The telesurgical approach is feasible in advanced laparoscopic procedures like Nissen fundoplication. At the present time there is however no obvious added benefit from this new technique.

The most disturbing complications of gastric banding technique are gastric perforation and pouch dilation. Their incidence may be reduced by improving the technique and by considering pitfalls of the procedure.

Morbid obesity is a difficult problem. Dieting fails to cure many patients' and non-surgical techniques have a failure rate close to 100 per centz. Kuzmaks gastric banding technique is the least invasive operation for morbid obesity and has proven efficacy-'. In this procedure the stomach is partitioned into a 25-ml proximal part and a distal larger portion comprising the body of the stomach. The partition is created by a silicone band with a deflatable device COMKted to a subcutaneous control system. This permits further adjustment of the 'stoma' after surgery by injection or withdrawal of saline. The present paper describes Kuzmak's gastric banding operation performed via a laparoscopic approach. Surgical techniqueLaparoscopic Kuzmak gastroplasty was performed on a 60-year-old woman of weight 100 kg and height 154 crn (body mass index 32 kg/m2). The surgeon stood between the patient's legs, with a first assistant to the left and a second to the right. Four cannulas (Ethicon, Somerville, New Jersey, USA) were distributed around a 15-cm cannula (US Surgical, Norwalk, Connecticut, USA) that was used for the 0" optical system and located 5 cm proximal to the umbilicus. A 5-mm cannula was placed in the right upper quadrant and one in the left anterior axillary line. A 10-mm cannula was sited in the left mid-clavicular line for dissection and suturing, and one below the xiphoid process to take the clip applicator and liver rctractor.A window was made in the most cephalad part of the gastrosplenic ligament. The lesser curvature was then dissected with the coagulating hook about 2 cm caudal from the cardia. A retrogastric funnel joining both dissected areas was created by blunt dissection under direct vision. the stomach being held ventrally. A 2 5 4 balloon catheter with a pressure gauge at its tip was advanced through the mouth into the stomach and inflated. A silicone band (hamed, Carpinteria. California, USA) was introduced intraperitoneally, placed around the stomach at the level of dissection and tightened around the tip of the intragastric balloon catheter, until a pressure corresponding to 12-mm diameter was obtained.The band was sutured to itself (Fig. I ) using an intracorporeal knotting technique to fix its position; the redundant part was cut and removed. A stitch was placed between the serosa of the stomach just proximal and distal to the band to prevent slipping. The chamber connected to the silicone band was buried in the ventral r a m s fascia, by slightly enlarging a cannula opening.Oral intake was permitted from the first day after operation, by which time the patient was free to move about; she was discharged from hospital on the fifth day after surgery.

Between May 1991 and November 1992, 80 consecutive patients with gastro-oesophageal reflux disease underwent laparoscopic Nissen fundoplication. The technique used was exactly the same as for the conventional open approach. There were no deaths but there were four peroperative complications: one gastric perforation, two pleural perforations and one hepatic laceration. Three conversions to laparotomy were necessary, one because of a defective needle holder and two as a result of left hepatic lobe hypertrophy. The duration of operation ranged from 40 to 300 (median 150) min. The median postoperative stay was 3 days, but increased to 10 days in two patients who developed pulmonary infection. One major postoperative complication (necrosis of the wrap) required a laparotomy on day 8 after operation. No recurrence of heartburn has been observed and there were no instances of long-term dysphagia after surgery. These findings indicate that laparoscopic Nissen fundoplication can be performed safely if the team is well trained.

Perioperative, short-term, and mid-term outcomes were comparable between the two groups. At 2-year follow-up, a significant shorter operative time after MTLTEP and a greater cosmetic satisfaction after SILTEP have been found.