Other Laparoscopic Bariatric Procedures

World J. Surg. 22, 964 –968, 1998

WORLD Journal of

SURGERY © 1998 by the Socie´te´ Internationale de Chirurgie

Other Laparoscopic Bariatric Procedures H. Lo ¨nroth, M.D., Ph.D., Jan Dalenba¨ck, M.D., Ph.D. Department of Surgery, Sahlgrenska University Hospital, S-413 45 Go ¨teborg, Sweden Abstract. Laparoscopic surgery is regarded as a major improvement reflected by a rapid recovery and low perioperative and postoperative morbidity. In obese patients the gains of this new technique may be affected by obesity-related problems, such as impaired respiratory function, high intraabdominal pressure, thick abdominal wall, and liver steatosis. This review describes the development of laparoscopic vertical banded gastroplasty (VBG) and gastric bypass procedures; and it addresses questions such as feasibility, comparability to open procedures, procedure-related problems, and recovery. The clinical outcome after laparoscopic VBG and gastric bypass is also updated. Up to May 1997 we have operated on 105 patients with laparoscopic VBG and another 26 completed laparoscopic gastric bypass procedures. The weight loss after both procedures are in accordance with the weight loss seen with open surgery. Procedure-related complications are described in detail in this paper. It is concluded that laparoscopic bariatric surgery will remain an area of importance for clinical practice, research, and development.

Although today’s research to a large extent focuses on the development of pharmacologic agents for the treatment for morbid obesity, surgery is still the only documented effective treatment for long-term weight control. Laparoscopy is regarded as a major improvement reflected by rapid recovery and low perioperative and postoperative morbidity when performing a number of surgical procedures. The obvious advantages with laparoscopic surgery can now be applied also to the treatment of massively obese patients [1– 4]. Laparoscopy in obese patients may be associated with specific problems, such as impaired respiratory function, high intraabdominal pressure, thick abdominal wall, and liver steatosis with lack of access. With these potential complicating factors in mind, we embarked on a clinical research program trying to elucidate, among others, the following questions. Is it technically feasible to do bariatric procedures, with established long-term weight effects, by use of the laparoscopic technique? Is it possible to obtain comparable effects on the level of weight control? Are there specific, procedure-related problems that require particular attention? Are there particular considerations to be taken when doing these procedures to counteract peroperative and postoperative dysfunction? This review addresses these questions and allows us also to give an update on the clinical outcome after laparoscopic vertical banded gastroplasty (VBG) and gastric bypass. Correspondence to: H. Lo ¨nroth, M.D., Ph.D.

Laparoscopic Vertical Banded Gastroplasty Our initial experience with the laparoscopic (VBG) started October 1993 whereupon we found that the laparoscopic VBG was technically feasible and could be safely performed [5]. We soon realized that these patients had a short, smooth postoperative recovery period compared with conventionally operated obese patients. In the following sections we have chosen to take the reader through the operative procedure, step by step, to facilitate understanding of the technical details and to broaden the introduction of the operation into clinical practice. Patients Until now, two surgeons have operated 85 massively obese patients at our institution and another 20 patients we operated on as guest surgeons at other institutions. Demographics are given in Table 1. According to the definitions of the World Health Organization (WHO), severe overweight corresponds to a body mass index of $30 kg/m2 and morbid obesity with a body mass index (BMI) $40 kg/m2. The risk ratio for specific diseases and the associated increased mortality and shortened life expectancy is proportional to the degree of overweight and is monumental in the group of patients with a BMI .40. According to the recommendations of the National Institutes of Health (NIH) Consensus Conference [6], surgical treatment should be an option for all patients with a BMI .40. Patients who suffer from obesity-related social handicaps or associated disease should also be considered for surgery if they have a BMI .35. These considerations have been followed when accepting our patients for surgical treatment of their obesity. Surgical Equipment The equipment needed, apart from standard laparoscopic tools, is listed below. 1. 2. 3. 4. 5. 6.

