric procedure for morbid obesity. ¹ It is a safe procedure, easy to perform, reversible, and effective. Unlike other bariatric surgical procedures such as sleeve gastrectomy or gastric bypass, which alter the anatomy of the alimentary tract, LAGB is essentially a restrictive procedure that limits food capacity. These limits can be adjusted by injecting saline into the band system through a reservoir port, which alters the stoma diameter. Despite this merit of LAGB, a small group of patients who undergo LAGB do suffer complications such as band slippage, system infection, and band migration. Port-related complications can also occur, including infection, disconnection, and port tubing rupture. Port infection can even lead to band infection.

Although not considered complications, patients can suffer discomfort due to large incision scars at the port implantation site, port prominence after massive weight loss, and port flipping that causes access difficultly. Port-related problems may be unavoidable because both the port and the tubing are subject to wear and tear. We hypothesized, however, that a proper port implantation method can minimize port-related complications. Based on our initial anecdotal clinical experience with patients who were satisfied with the subfascially implanted port (for those who had relatively thin subcutaneous fat, those who underwent subfascial port replacement due to port infection), more and more ports have been placed subfascially in recent years.

Clough et al. ² performed subfascial port placement in 68 patients using a Swedish adjustable gastric band system. In this study, we performed “transumbilical” subfascial port (SP) placement; after the intraabdominal procedure was completed, the laparoscopic adjustable gastric band tubing was externalized, located to the subfascial space, and connected to the port. We compared the results of SP placement with those of conventional placement of laparoscopic adjustable gastric band ports (CP).

Subjects and Methods

We retrospectively reviewed data from patients who underwent SP implantation between March 2009 and July 2011. We compared these results with those of the CP procedure on the anterior rectus fascia by the four-point suture technique with subcutaneous tunneling of the port. All bands were implanted laparoscopically with the Lap-Band^® (Allergan Medical, Santa Barbara, CA), and all operations were performed by the same surgeon (S.M.K.). We used a pars flaccid dissection technique in all cases, and two or three gastrogastric sutures were placed using 2-0 Ethibond^® (Ethicon, Somerville, NJ).

Technical presentation of the implantation technique

The standard four- (or five-) trocar technique was used in the CP group as previously described. ³ A Nathanson liver retractor (Cook Medical, Brisbane, Australia) was inserted through a 5-mm skin incision in the subxiphoid location and curved upward to retract the left hepatic lobe. After the intraabdominal procedure was completed, the tubing was retrieved through the left upper quadrant 10-mm trocar site. With the laparoscopic grasper inserted through the 15-mm trocar incision site, a subcutaneous tunnel was made, through which the end of the tubing was grasped. The tubing was retrieved though the subcutaneous tunnel, excess tubing was trimmed, and then the port was connected to the tubing. The port was secured onto the anterior rectus fascia by four stitches made with Prolene™ sutures (Ethicon).

In the SP group (Fig. 1), the trocar positions included a 15-mm umbilical port for the camera and two 5-mm ports, one in each subcostal area, for the acting instruments. A liver retractor was inserted through a 5-mm skin incision in the subxiphoid location and curved upward to retract the left hepatic lobe. After the intraabdominal procedure was completed, the silicone tube from the inflatable band was pulled from the abdominal cavity through the 15-mm umbilical trocar site. Through the umbilical incision, the left anterior rectus sheath was incised about 2 cm longitudinally. A subfascial space was created by muscle retraction and sponge stick swabbing. With a right angle grasper, the end of the tubing was grasped and pulled into the subfascial space, excess tubing was trimmed, and the port was connected to the tubing. The port was located under the rectus muscle. After proper positioning of the port was confirmed by manual palpation, the anterior rectus fascia was closed interruptedly.

OPEN IN VIEWER

FIG. 1.

(A) Coronal and (B) axial abdominal computed tomography scans showing the port and the connecting tube (CT). UB, umbilicus. (C) A subfascial port should be located on the posterior rectus sheath within the rectangular space created by lines b1b2 and c1c2.

We analyzed the following outcomes in both groups: (1) infection requiring reoperation, (2) mechanical port problem (port inversion/migration/leakage), and (3) other cosmetic problems (skin erosion/port site hernia/port protrusion/hypertrophic scar at the port site). We chose to exclude the patients who had previous abdominal operation (including second gastric band surgery), those who had a substernal port or a nonfixed port in the CP group (now, we do not use these techniques), and those whose follow-up was relatively short (less than 2 months). This study was approved by the Institutional Review Board of Gil Medical Center, Gachon University of Medicine and Science, and informed consent was obtained from each patient to use the data for analysis.

Results

In total, 66 consecutive patients were enrolled in this study: 33 patients in the SP group and 33 patients in the CP group. Both groups were matched for age (31.4±6.5 years versus 34.0±8.7 years, P=.168), gender (female:male 30:3 versus 27:6, P=.282), and preoperative body mass index (36.6±5.4 vs. 36.9±4.1, P=.786). The mean follow-up period was 9.6±3.9 months for the SP group and 18.9±5.3 months for the CP group (Table 1). During the follow-up period, the SP group had a lower incidence of port infection (SP group, 0/33; CP group, 3/33; P=.076), and no patients complained of hypertrophic scarring at the port site (SP group, 0/33; CP group, 4/33; P=.04). Two patients in the CP group had port inversion/migration or ports that were difficult to access. Two patients in the CP group had port protrusion. Two patients in the CP group underwent port revision surgery under general anesthesia (subfascial port implantation) 6 months after the original port was removed. One patient in the CP group underwent a port exchange surgery under local anesthesia for port leakage using a Port Access Kit (Allergan Medical). During the study period, none of the patients in the SP group experienced the above port-related complications (Table 2).

