open or laproscopic?

Complications

Open and Laparoscopic Bariatric Surgery

Bariatric surgery may be performed through “open” approaches, which make abdominal incisions in the traditional manner, or by laparoscopy. With the laparoscopic approach, sophisticated instruments are inserted through 1/2-in*****isions and guided by a small camera that sends images to a television monitor. Most bariatric surgery today is performed laparoscopically because it requires a smaller cut, creates less tissue damage, leads to earlier discharges from the hospital, and has fewer complications, especially postoperative hernias.

However, not all patients are suitable for laparoscopy. Patients who are extremely obese, who have had previous abdominal surgery, or have complicating medical problems may require the open approach.

http://www.asbs.org/html/patients/bypass.html

LAPAROSCOPIC GASTRIC BYPASS

Although the open RYGBP can be performed with a relatively low morbidity and mortality, the wound-related complications such as infection and incisional hernia can be troublesome. Wound infection occurs in as many as 8% of patients after open RYGBP and late incisional hernia occurs in as many as 20% of patients. However, some surgeons have reported a much lower rate. The laparoscopic approach to RYGBP was initiated in an effort to improve the early outcomes including a reduction in postoperative complications arising from a large incision in a severely obese patient.

I***** Drs. Wittgrove and Clark reported the first case series of laparoscopic RYGBP. The primary differences between laparoscopic and open RYGBP are the method of access and method of exposure. Laparoscopic RYGBP is normally performed through 5-6 small abdominal incisions (0.5-2.0 cm), the peritoneal cavity (abdomen) is insufflated with carbon dioxide gas which creates a space within which to work, allowing exposure of the operative field (Figure 1a). In contrast, open RYGBP is performed through a larger incision and abdominal wall retractors are used for exposure (Figure 1b). By reducing the size of the surgical incision and the trauma associated with the operative exposure, the surgical insult has been shown to be less after laparoscopic compared to open RYGBP. However, not all patients are candidates for a laparoscopic approach based on body habitus, previous intra-abdominal surgery, etc.

Clinical studies have demonstrated that laparoscopic RYGBP is a safe and effective alternative to open RYGBP for the treatment of morbid obesity. Higa and colleagues reported the largest laparoscopic RYGBP experience with 1,500 operations. There have been three prospective, randomized trials comparing the outcomes of laparoscopic vs open RYGBP. The largest trial was reported by Nguyen and colleagues in 2001. In 2004, a group from Murcia, Spain published their results. Long-term weight loss after laparoscopic and open RYGBP should not differ, as the primary differences between the two techniques is largely in the method of access and not the gastrointestinal reconstruction.

Despite the advantages of the laparoscopic approach, open bariatric surgery still plays a prominent role in management of morbidly obese patients. Relative contraindications for laparoscopic bariatric surgery include patients with extremely high body mass index, patients with multiple previous upper abdominal surgeries, and patients with prior bariatric surgery. Another limitation of the laparoscopic approach is the steep learning curve of this technically challenging procedure for the surgeon, so it is not an operation for the surgeon who has not been trained specifically in this technique. The advantages and disadvantages of laparoscopic RYGBP are listed below.

Advantages of laparoscopic compared to open RYGBP

Lesser intraoperative blood loss
Shorter hospitalization
Reduced postoperative pain
Less pulmonary complications (atelectasis)
Faster recovery
Better cosmesis
Fewer wound complications (incisional hernias and infections)

Disadvantages of laparoscopic compared to open RYGBP

Complex laparoscopic operation associated with a steep learning curve
Possible increase in the rate of internal hernia

http://www.laparoscopy.com/obesity/roux.html

Over the last 20 years the Roux-en-Y Gastric bypass has been successfully used as one of many surgical treatments to achieve significant long term weight loss (71% mean excess weigh loss). However, this procedure was not free of post operative complications. Wound infection, wound dehiscence, pulmonary embolism and cardiac problems made the recovery of these patients very long and difficult. By using a mini-invasive approach a big incision is spared, resulting in a faster recovery time with less pain and prompt ambulation . According to Dr.Schauer, his procedure is a modification of the technique described by Wittgrove et .al. i*****