Circular stapler (ECS 25, Ethicon) Linear 60-mm stapler (ET 460, Ethicon) Liver retractor Lapotract or Martin arm for fixation of retractor 10 mm Babcocks Ruler (USSC)

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Table 1. Demographic data of patients operated on with laparoscopic VBG at Sahlgrenska University Hospital, December 1993 to May 1997.

Table 2. Preoperative weight and weight reduction during the first 6 months after a laparoscopic VBG.

No. of patients Age (years) Sex (F/M) BMI (kg/m2), mean 6 SE

Time of measurement

85 39 (21– 65) 64/21 41 6 1

7. Modified Ally’s clamp (Ethicon) for grasping circular anvil 8. Band material for stoma reinforcement (Marlex mesh or prestretched PTFE 2-mm plate 1.5 3 10 –15 cm) 9. Semiflexible gastric tube with a 9 mm diameter Operative Procedure 1. Establish five 10- to 12-mm ports. For positions see Lo ¨nroth et al. [5]. 2. The left liver lobe is held by a self-retaining retractor. 3. The fundus is gently pulled downward, and the peritoneal reflection lateral to the angle of His is incised. 4. The lesser sac is entered by opening the minor omentum above the caudate lobe of the liver. 5. The retrogastric space is entered through the opening below the left gastric (coronary) vein. 6. The window at the angle of His is opened by blunt dissection from the lesser sac. 7. The position of the circular window is defined by measuring with the ruler from the angle of His on the anterior part of the stomach. The preferred distance is 4 cm. Marking is made by electrocautery. 8. A window is made through the lesser omentum inside the nerve of Latarjet at the same level. 9. PTFE band is introduced through this window. 10. The upper midline port is changed to a 33-mm port. 11. A 25-mm circular anvil is introduced through the upper midline port and grasped with Ally’s clamp. 12. A circular anvil is introduced through the lesser sac and penetrates the stomach after positioning. 13. The circular stapler is applied and closed. 14. A 9-mm tube is introduced through the stoma before firing the stapler to adjust the size of the stoma. 15. The working port on the left hand side of the patient is changed to an 18-mm port. 16. Change the position of the optics to the left working port, and introduce a 10-mm Babcock from the assistant port through the window of the stomach up through the window of the angle of His. Grasp the triangular ligament. 17. Introduce the 60-mm stapler through the 18-mm port. Use the Babcock on the left side as a guide line for the posterior fork. Check the position and fire the stapler with the 9-mm tube still in place. 18. Suture the band around the stoma with three stitches while the 9-mm tube is still in place. The ideal circumference is 5.0 cm. Markings on the band could be made in advance to secure this length. Excessive band material is cut and extracted. 19. Withdraw the 9-mm tube before finishing the operation. Postoperative Evaluation Our patients have been evaluated at 1, 3, 6, and 12 months after surgery. After 1 year the patients are followed on a yearly basis

Preoperatively Postoperatively at 1 month Postoperatively at 6 months

Mean weight (kg) No. of patients

Preoperative

Minimal

Maximal

83 78

119 107

86 74

169 156

71

94

58

147

with weight assessment and symptom evaluation regarding reflux, retention, and eating disturbances. All complications have been documented.

Results Among the total number of 105 cases operated on at our own or other institutions, six cases have been converted due to lack of access. The main reason has been severe liver steatosis. Among our 15 first cases, 3 patients were reoperated during the early postoperative period, in one case due to gastric leakage and in another case due to incompleteness of the staple line; in the third case reexploration was done because of postoperative fever with suspected leakage (although none was found at reoperation). After these initial 15 patients, none has had an early reoperation due to any complications. One patient has been endoscopically dilated due to stoma stenosis. One late postoperative death was due to pulmonary embolism 5 weeks after surgery in a patient who recovered at home after an uneventful initial postoperative course. The weight losses during the first 6 months are detailed in Table 2.