Discussion

In this study, we found that subfascial insertion of a Lap-Band port is better than traditional subcutaneous insertion in terms of port-related complications and patient satisfaction. Unlike the common complications related to gastric band surgery such as slippage, erosion, and infection, port complications are still underestimated because they have been considered minor problems, and relatively few require surgical treatment. The port, however, is the Achilles' heel of gastric band surgery, ⁴ and access-port complications are actually the most frequent complication. ⁵ According to the literature, as many as 4%–20% of patients have port complications.^5–8 The definitions of port-related problems vary widely. In some studies, only port problems that require surgical treatment are included, whereas other studies also include difficulty puncturing the port and aesthetic problems, which results in a higher complication rate.

In developing the present technique for port implantation, we were focused primarily on improving port durability and patient satisfaction. This subfascial port implantation technique did not result in cosmetic or discomfort complaints. This technique improves three important aspects of port complications: (1) port site infection, (2) mechanical problems, and (3) cosmetic satisfaction and patient comfort.

Infection is most the frequent laparoscopic adjustable gastric band port complication and can result in infection of the entire band system, requiring band removal. Because the Lap-Band is a silicone foreign body, infection at the port site, which is remote from the surgery, is a sign of band erosion before esophagogastroduodenoscopy confirmation. The band and port are contained within a single chamber surrounded by a fibrous capsule. It is notable that one patient who had a subfascial port did not experience port infection despite the presence of erosion, which may be an advantage of subfascial port implantation. Port site infection and breakdown are annoying for both patients and clinicians, and they hinder conservative treatment and postponement of surgery when band erosion does occur. The relatively poor immunologic capacity of the subcutaneous fat layer to adequately handle even small amounts of gastric secretions results in chronic irritation and eventually infection that presents as wound breakdown. The subfascial space is resistant to sepsis ² because of sufficient vascularity of the surrounding muscles originating from the superior and inferior epigastric arterial branches. As further evidence, two patients who had a subcutaneous port were diagnosed with port infection and underwent port re-implantation in the subfascial space. To date, these patients have shown no signs of infection.

In this study, patients with subfascial ports reported no mechanical port complications up to about 12 months post-LAGB. We observed no port leakage in the subfascial port group, which may be the consequence of our filling techniques. Some clinicians only use X-ray support for “problematic port punctures,” whereas others routinely use radiology to guide port filling. Because the subfascial port cannot be palpated blindly, we adopted the latter approach, which eliminates the possibility of inadvertent port puncture. Calibration without radiological control should be abandoned because of the risk of port perforation. Usually we access all of the ports by fluoroscopy for accurate adjustment. In addition to targeting of the port, stoma diameter, pouch shape, and configuration of the entire band system can be evaluated at the same time. Half of all disconnections occur at the port and are due to needle puncture. A subfascially inserted port with radiology-guided port filling should eliminate this iatrogenic puncture of the tube during adjustments. The subfascial port placement prevents tube leakage and disconnection. The port position in the LAGB procedure protects the port tube from abdominal wall movements, which may break the connection between the tube and the port. Disconnection of the catheter when the junction is intraperitoneal is more rare. ⁹ With our technique of subfascial port placement there was no angulation of the port/tube system without acute angulation of the tubing where it penetrates the abdominal wall because nearly all of the system is intraperitoneal. Our placement also permits continuous abdominal wall movement, such as strenuous exercise and abdominal straining.

Another benefit of subfascial port placement is related to the cosmetic concerns of patients. This technique prevents the formation of a large scar as a consequence of port implantation. No patients in the SP group complained of hypertrophic scarring at the port site. In the SP group, there were no cases of difficult port filling due to flipping, inversion, or migration, despite the lack of port fixation. In contrast, in the CP group, two patients complained of port protrusion and a slightly migrating Lap-Band port after sufficient weight loss, despite port fixation.

The findings of this study are limited by several factors. First, the sample size is rather small, and the follow-up period is still short. Furthermore, the CP group had a significantly longer follow-up. Additionally, lap-band ports are subject to wear and tear; thus some complications tend to develop in the long term. Although the incidence of port-related complications is likely related to the length of follow-up, all port complications in the CP group, except port leakage, occurred during the first 12 months postoperatively. Therefore, comparisons between these groups are clinically significant because most of our SP patients have reached 1 year postoperatively. Second, more patients in the CP group were part of our learning curve. Therefore, the increased incidence of port complications in the CP group could be technical problems due to a lack of surgeon experience. Third, we did not analyze the time required for SP port implantation or objective parameters of patient satisfaction. Although implanting the port under the rectus muscle is somewhat technically demanding, based on our experience, an experienced surgeon can perform SP implantation in 5 minutes, and most patients were satisfied with the cosmetic aspects of the procedure. Furthermore, there is no need to fix the port onto the fascia with the SP technique, which saves time. To ease discomfort during filling we always use local anesthetics and fill under radiologic guidance, only puncturing the port once during each filling session. Therefore, the pain associated with band adjustment was minimized in both groups. Lastly, there may be concern that subfascial placement of an access port in a patient with excessively thick abdominal wall (e.g., superobese) will require an unusually large incision to obtain adequate exposure. Our clinic does not recommend LAGB as an initial bariatric procedure for patients whose body mass index is above 50 kg/m² because treatment outcome has been known to be suboptimal. In our experience of SP implantation, BMI (<50 kg/m²) or body habitus did not cause technical problems. In fact, the deeper the umbilicus is, the larger the transumbilical incision is. This phenomenon has been noted in transumbilical gastric banding single-incision laparoscopic surgery, and a larger umbilical incision made the SP procedure easier. In conclusion, inserting the Lap-Band port system through the umbilicus and locating it in the subfascial space did not cause the usual port complications during the first year postoperatively when sufficient weight loss occurs.