Chapter 4

Open bariatric surgery in the age of the laparoscope? You've got to be joking. Certainly I must be a dinosaur or an old dog who refuses to learn new tricks. Maybe I am afraid of the “learning curve.” Or just maybe I know something others may not, or are reluctant to acknowledge for one reason or another. How do we define “minimally invasive”? Smaller (or less morbid) incisions, quicker recovery, and less pain are the impressions most would have. Is the laparoscope absolutely required in this definition?

The biggest advantage of the laparoscopic approach to bariatric surgery compared to standard open procedures is the “vast improvement” in wound morbidity. As a matter of fact, in the American Society for Bariatric Surgery (ASBS) and the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) guidelines for laparoscopic and conventional surgical treatment of morbid obesity, under Surgical Techniques, it is mentioned that “… wound complications such as infections, hernias, and dehiscenses appear to be significantly reduced.”1 This statement is made based on the assumption that we are comparing laparoscopic to open bariatric surgery via an upper midline incision.

Since we are not making one large incision, the assumption is that multiple small incisions produce less pain, a less expensive and shorter hospital stay, and a more rapid return to work and one's usual activities. However, I will demonstrate from my own experience and with the support of published data, that if one simply alters the open incision, that part of the question becomes moot, and other aspects of the “open” postoperative recovery period are at least equal, if not superior, to laparoscopic Roux-en-Y gastric bypass (LRYGBP). Note that my remarks are directed toward Roux-en-Y gastric bypass (RYGBP), not malabsorptive or restrictive procedures considered elsewhere in this book.

I begin my argument by presenting my data concerning primary open RYGBP (ORYGBP). In a series of over 2,400 cases over a 17-year period, the excess weight loss at 10 years postop was 62%, comparable to several other published series.2–5 The leak rate was 0.5% in primary (1°) RYGBP and the mortality rate was 0.2%.5 A more recent report6 plus over 700 gastroplasty procedures beginning in 1979 now totals over 3,800 primary and revision bariatric procedures. Reoperations in this series of 1° RYGBP procedures has been 1.4%33 due to leaks, staple-line failures, incisional hernias, wound dehiscence, and definitive surgery for peptic ulcer disease. I have excluded many dermatopanniculectomies, which were done following successful weight loss, as well as a few cholecystectomies. I have used the following criteria for cholecystectomy at the time of bariatric surgery: (1) gallstones, symptomatic or not, (2) a strong family history of gallbladder disease, (3) a relatively strong family history of American Indian or Latin American heritage, or (4) cholesterolosis of the gallbladder at the time of surgery. Using these criteria, the handful of patients who have returned for laparoscopic cholecystectomy at a later date is ...

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