Question:
Why would a doctor recommend the open RNY over the Lap (if the Lap is less evasive)?
— 4372obhelp (posted on December 21, 2004)
December 20, 2004
Lack of skills or tools to the surgery LAP. Some surgeons just arent
equipped to do it LAP:( Or a extremely high BMI like over 60. It takes LOTS
of skills and experience to do surgery LAP and some surgeons are more comfy
with open. LAP offers generally less pain, faster recovery, near zero
chance of incisional hernias, and lower risk of infection. This all from my
surgeon Dr Philip Schauer.
— bob-haller
December 20, 2004
Skill. Lap RNY is much more difficult to perform. If your surgeon is more
comfortable with open, I would go that way as complications can be higher
with a less skilled surgeon. Some surgeons recommend open for those with
higher BMIs as well, although not all.
— mom2jtx3
December 20, 2004
The specific answer to this question for you should come from your surgeon.
Did he say anything? Many times surgeons will choose open vs lap because
of the patients body type. If you carry a lot of your weight in your
abdomen lap might be more risky. Have you had precious abdominal surgeries
that might mean you have internal tough scar tissues which would make the
lap proceedure more difficult. Has he done any lab tests that might have
determined that you have a very fatty liver? If the liver is enlarged it
takes up more space in the abdomen and gets in the way of the lap
instruments. So ya see it could be any or the above, plus the surgeons
skill of course that determine which procedure is chosen. Now some drs
will reccommend a diet for a few weeks before surgery to reduce the size of
the liver if that is the problem.
Ask your surgeon to tell you his exact reason and it might be something you
can negotiate.
Rosemary
— SARose61
December 20, 2004
Oops should have checked my spelling. meant "previous" abdominal
surgeries...not precious....lol.
Rosemary
— SARose61
December 21, 2004
I have to disagree with some of the replies... I'm sorry. It isn't
"always" that the surgeon doesn't have the skill or the tools to
the RNY as a lap surgery instead of open... it very well has ALOT to do
with insurance companies who are MORE WILLING to pay for OPEN over LAP
simply because the open procedure costs the insurance companies less
"up front". Keep in mind, however, that the insurance companies
fail to realize the rate of hernia repair surgeries that are required for
the open procedure... so, really, in the long run, they didn't save, but
they don't care... it's not them... This I know from experience... and
dealing with my own insurance company/surgeons on this matter.
— [Deactivated Member]
December 21, 2004
I agree with the poster who suggested asking your surgeon this question.
I, too, shy away from the blunt explanation, "skill," because
it's true as far as it goes but it's not the entire picture. My surgeon's
done over 3,000 open RNYs. There was a time he attempted branching into
lap, got more complications from doing it (as any new lap surgeon probably
would), and went back to what he knew and did well.<P>This didn't
keep me from picking him as my surgeon, because (a) he was factual in
explaining why *he* doesn't do lap, and (b) I was far more interested in
finding a bariatric surgeon with many years of experience, and a good
aftercare program, than I was in whether it was done lap or open.<P>I
developed no hernias, had a single scar of 3 1/2 inches from the
"open" (completely cut out with my LBL anyway), and took off no
more work (and spent no more time in the hospital) than many typical lap
patients do.<P>It's surely important to consider the risk of hernia
with open, though lap also presents a less-talked about risk of internal
hernias that can be more difficult to diagnose. Plus, I had two friends
who wanted lap, each with a different surgeon from each other or me -- one
wound up going in for emergency surgeon a few days after her lap RNY to
address an life-threatening twisted bowel, and the other, after five hours
in surgery, was discovered to have a problem with her stomach that
necessitated having "open" after all (so she got the worst of all
worlds -- *all* the open *and* lap scars).<P>Pick the best surgeon
you can find, with a good aftercare program. How he gets in to do the job
is secondary, IMHO, so long as he's good at however he does it and runs a
decent WLS program.
— Suzy C.
December 21, 2004
Please don't take this the wrong way, this is just a 'pet peeve' of
mine---but the word is 'invasive', not 'evasive'. 'Evasive' means 'to turn
away from' while 'invasive' means 'insertion into the living body'.
— MsBatt
December 21, 2004
I too am a bit offended at the 'skill' remarks. I had the choice and chose
open. The surgeon I chose performed the surgery open and has in the past
performed it Lap. His answer as to why he preferred open to lap was that
is was far less risky to do it open, less of a chance to accidentally knick
something while you are in there. And to be able to see what you are
doing and to feel what you are doing, not relying on a camera and tools is
an important aspect as well. So before you spout off 'Skill" and
assume that all doctors performing open surgery are less qualified than one
that does it Lap, take into consideration that my surgeon, who performs
only open surgeries, has been doing this for over 30 years and has trained
MANY surgeons to do the same procedure. It is a preference, not skill
level.