Laparoscopic Gastric Bypass Gastric bypass for treatment of morbid obesity as described by Mason [7] and Griffen et al. [8] is a procedure regarded by many as the “gold standard” of obesity surgery with excellent weight reduction and few side effects. The few drawbacks that burden this procedure are that the operation per se is a comparatively “larger” operation compared to other bariatric options; and being a combination of a restrictive and a malabsorptive method, a mild metabolic disturbance could be expected, mainly vitamin B12 deficiency and a deficit of iron and calcium. With improved instrumentation and experience, reconstructive routine procedures such as gastric bypass can now be safely performed with laparoscopic techniques. Our initial experience with gastric bypass (GBP) through the laparoscope with division of the stomach and omega loop enteroanastomosis was encouraging [9]. There are, however, functional and theoretic advantages with the Roux limb. When the Roux-en-Y laparoscopic gastric bypass was first presented by Wittgrove and coworkers, [2,10], we switched our surgical approach. These initial experiences with the GBP indicated that morbidity after this laparoscopic procedure was comparable to that seen with the open operation, and the immediate postoperative recovery was improved.

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Table 3. Demographic data of patients operated with laparoscopic GBP at Sahlgrenska University Hospital, August 1994 to May 1997. No. of patients Age (years) Sex (F/M) BMI (kg/m2), mean 6 SE

29 33 (22– 63) 24/5 42 6 2

Patients During the period August 1994 to May 1997 we performed 29 attempted and 26 completed laparoscopic gastric bypass procedures (Table 3). In the initial series the patients were operated with division of the stomach and performance of an omega loop gastroanastomosis. The subsequent patients were all operated with a retrocolic Roux-en-Y gastroenterostomy. The criteria for patient selection for LGBP followed the inclusion criteria for LVBG, as noted above. Surgical Equipment Apart from routine laparoscopic instrumentation we have found the following equipment to be useful. 1. 2. 3. 4. 5.

Endoscopic linear cutting stapler, 60 mm Endoscopic linear cutting stapler, 35 mm Lapra-Ty. Atraumatic Babcock, 10 mm Surgical port 18 mm

Operative Procedure 1. Six 10- to 12-mm ports are inserted. Port positions are as for the VBG with an extra port below the umbilicus. 2. The left liver lobe is removed from the operating field by a self-retaining retractor. 3. The fundus is gently pulled downward, and the peritoneal reflection lateral to the angle of His is incised. 4. The lesser sac is entered by opening the minor omentum above the caudate lobe of the liver. 5. The retrogastric space is entered through the window made below the left gastric (coronary) vein. 6. The window at the angle of His is opened up by blunt dissection from the lesser sac. 7. The size of the pouch is defined by measuring with a ruler from the angle of His on the anterior part of the stomach. The preferred distance is 4 cm, which is marked by electrocautery. 8. A window is made in the lesser omentum inside the nerve of Latarjet at the same level. 9. The left working port is changed to an 18-mm port. 10. An endoscopic linear stapler (ELC 60) is introduced through the 18-mm port and a posterior metal fork through the window at the minor curvature. The diathermy mark indicates the size of the pouch. Two 60-mm stapler magazines are needed to reach the angle of His. 11. The position of the liver retractor is changed to pull up the omentum and transverse colon. 12. The optic is moved to the port below the umbilicus to visualize the ligament of Treitz. 13. An opening is made in the colon mesentery 2 cm above and 2 cm medial to the ligament of Treitz. This allows a retrocolic

14. 15. 16. 17. 18.

