Bariatric surgery is increasing in North America. In a population-based study, Pope et al.1 reported that the number of bariatric procedures performed in the United States increased from 4,925 operations in 1990 to 12,541 operations in 1997, then increased sharply to 70,256 procedures in 2002.2 Although the first case series of laparoscopic gastric bypasses (GBPs) was reported in 1994, the dissemination of the laparoscopic approach did not occur until 1999.2,3 The subsequent growth of bariatric surgery in 1999 was similar to the expansion of antireflux surgery in 1993 after introduction of the laparoscopic Nissen fundoplication technique.4 The impact of laparoscopy on bariatric surgery has been even greater with bariatric operations, including GBP and other procedures, estimated to reach more than 120,000 procedures in 2005.
Despite acceptance of laparoscopic bariatric surgery by both surgeons and the public, some third-party payers are reluctant to provide insurance coverage for the laparoscopic method. In September 2003, the Blue Cross and Blue Shield Association's Technology Evaluation Center indicated that there was insufficient evidence to form conclusions about the relative efficacy and morbidity of the laparoscopic approach to GBP.5 The high demand for minimally invasive bariatric surgery combined with increase in surgeons who are skilled in the technique demands a clear understanding of the evidence-based data on which the safety of minimally invasive bariatric surgery is based. This chapter reviews the current scientific rationale for the use of minimally invasive technique in bariatric surgery.
At the onset, it is important to consider why laparoscopic bariatric surgery was introduced as an alternative to open bariatric surgery. No doubt, open bariatric surgery can be performed with a good outcome, but the wound-related complications such as infection and late incisional hernia can be troublesome. Postoperative wound infections occur in as many as 15% of morbidly obese patients and late incisional hernias occur in up to 20% of patients.6–8 Accordingly, bariatric surgery would be improved by minimizing the morbidity of the access incision. In addition, morbidly obese patients undergoing the laparoscopic approach benefit from a reduction in postoperative pain, shorter length of hospital stay, and faster recovery. These attributes have all been well-documented from several laparoscopic intra-abdominal operations including cholecystectomy, antireflux surgery, and removal of solid organs. The minimally invasive technique is a reasonable approach in the morbidly obese as these patients have many comorbidities that can magnify the likelihood for postoperative complications. In essence, minimally invasive bariatric surgery was initiated to improve the perioperative outcomes—primarily a reduction in postoperative complications arising directly or indirectly from the abdominal wall incision.
The ideal model for evaluating the safety and efficacy of minimally invasive bariatric surgery is a trial of the laparoscopic versus open GBP. Gastric bypass is a complex bariatric operation that can be associated with certain perioperative and long-term morbidity. The laparoscopic approach to GBP was designed to achieve the same intra-abdominal procedure as the open GBP but through multiple ...