— RebeccaP
December 21, 2004
The bariatric program at HUP says the "higher incidence of incisional
hernias" for the open RNY vs the lap RNY is way overblown. My
surgeon, Dr. Raper at HUP, who only does open RNYs, has a very low
incidence of incisional hernias. At the support group, the head of the
bariatric program said that she only knows of 2 patients of Dr. Raper's who
have had incisional hernias. This out of hundreds of open RNYs...JR
— John Rushton
December 21, 2004
My doctor, who at the time I had my surgery had done > 1500 open RNY
surgeries said that at the time I had mine that Laps were still considered
experimental by the FDA, and that some of the equipment that was being used
to do the Lap (the cutting stapler) was having to be modified by the
surgeon doing the Lap RNY, rendering that piece of equpment's warrenty
void. (what he didn't say - That product liability would also increase the
surgeon's malpractice risk) I didn't care to be in an experimental group
then or now. I do not know if the lap is fully approved by the FDA yet, I
do know that the lack of approval was causing some insurance companies to
refuse to pay for a Lap RNY procedure. I do know know if that is accurate
now or not. I know I would do what I did again. the open was painful, but
the people I know who had lap procedures looked as uncomfortable as I felt.
I would definately want an open if it was the choice between open or
nothing. My RNY has changed my life!
— **willow**
December 21, 2004
As some have already stated there are a number of issues that factor in.
When I had my open RNY in Feb 03 my surgeon would not even consider a LAP
surgery on a 50 BMI or higher. He is a trauma and general surgeon in
addition to doing bariatric surgery for about 15 years at that time, so he
definitely was experienced. He was an excellent LAP surgeon also.
However, his feeling at the time was that he wanted me on the table for as
short of time as possible. The larger you are the longer you are under
anesthesia the greater the risk. He wanted to get in and out as quick as
possible and for him that meant Open. He also could clearly see what he
was doing and could fix anything that came up quickly. At that time he had
not been having a lot of success in completing LAP RNY surgeries on smaller
BMI people and most of the time ended up converting to open anyway, greatly
increasing the length of their surgery time. He had done extensive
training with two of the top LAP RNY docs in the country but still wasn't
that successful. Because I was a 65.3 BMI, in WI there really were not
many options, if any, for me to get it done LAP. There was one surgeon in
Milwaukee who might consider it but it was an 8 month wait just to see him.
Having it LAP wasn't that important to me to wait potentially a year when
I could get in done within a few months. I do not regret my decision at
all. Even before I had a bunch of PS which got rid of the open RNY scar, I
was okay with it. Now it is hardly noticeable and one needs to look pretty
hard to see it. I personally found the recovery from my LBL, at 240 lbs
lighter than my RNY was a ton worse recovery. I was sore and felt like I
had done 1000 ab crunches after the WLS but each day it improved and within
2 weeks I could pretty much move as needed. Still with a small degree of
discomfort but nothing I could not handle.
<p>This past year my surgeon has made great stides in doing LAP and
is very successful on the under 50 BMI's and even on the larger people. He
evaluates each situation based on medical problems etc. If a person is a
high risk breathing issue type patient you can bet he is going in open from
the start as it is the fastest way to get that person out of anesthesia. I
personally do not think it is a huge deal to have it done either way. Just
get it done! Some insurances will dictate. While they shouldn't, I would
not make an issue out of it and refuse to get the surgery just because of
that. They are going with the statistics. Granted they may be somewhat
outdated statistics, but it is more important to get the surgery and get on
with your new life. I know of people that my surgeon said he would do LAP
on, back in 2003, that refused and said they wanted open because they
wanted to get out of surgery fast and because they wanted the surgeon to be
able to see everything. They felt they had a much bette chance of not
having complications. Right or wrong, it's what made them the most
comfortable.
— zoedogcbr
December 21, 2004
My skills comment referes specifically to LAP skills. LAP RNY surgeries
dont consider a surgeon skilled till they have a done a minimum of a 100
LAP. A open surgeon can have wonderful skills to do opens, while not being
experienced LAP at all. My surgeon did my wife LAP with a BMI of 60+ in 1.5
hours. most open surgeries take that long. It appears from the number of
hernias reported here nearly ALL are opens. In 4 years I ONLY remember one
that was LAP. Insurance generally embrances LAP since it shortens hospital
stays to just a couple days with opens much longer.<P> Having been
here 4 years LAP has become much more common and prefered by many. Time has
changed this a lot.