19.

window to enter the lesser sac by blunt dissection anterior to the pancreas through the mesentery of the transverse colon. The Roux limb is constructed by dividing the jejunum with a 35-mm linear stapler (blue magazine), and the jejunal mesentery is divided using the same stapler (white magazine). The enteroanastomosis is constructed with 35-mm staples. An atraumatic Babcock is used to grasp the Roux limb and introduce it retrocolically up to the gastric pouch. The retractor is repositioned to lift the liver, and the Roux limb is caught by another atraumatic Babcock above the main stomach. The gastroenteroanastomosis is done with a 35-mm stapler for the posterior wall and running 3-0 resorbable suture for the anterior wall. The anastomosis is secured and reinforced with extra single sutures. Before closing the anastomosis a nasogastric tube is introduced through the stoma into the Roux limb. The end of the running suture is secured with Lapra-Ty Vicryl clips if the suture is too short for a proper knot.

Results The three conversions among our 29 cases were due to an accidental perforation of the stomach in one case and inadequate exposure of the operating field owing to enlargement of the left liver lobe in the other two. Cases 11 through 29 have all been a Roux-en-Y GBPs. The following complications have been encountered up to May 1997. 1. Four patients required postoperative blood transfusions. One patient was explored laparoscopically: Blood was evacuated, but no bleeding source could be found. Two of the four patients were subsequently found to have leaks in the gastrojejunostomy and are further commented on below. 2. One relaparoscopy was done because of suspicion of leakage, but no leak could be detected. 3. Two patients had clinically overt leakages in the gastroenteroanastomosis that required reoperation during the early postoperative period. 4. Four patients had postoperative pneumonia. 5. One late (6 weeks) open reoperation was necessary for mechanical obstructions due to internal herniation through the window in the colonic mesentery. 6. One patient was reoperated 2 years 5 months after the bypass procedure due to a perforating ulcer in the gastrojejunostomy secondary to excessive nonsteroidal antiinflammatory drug (NSAID) intake. Despite these complications all patients have ultimately recovered, and there have been no deaths. In conclusion 4 of 26 (15%) laparoscopically operated patients required reoperation due to severe early postoperative complications. The weight reduction in our first 15 cases followed more than 1 year has been 67% of excess body weight, or a mean 42.5 kg (range 20 –109 kg). No severe side effects have been documented. Laparoscopic Jejunoileal Bypass The obvious drawbacks of jejunoileal bypass with the occurrence of hepatopathy, kidney stone formation, renal failure, enteritis, and others has led to this procedure mainly being abandoned

Lo ¨nroth and Dalenba ¨ck: Laparoscopic Bariatric Procedures

despite its excellent weight-reducing effect. Technically, one would expect that a similar procedure could be performed with the laparoscopic technique provided the surgeon is experienced in current suture techniques. In fact, a case report has been presented describing the technical feasibility of the procedure, although neither the number of patients operated nor any data on outcome were given [11]. Discussion Adding to the objective documentation of its clinical efficacy, bariatric surgery has entered a new and challenging era by the introduction of laparoscopic approaches. As seen in other fields of general surgery, when laparoscopists have tried unusual or even totally novel surgical techniques to solve old problems, bariatric operations previously not found to have optimal efficacy have stimulated renewed interest. During the period of open bariatric surgery we have learned that the GBP should be the “gold standard,” which means that new techniques or modification of old ones should always be compared with that standard. Many years of close follow-up are mandatory to document comprehensively a procedure’s efficacy and its eventual disadvantages. For instance, long-term data have consistently shown serious metabolic and other side effects of jejunoileal bypass, making this procedure less attractive, albeit it can be done through the laparoscope. It must be born in mind that a few patients may eventually benefit from such a procedure, so it should be kept as an operative treatment option in advanced centers where operative treatment of massive obesity is offered. Although not the “gold standard” of surgical therapy for obesity, VBG has been fully evaluated in large studies with long-term follow-up [12]. Over the years controversial areas have emerged relating to the questions about the size of the pouch, the need for division of the staple line, and of course the optimal size of the stoma. Despite this debate it can be concluded that the pouch must be made small, perhaps by adequate measurements during the operation, moreover, the stoma is reinforced as presently described and should be 9 to 10 mm in diameter. Taking into consideration all the important information when we embarked on a program to develop a laparoscopic technique to perform a VBG, we have clearly shown that these procedures can safely and effectively be done through the laparoscope. Another important aim of this program was to adhere to all essential points learned from the open procedures. In fact, our laparoscopic VBG is technically identical to those done by the conventional laparotomy route. The safety and feasibility of the laparoscopic VBG is now established, as are its early postoperative functional and clinical advantages. The weight development during the postoperative course up to at least 2 years (to be published) looks promising, with the data being clearly comparable to what has previously been observed with open VBG. The gastric bypass is a more difficult procedure and more demanding for us despite our experience with similar techniques in massively obese patients. Therefore the message today is that laparoscopic techniques and experience with GBP must be developed further before it can be recommended for more widespread clinical use. Our initial experience with the omega loop GBP was reassuring, but we abandoned the technique more on theoretic than on clinical grounds. Provided a safe gastroenterostomy is done, the Roux approach has proved effective. The use of staplers

