Chapter 19 Laparoscopic Gastric Bypass
INTRODUCTION
During the 5 years from 1998 to 2003, the field of bariatric surgery in the United States underwent a veritable revolution. The number of Roux-en-Y gastric bypass (RYGB) procedures performed annually in the country increased from approximately 20,000 to 140,000.1 The major reason for this may be debatable, but this author’s hypothesis is that the explosion in popularity of the operation was driven largely by the availability of the performance of the operation using a laparoscopic approach. The temporal relationship of the advent of the laparoscopic approach and the rise in popularity of the operation are strongly correlated. Laparoscopic surgery was popular among young surgeons, and the popularity spread to bariatric surgery. The public and referring physicians had already demonstrated the inclination to view a laparoscopic approach to surgery as much more acceptable as a treatment option for operations such as cholecystectomy and antireflux surgery. This pattern continued with bariatric surgery. Multimedia and the Internet made the spread of information about laparoscopic gastric bypass much more rapid and prevalent. Laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery became one of the most commonly performed abdominal operations in this country by the year 2003. During that year, approximately 130,000 gastric bypass operations were performed in the United States; in 1998, the number was approximately 20,000. The rapid proliferation of the operation resulted in the need for training opportunities for surgeons interested in beginning their experience with the operation. The complications that could occur with an inexperienced surgeon performing the operation became problematic in some situations. The large number of procedures performed led to a variety of complications being reported in the surgical literature. Although these were often not well quantitated in terms of frequency, the author’s own significant institutional experience along with the literature will serve as the primary basis for judging such frequencies, in instances in which the literature is lacking.
The relative brief duration of performance of LRYGB in large volume may preclude a true estimation of the incidence of certain long-term complications, yet the operation itself, done as an open procedure, has a track record of over 40 years of careful scrutiny by the bariatric and surgical community.2 Unless directly related to the method of access, such long-term complications are as likely to occur after open as after laparoscopic RYGB. Therefore, an underestimation of their frequency is less likely. The literature already supports the fact that two considerable advantages to the laparoscopic over the open approach for RYGB are the significantly lower incidence of wound complications and the remarkably lower incidence of incisional hernias.3
INDICATIONS
OPERATIVE PROCEDURE
Creation of a Pneumoperitoneum
Viscus Injury
• Consequence
• Repair
• Prevention
Gas Embolism
• Consequence
• Repair
• Prevention
Cardiac Arrhythmia
• Consequence
• Repair
• Prevention
Subcutaneous Emphysema
• Consequence
• Repair
• Prevention
Organ Injury
• Consequence
• Prevention
Vascular Injury
• Consequence
• Repair
Abdominal Wall Vascular Injury/Hematoma
• Consequence
• Repair
Inappropriate Port Placement
• Consequence
• Prevention
Laparoscopic Survey and Assessment of the Abdominal Organs
Missed Abdominal Lesion
• Consequence
• Prevention
Fatty Liver with Cirrhosis
• Consequence
• Prevention
Excessive Adhesions
• Consequence
• Repair
Hernia of the Abdominal Wall
• Consequence
• Repair
Enterolysis If Necessary to Free the Omentum and Clear the Left Upper Quadrant
Injury to the Abdominal Organs
• Consequence
Hemorrhage
• Consequence
• Repair
Division of the Small Bowel and Creation of the Roux-en-Y Limb
Misidentification of the Proximal Jejunum for Division
• Consequence
• Repair
• Prevention
Tear/Injury in Handling the Small Bowel
• Consequence
• Repair
• Prevention
Ischemia of the Tip of the Small Bowel after Division
• Consequence
• Repair
Hemorrhage of the Small Bowel Mesentery
• Consequence
• Repair
• Prevention
Inadequate Length of Roux-en-Y Limb Mobilization
• Consequence
• Repair
• Prevention
Misidentification of the Roux-en-Y Limb Versus the Biliopancreatic Limb
• Consequence
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