Chapter 17

The learning curve in laparoscopic bariatric surgery has been described by experts in the field as

1. “daunting and far more demanding of the surgeon's patience and tenacity”1;

2. “a long and arduous journey”2;

3. “a technically challenging procedure with a steep learning curve”3;

4. “a high degree of difficulty translates into a steep learning curve.”4

These statements certainly cause anxiety in the surgeon who starts a program on laparoscopic bariatric surgery.

Every paper that has addressed the issue of the learning curve has noted that operative times decrease with experience. Operative time is really not an issue. The issue is whether the surgeon experiences a cluster of serious complications and deaths early in their experience. The length of this steep and treacherous learning curve is around 100 cases, as measured by various complications such as bowel obstruction,5 leaks,6 or all complications.7–9 Flum10 reported that this learning curve applies to open as well as laparoscopic bariatric operations. We, along with several other authors, do not think that the learning curve need be dangerous for patients.11–13

We have attempted to measure the slope of our learning curve by quantifying our errors. We conceptualized a program of laparoscopic Roux-en-Y gastric bypass (lap RYGBP) in August 1998 and performed our first laparoscopic operation in February 1999. Both authors were experienced in bariatric surgery, having performed approximately 1,500 open bariatric operations during their careers. Each surgeon attended a separate 2-day course in laparoscopic bariatric surgery. In addition, laparoscopic gastric bypasses were performed on seven experimental animals, with approval of the animal experimentation committee. Laparoscopic staplers were used on six open cases prior to our first clinical lap RYGBP.

Guidelines for patient selection for laparoscopic surgery were established prior to the series. Initially patients with a waist measurement less than 125 cm, BMI less than 50 kg/m2, and no prior upper abdominal surgery were selected. Patients with central obesity, as determined by physical examination and waist/hip ratio, were avoided. These guidelines were later liberalized to include patients with a waist measurement of 150 cm. No revisions of any previous bariatric operation were attempted with the laparoscopic approach.

The laparoscopic operation attempted to duplicate our experience with open operations.14 The laparoscopic operation created a 20 mL or less gastric pouch. A 12-mm banded gastroenterostomy was created with a linear stapler. The stapler defect was sutured to complete the anastomosis. The biliopancreatic limb was 15–30 cm in length and the Roux-en-Y limb was 75–150 cm depending on the patients’ BMI.15 The enteroenterostomy was created with two 45-mm or one 60-mm stapler. The stapler defect was closed with an additional 45-mm stapler or hand sutured. The Roux-en-Y limb was routed retrocolic and retrogastric. The mesenteric, transverse mesocolon and Petersen's defects were closed with permanent suture.

There were several differences between the laparoscopic ...

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