— bob-haller
December 21, 2004
Because it is faster for a doctor to do an open over a lap. The doctor can
see the operative field easier with an open procedure over lap. Therefore
if he/she can see better it is faster especially if your bmi is over 50
like yours is. There is a far greater risk for a person your size to be
under aesthesia any longer than needed. If I remember correctly the lap
procedure is 30 minutes longer than the open. And with some doctors you are
in the hospital 1 day longer with lap because there are more things that
can go wrong that the doctor may have not seen when he was looking through
the camera lens in your insides.
— ChristineB
December 21, 2004
A doctor would recommend an open lap because of a couple of reasons... It
is easier for him. Your recovery time is PAINFUL and long- approx 6-8
weeks. A laproscopic surgery takes a skilled surgeon with fine skills in
using the tiny instruments inserted thru the small cuts in your belly. I
had my surgery 6 days ago. I feel great, I am tolerating eating well and I
do not HURT!!!!!!!!!!!!!!!! I have been out Christmas shopping (I tire easy
and can just do 2 stores at a time) My advice is to find yourself a
different dr. My surgeon will NOT do it open-at all. He is Peter Tomasello-
Plantation FL.
— Dec16-04
December 21, 2004
I had open RNY and open VBG and open small bowel obstruction repair. Was it
fun? No, but I was not out 6-8 weeks, I was not in PAIN, but was sore. I
wasn't out shopping, but then, it wasn't Christmas time for either of my
surgeries. Just b/c someone has OPEN doesn't mean they will be in PAIN and
out of commision for 6 weeks, just like if someone has LAP it doesn't mean
it's smooth sailing. Everyone is different, we all have different pain
tolerances and reactions to major surgery.
<P>
As for the skill thing, just b/c a surgeon chooses not to do LAP, doesn't
mean they can't or don't have the skill. What it means is that there is a
length of time to train, there is a length of time to become proficient. To
the surgeons that have lots of years experience, learning to do LAP means
time away from the work that is making them money. They won't be able to
see as many patients during their training period, so that means less
money, and less patients being treated. I'm not saying they are all money
hungry, but I don't know too many people that work for free!!
— Ali M
December 22, 2004
In doing my research and having a step sister that had the LAp proceedure,
there is a greater risk of complications with LAP than with OPEN. In the
OPEN proceedure you touch and see the organs as opposed to looking on a TV
monitor and using small instruments to feel and cut and suture your organs.
My step sister had LAP and it wind up being OPEN because she had a leak in
the back of her pouch which the doctor did not see until 1 week after she
came home and was back in the hospital to end up with the scar of a open
proceedure anyway. I personally would rather my doctor feel with his hads
and see my insides rather than insert a camera to see inside me a use tools
to complete the surgery. Every one is diffrent and I am sure our insides
are all laid out different. I would rather have a doctor open me and see
where my stomach stoma ect is at. It is just my feelings and you should go
with what you feel comfortable with. By the way my sister was out of work,
in and out of the hospital and just plain sick for well over a year, with
her original LAP proceedure and she may need a feeding tube. I have a
cdousin and a freind who had the open with no complications except one had
a hernia, they lost their weight had lifts and tucks and look absolutely
marvouslous.
— JerseyGirl
December 22, 2004
How about a New Year's Resolution to do yer "Lap Rocks - Open
Sux!" riff just *once* per thread, Bob? :-D
— Suzy C.
December 22, 2004
uzy I revisted this because apparently my skills comment upset some. I
wasnt knocking their surgeons, just pointing out LAP skills are different
than open skills<P>
When choosing a surgeon here are some pointers. The best safest results
appear using a large busy bariatric practice at a teaching hospital. Large
busy practices at teaching hospitals appear to have the safest best results
no matter the spoeciality. Be it heart or weight loss. Lap its best to pick
a surgeon who has done at least a 100, and a 1000 is better. Bigger
operations tend to recognize problems faster, and specialists to treat
problems help too. <P> This statement is a generality, certinally
there are excellent surgeons of all types.
— bob-haller
December 22, 2004
I had an open DS. I have a long scar, from the tip of my sternum down to
inside my navel. I was in the hospital four nights, which is pretty much
standard for the DS, whether open or lap.
As for pain---I've hurt myself worse, in accidents around the house. (Try
spraining both ankles at the SAME time, if you want some serious pain!)
Within two weeks post-op, I felt better than I had for MONTHS pre-op.Don't
be afraid of having an open procedure.
When laproscopic prosedures were first developed, the instruments were,
naturally, designed for use on patients of 'normal' size. MO and SMO people
can't always be operated on using these instruments---they just aren't long
enough. Some surgeons don't have access to the specially-made, extra-long
lap tools required for use on patients with really high BMIs.
— MsBatt
December 22, 2004
It is more likley that you insuance would cover an open ryn than a lap.
