A 47-year-old morbidly obese woman comes to the physician seeking advice regarding weight loss. She has tried diet and exercise a number of times without success. Her other medical problems include type 2 diabetes mellitus and obstructive sleep apnea. Her body mass index is 43 kg/m². After a discussion about available surgical options, she expresses interest in the adjustable gastric band, an inflatable silicone device that is placed around the cardiac part of the stomach. In order to encircle the stomach, the band must pass through which of the following structures?

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11ec160b_3586_a2b6_9249_8f4ae3ac696b_MD0001_00 Adjustable gastric banding is a type of restrictive bariatric surgery designed for obese patients. The adjustable gastric band is an inflatable silicone device placed around the gastric cardia. It is intended to slow the passage of food, increasing satiety and limiting the amount of food consumed. To encircle the upper stomach, the gastric band must pass through the lesser omentum. The lesser omentum is a double layer of peritoneum that extends from the liver to the lesser curvature of the stomach and the beginning of the duodenum. Anatomically, the lesser omentum is divided into 2 ligaments: Between the 2 layers of the lesser omentum, close to the right-sided free margin, lie the hepatic artery, common bile duct, portal vein, lymphatics, and hepatic plexus. The right and left gastric arteries and gastric veins also lie between the 2 layers, near where the lesser omentum attaches to the stomach. (Choice A) The falciform ligament attaches the liver to the anterior body wall. It is a derivative of the embryonic ventral mesentery and contains the round ligament, the remnant of the fetal umbilical vein. (Choices B and C) The greater omentum is a large fold of visceral peritoneum that extends from the greater curvature of the stomach, travels inferiorly over the small intestine, and then reflects on itself and ascends to encompass the transverse colon before reaching the posterior abdominal wall. The gastrocolic ligament is the section that stretches from the greater curvature of the stomach to the transverse colon. It forms part of the anterior wall of the lesser sac and is often divided during surgery to provide access to the anterior pancreas and posterior wall of the stomach. (Choice E) The splenorenal ligament is derived from the peritoneum and lies between the left kidney and the spleen. It contains the splenic vessels and the tail of the pancreas. Educational objective: The lesser omentum is a double layer of peritoneum that extends from the liver to the lesser curvature of the stomach and the beginning of the duodenum. It is divided into the hepatogastric and hepatoduodenal ligaments.

A 47-Year-Old Morbidly Obese Woman Comes to the Physician Seeking