The advent of videolaparoscopy at the end of the 1980s revolutionized digestive tract surgery. Skepticism of the surgical community was overcome by proof of the real advantages provided by this new abdominal access. Less surgical trauma, shorter length of stay, shorter sick leave from work, less pain, and better esthetic result convinced surgeons they had to learn about and train in the new technique.
Bariatric surgery was not different, particularly gastric bypass, in which surgeons have improved to better master gastric videolaparoscopy, since Wittgrove et al.1 (see Chapter 14) described the applicability of laparoscopy to perform this complex procedure. However, laparoscopic approach should not substantially change the principles that guide the technique to be employed. The technique already proven by laparotomy must be reproduced through a minimally invasive procedure.
On the basis of these assumptions, we initiated our experience with bariatric surgery reproducing the technique extensively used by the San Diego Group, coordinated by Dr. Allan Wittgrove and Wesley Clark.1 It consists of no banding, performing gastrojejunal anastomosis with a no. 21 circular stapler; the anvil is introduced through the mouth and the stapler through the abdomen, not closing the defects (mesentery, mesocolon, and “Petersen”) created by the surgery. Since it is difficult to introduce the anvil through the mouth and there is an additional cost of the stapler, we decided to perform a totally manual two-layer gastrojejunal anastomosis. Because of the high incidence of bowel loop sliding to the supramesocolic area, we carefully close the intracavitary spaces to avoid formation of internal hernias.2 The manual anastomosis is a cheaper procedure; however, it takes longer and is not completely reproductible.
On the basis of the experience of Ken Champion (Atlanta, GA), we started performing gastrojejunal anastomosis with a linear stapler3,4 and transposing the jejunum by an antecolic and antegastric approach. The purpose was to reduce the incidence of internal hernias, which are more frequent in laparoscopic surgeries than in laparotomies.2,3,5
After the initial experience with this technique, we observed that patients submitted to laparoscopy with no banding, as compared with the historic group with banding, had a smaller and inconsistent weight loss.6 On the basis of this finding we decided to perform the following routine: Laparoscopic Roux-en-Y banded gastric bypass.7–10
The surgery is performed with the patient in supine position, under general anesthesia, and the surgical team is displaced as follows: The surgeon and the camera are on the right and the assistant surgeon and the scrubbing nurse are on the left.
One 10-mm portal is used for the camera and one 12-mm portal is used for the staplers. Four 5-mm portals are used for the other forceps. A 15-mm Hg pneumoperitoneum is used to initiate the operation.