Adjustable Gastric Band Adjustment Procedure Note

Date and time of procedure: [Date and time]

Location: [clinic / fluoroscopy suite / other]

Operator: [Name, credentials, and role]

Patient identifiers: [Per organizational standard]

Note type: Adjustable Gastric Band Adjustment Procedure Note

Procedure Summary

• Procedure performed: [AGB fill / AGB unfill / port access and assessment only]
• Indication: [too tight with restriction symptoms / too loose with inadequate satiety or weight plateau/regain / other]
• Volumes (mL): Prior total [value / unknown]; Removed [mL]; Added [mL]; Net change [mL]; Final total [mL] (If any value is unknown, state why and document risk mitigation.)
• Immediate tolerance: [tolerated observed liquid swallow / required reversal / not performed]
• Complications: [none / specify]

Indication and Pre-Procedure Assessment

Clinical Presentation

[HPI including stated reason for visit, classification as restriction symptoms versus inadequate satiety/weight control, time since last adjustment, relevant context such as diet adherence or recent illness, and clinical goal of this adjustment]

Symptom Screen

• Reflux/GERD: [severity, frequency, daytime vs nocturnal, cough/aspiration symptoms / denies / not documented]
• Vomiting/regurgitation: [frequency, triggers, ability to tolerate liquids / denies / not documented]
• Dysphagia: [solids vs liquids, food sticking, inability to swallow saliva / denies / not documented]
• Additional symptoms: [abdominal pain, chest pain, dehydration, weight trend, satiety pattern / none / not documented] (Include only if addressed.)

Pertinent History

• [Original bariatric surgery type and date]
• [Band brand/model if known]
• [Last adjustment date and volume]
• [Prior band complications: slip, pouch dilation, erosion, port/tubing issues]
• [Relevant medications and allergies]

(If band model or prior volume is unknown, document sources attempted and plan to determine.)

Focused Examination

• Vital signs: [Values / not obtained]
• Port site: [Inspection findings: erythema, warmth, tenderness, drainage, palpability]
• Hydration status: [Assessment if symptomatic / not assessed]

(If findings suggest infection or patient cannot tolerate liquids at baseline, document deferral rationale or escalation plan.)

Consent and Safety Verification

Informed Consent

Consent status: [obtained / declined / not documented] (Do not infer consent from procedure completion.)

• Procedure discussed: Port access with saline adjustment of adjustable gastric band
• Expected benefit: [Symptom relief / improved satiety]
• Material risks reviewed: Pain, bleeding, infection, port/tubing damage, over-restriction requiring urgent deflation, need for imaging if symptoms persist
• Alternatives: No adjustment, dietary modification, medication trial, imaging/endoscopy, surgical referral

Time-Out

• Correct patient (two identifiers): [verified / not documented]
• Correct procedure: [AGB adjustment verified]
• Correct site: [Subcutaneous abdominal access port verified]
• Allergies reviewed: [yes / not documented]
• Equipment confirmed: [Access needle, saline, imaging if planned]

Procedure Details

Setup and Access

1. Position: [supine / semi-recumbent / other]
2. Skin prep: [Prep agent]; sterile technique used
3. Local anesthesia: [agent and volume / not used]
4. Port localization: [palpation / ultrasound guidance / fluoroscopy guidance]
5. Access needle: [Non-coring needle type, gauge/length]
6. Confirmation of access: [saline aspiration / easy instillation / fluoroscopic confirmation]
7. Aspirated fluid: [volume mL and appearance / none / unable to aspirate]

Adjustment and Volumes

• Prior known total: [mL / unknown]
• Volume removed: [mL]
• Volume added: [mL]
• Net change: [mL]
• Final total in band: [mL]

(If any volume is unknown, state why and how risk was mitigated.)

Tolerance Testing

Observed liquid swallow: [tolerated without difficulty / coughing or regurgitation / discomfort requiring reversal / not performed / not documented]

(If intolerance occurred, document reversal performed and post-reversal status. If not performed, document reason.)

Completion

• Hemostasis and dressing: [Achieved; dressing type applied]
• Estimated blood loss: [mL]
• Complications: [none / vasovagal episode / bleeding / inability to access port / suspected leak / other]
• Disposition: [home / extended observation / ED referral / imaging ordered]

(If procedure was aborted, document the step at which it stopped, reason, and safety/follow-up plan.)

Post-Adjustment Plan

Instructions Provided

• Diet progression: [Institutional protocol or provider-specified timing for liquids → soft foods → regular texture]
• Hydration goals: [Daily fluid target]
• Behavioral guidance: Small bites, slow eating, thorough chewing, stop with satiety
• Medication adjustments: [Crush/liquid forms, NSAID avoidance, other / none]

Red-Flag Symptoms

Patient instructed to seek urgent evaluation for: inability to swallow liquids or saliva, persistent vomiting, severe abdominal or chest pain, signs of dehydration, fever, GI bleeding, or respiratory/aspiration symptoms.

Follow-Up

• Planned follow-up: [Timeframe and modality]
• Urgent deflation access: [Contact method and after-hours process]
• Referrals: [upper GI study / endoscopy / surgical consult / dietitian / behavioral health / none] (Include rationale if ordered.)