Because with a lap you need two surgeons rather than one. and what i was
told by my doctor is that you are more prone to infection. and with open
they can look at all of your other organs my doctor has found cancer and
other thing like that while doing the open. In my opion i would like to
see if every thing else is ok too.
— kristineeveleth
December 22, 2004
I had a lap RNY 22 months ago. At the time of my consult my Dr. asked me
if I wanted it lap. He does all of his that way unless there are
unexpected complications. I told him I didn't care if he cut me from my
neck to my navel in the middle of Times Square, if he thought that was the
safest way to go. My feeling is, be confident in your surgeon's skill and
ability. We all heal eventually. If he has a valid reason for doing it
open, I would accept it. A few weeks either way would not sway me. As
for the need of 2 Drs. for the lap, it is not necessary for there to be 2.
I asked my Dr. about this, because this was my impression, and my sister's
lap was done that way. My Dr. got stuck out of town and his partner did my
surgery. I immediately asked her who would be with her since he was away.
She told me that she would do the entire the surgery, and the 2nd person
basically is an extra pair of hands to hold the instruments in place while
the Dr. cuts and staples. This is a very high profile practice that would
in no way risk a problem. Again, have trust in your Dr..
— Fixnmyself
December 23, 2004
To answer your question is difficult without knowing why he says this.
First, it could be that he is not proficient in doing it LAP. If that's the
reason, find a new doc. Second, you may have had previous surgery that
requires it. That is what happened to me. I DO NOT recommend doing it OPEN
if you can find someone who does good at LAP. I had many complications:
spleenectomy, abcess, leak... There are a lot of docs that don't know how
to do it LAP well enough. If you want it done LAP, keep looking. Yes, there
can be complications with LAP, but OPEN has a lot more PAIN, longer
recovery, and the greater potential for all the other complications. I've
had LAP for other surgery and there is no comparison. LAP is so much
better!! Go for it!!!
— debi327
December 23, 2004
Rhonda..There are many reasons to do open instead of LAP. Factors include
surgeon training and his cmfort level,your size and weight distribution,
previous abdominal surgeries, current health problems that influence
anesthesia risk. Do you have asthma, COPD,heart disease etc? Surgery time
is usually shorter with an open procedure. Incisional hernias are very
common with obese people--wear a good abdominal support and follow orders
on activity and lifting. I had open RNY by choice because I wanted my
surgeon to be able to see exactly what he was doing. He is a skilled LAP
surgeon also. I went back to work full time at 3 weeks post op. Stay ahead
of the pain and keep moving.You won't get as sore and will heal faster and
better. Good luck.
— dianne E.
December 23, 2004
There's lots of good info given already below. I just wanted to say that
my surgeon preferred open because he can do it faster. I went w/ his
comfort skill. My surgery was 37 minutes, 2 day hospital stay. I disagree
with the other poster that you need to find a different surgeon if yours
won't do lap.
My scar is 3 1/2 inches long, I was back to work in 2 weeks. The intense
pain was the day after surgery, after that, more nagging pain than anything
else- very tolerable. Everyone is different though, and a lot would depend
on your pain tolerance and how you heal.
I get a little upset over the whole "lap is better" drama that
goes on. There are many factors to determine which is better for each
individual. My experience with open was GREAT.
Good luck! Shannon Open RNY 2/25/04 251/179/140
— M. Me
December 24, 2004
my doctor, neil hutcher, doesn't do anything but the open, while all of his
colleagues do the lap. his reasoning is that he wants to do
"exploratory" surgery and look around in there and make sure that
everything is what it is supposed to be. i chose to go with him because he
has a huge reputation as competent. as it turned out, i had some problems
with my liver and they had to play with it a bit to be able to do the
surgery. while my scar is longer and i was a little sorer, i wonder what
would have happened if they had done it lap. for sure, he made sure there
were no leaks and believe me, i was thoroughly "vetted" over the
course of my hospital stay. i wasn't hugely obese, but i did have some
health issues and even though it has been hard going, i have the security
of knowing that things inside me were looked at properly and thoroughly.
you have to do what you feel comfortable with, and at my age, i wanted the
knowledge that everything was alright in there! :)
— ellen Y.
December 25, 2004
My doctor refused to do a LAP on me. At first I was upset, but he explained
to me that since my bmi was over 55, and I carried a large amount of my
weight in my stomach area, that it would be difficult to see what was going
on in there without cutting me open. Putting it bluntly, all my fat would
get in the way. So I trusted him to do the open RNY, and not only was there
very little post-op pain, but I am healing nicely, and 80 pounds down with
no complications. I'm glad he did it the way he felt would be the safest
for me.
— [Deactivated Member]
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