Laparoscopic Operations
SILS - Single Incision Laparoscopic Surgery
Laparoscopic Gastric Bypass Operation
Laparoscopic Adjustable Gastrric Band Operation
Laparoscopic Gastric Sleeve Operation
Laparoscopic Operations
Bariatric Surgery – also known as weight loss surgery – is almost always now performed using laparoscopic technique. Laparoscopy involves placing a scope through a small incision into the abdominal space to visualize the organs being operated upon. Other small incisions are made depending on what type of instruments, retractors, etc are necessary to do the procedure. For my standard bariatric operations I use five incisions ranging from 0.5 cm to 2 cm in length. After the incisions are made, trochars –narrow plastic tubes – are passed from outside into the abdominal space. Usually the first trochar is placed with the scope inside so the surgeon can see exactly when it enters the abdominal space. After placement carbon dioxide (CO2) is insufflated into the abdominal space to blow it up enough to see and provide space enough to work. The trochars remain in the abdominal wall during the operation to provide a passageway for the surgical instruments, and the laparoscope, to be inserted and removed. They are removed at the end of the procedure after the CO2 is released and the abdominal space is decompressed.
Laparoscopy has several well documented advantages over open surgery. Because the incisions are small and dispersed there is less post-operative pain. This means that patients can resume many of their normal activities almost immediately. Patients are able to walk within 2-4 hours after a laparoscopic operation. This is very important in avoiding certain complications such as blood clots in the veins of the legs (deep venous thrombosis or DVT) and pulmonary complications (atelectasis and pneumonia). Early ambulation has also been shown to decrease the overall pain related to the operation. Most patients can go home the same day after a laparoscopic adjustable band operation, and early the following day after a laparoscopic gastric bypass operation or a laparoscopic gastric sleeve operation. Return to work is much easier, usually within 7-10 days. However, patients may return to work in 3 days if necessary. Other activities such as driving and sexual activity can be resumed earlier than after an open operation.
Other complications are much less likely after laparoscopic surgery. Wound infections are much more rare and more easily treated than those that occur in a long incision after an open operation. Scars inside the abdomen – also known as adhesions – occur to a lesser degree. This may reduce the risk of subsequent bowel obstruction from the intestine being trapped or twisting the adhesions. Finally, because the tension on multiple, dispersed small scars is less than on a long, single midline incision the patient is less likely to develop a hernia under the incision. This is very important because incisional hernias will need to be repaired surgically, and the repairs carry significant operative risk.
Because of the advantages of less pain, earlier return to normal activities and avoidance of significant postoperative problems, laparoscopy has become the method of choice for performing bariatric surgery.
Laparoscopic Gastric Bypass Operation
The laparoscopic gastric bypass operation is classified as both a restrictive and a mal-absorptive weight loss surgery. It is restrictive because the upper part of the stomach is divided to create a small pouch (15-30 ccs) which can easily be filled with a small amount of food to create satiety. It is also mal-absorptive because the distal stomach and the first part of the small intestine are bypassed – the food never passes through these sections of the bowel. The roux limb carries food from the small pouch down to where it joins the biliary limb – the bypassed intestine – and then the food passes down the much longer common channel of small intestine and empties into the large intestine. Digestive juice from the distal stomach, liver, and pancreas are all carried in the biliary limb and meet the food at the connection point (the jejunojejunostomy). Digestion – the picking up of nutrients by the bowel wall and transferring them to the bloodstream – occurs almost exclusively in the small intestine. Since the segment of bypassed small intestine is short compared to other mal-absorptive weight loss surgeries most nutrients, vitamins, and minerals can still be well absorbed in the common channel. Only a few nutrients are affected – notably vitamins B1 and B12, folic acid, calcium and iron – by the short segment. Please refer to “how does a gastric bypass work.”
We perform the gastric bypass using laparoscopy which offers several advantages over open surgery (please see “laparoscopic operations”). This must be done under general anesthesia (completely asleep), as opposed to spinal or local anesthesia, because otherwise the insufflation of the abdominal space would be too uncomfortable.
The surgery is begun by dividing the omentum – a fatty sheet that hangs down from the stomach – to provide a channel for the roux limb of intestine to pass through. The ligament of Treitz is identified where the small intestine first emerges from under the large intestine. Approximately 30 cm distally the small intestine is divided using a surgical stapling device. This device both divides and closes both ends of the intestine. The closure is done with three overlapping rows of very small titanium staples, which look like a closed hem on a garment. The staples are barely visible on Xrays later, and titanium is an inert metal that is not recognized by the immune system – so no rejection can occur. Once the intestine is divided, it is measured between 100 and 150 cms down the distal limb and the proximal (biliary limb) is connected to the distal limb to create an anastamosis – the jejunojeunostomy. This is the “Y” in the term Roux en Y used to describe this operation. After these two sections are joined, the defect in the fatty sheet that carries blood vessels out to the intestine (the small intestinal mesentery) is closed with suture. This is to prevent an internal herniation of another part of the intestine through this defect later which can cause a small bowel obstruction.
Next, attention is turned to the stomach. The left lobe of the liver is retracted up and to the left to expose the most proximal part of the stomach, where the esophagus empties into it. The upper stomach is then divided, separating the small proximal part (5-10% of the stomach) from the distal part using the same surgical stapling device. The only difference is that we use a buttressing material (a peristrip) to help sandwich the thicker edges of the stomach and help prevent bleeding and leak from the edge. A defect is created in the front surface of the small pouch and the anvil of a circular stapling device is placed into the small pouch. The defect around the post of the anvil is then sutured closed. The closed roux limb of intestine – the original distal divided end – is brought up to the small pouch. It is opened and the circular stapling device is passed into the abdomen and into the opening in the bowel. The bayonet is then advanced through the bowel wall, snapped into the anvil post, and the stapler is closed down bringing the small pouch and roux limb into close opposition. When the circular stapling device is fired it creates a precisely sized (1 cm diameter) circular connection joining the stomach to the intestine with 3 overlapping rows of staples. The stapler is withdrawn and the redundant end of intestine is removed and closed. Sutures are placed to anchor the connection.
The upper connection is then tested for leakage by injecting 60 ccs of blue dyed saline under mild pressure. Finally, the defect where the roux limb of intestine passes over the transverse large intestine is sutured closed. The trochars are removed, and the muscle layer of the 2 larger sites is sutured at the level of the abdominal wall muscle. The skin incisions are closed with fine absorbable suture – which does not need to be pulled out later. The patient is then transported to the recovery room.
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