Chapter 25

Wittgrove, Clark, and Tremblay performed the first laparoscopic gastric bypass in 1993.1 Since then, there has been a dramatic increase in the number of bariatric procedures worldwide.2 Although improved outcomes and the dissemination of knowledge through the Internet have increased the awareness of the public of the benefits of bariatric surgery, the minimally invasive approach is primarily responsible for the increased demand.3 The laparoscopic/endoscopic anvil placement for creation of a circular-stapled gastrojejunal anastomosis remains one of the most ingenious applications of available technology to date. However, with initial anastomotic leakage rates of up to 5%,4 similar to leakage rates reported by colorectal surgeons5 using the circular stapler, we concluded that failure was probably related more to the limitations of the endomechanical device rather than surgical technique.

We had no anastomotic leaks in our open gastric bypass experience (<500 patients), similar to others using manual suturing techniques.6 Therefore, it seemed logical to use manual suturing for the gastrojejunal anastomosis in our laparoscopic operation.7 Michele Gagner was the first to describe the hand-sewn gastrojejunal anastomosis, but abandoned it for the transoral circular stapler technique.

Novice surgeons often evaluate new procedures based on the speed at which they can learn and master the technique as well as the total operative time. Safety and long-term outcomes are often secondary to the objective of completing the task at hand. Seasoned bariatric surgeons understand the importance of consistent anatomic construct for weight optimization, weight maintenance, and avoidance of secondary complications.8,9 Early laparoscopic solutions for the gastric bypass adopted methods of gastric pouch formation based more on a horizontal orientation4,10,11 rather than a true lesser curve based pouch, vertical in orientation that we advocate.9 Fortunately, it now appears that weight loss, weight maintenance, and complications are similar among the various pouch configurations and are probably related more to overall volume rather than orientation.

We performed our first laparoscopic gastric bypass in 1998, and our team has performed over 5000 procedures as of 2006. The basic orientation and approach has remained the same with few modifications based on experience and outcomes. For example, we now use continuous nonabsorbable sutures to close all mesenteric defects to decrease the incidence of postoperative internal hernias.12 Our laparoscopic approach to the gastric bypass is very familiar to that of the veterans of bariatric surgery. We have tried to incorporate the principles learned over decades of research and anecdotal experience and have tried not to violate those principles just to perform it laparoscopically. Our approach is serviceable, reproducible, and revisable, although perhaps the most technically demanding of procedures. However, it is useful as a platform for more advanced bariatric procedures, including revision operations.

A multidisciplinary team consisting of a surgeon, psychologist, nutritionist, anesthesiologist, and medical bariatrician evaluates each patient. In addition, a cardiac evaluation and directed weight management is advised on an individual basis. Weight loss prior to surgery ...

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