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solely for the construction of this vital anastomosis cannot be recommended according to our experience. It is our opinion that hand suture techniques for anastomotic reconstruction are mandatory to comprehend and practice in advanced laparoscopy. Having undergone a proper laparoscopic GBP, the patients face a smooth, rapid postoperative recovery with oral fluid intake resumed as early as the first postoperative day; it is recommended that they stay on a liquid diet for the first week. If no complications occur, these patients can leave hospital on the second postoperative day. We are now approaching a clinical situation where laparoscopic GBP should be formally compared with, for example, VBG in the framework of a randomized clinical trial. Before that is done, however, we are somewhat reluctant to accept laparoscopic GBP as the “gold standard” of bariatric surgery for the years to come. Conclusions Bariatric surgery has ultimately moved into the era of laparoscopy. Video documentation has proved to be an excellent way to communicate between colleagues and experts to launch and share techniques and experiences. According to our experience, the step-by-step manner of performing and teaching these operative procedures has been successful and is associated with minimal perioperative morbidity. If these fundamentals are combined with adequate patient selection and proper objective short- and longterm assessments, laparoscopic bariatric surgery will remain an area of importance for clinical practice, research, and development. Re´sume´ On pense que la chirurgie par laparoscopie repre´sente une ame´lioration majeure en raison d’une re´cupe´ration rapide et une morbidite´ pe´riope´ratoire basse. Chez l’obe `se, les avantages de cette nouvelle technique pourraient ˆetre contrebalance ´s par la de´pression de la fonction respiratoire, l’augmentation de la pression intra-abdominale, l’e´paisseur de la paroi abdominale et la ste´atose he ´patique. Cette revue de ´crit le de ´veloppement de la gastroplastie verticale et d’autres proce´de´s de partition gastrique et on essaie de re´pondre `a des questions concernant la faisabilite´, la comparabilite´ aux proce´de´s ouverts et la re ´cupe´ration. Une mise au point de l’e´volution clinique apre `s gastroplastie verticale par laparoscopie et le by-pass gastrique est fournie. Jusqu’au mois de Mai 1977, nous avons re´alise´ 105 gastroplasties verticales sous laparoscopie et 26 patients ont eu un by-pass. La perte de poids apre`s les deux proce ´de´s ´etait comparables `a celle observe´e en chirurgie ouverte. Les complications en rapport avec le proce´de´ sont de´crites en de ´tail. On conclue que la chirurgie bariatrique reste un sujet d’inte´reˆt clinique, de recherche et d’avenir. Resumen La cirugı´a laparosco ´pica es considerada como un avance mayor, el cual se refleja en ra´pida recuperacio ´n y baja morbilidad peri y postoperatoria. En los pacientes obesos los beneficios de esta nueva te´cnica pueden ser impedidos por los problemas relativos a la obesidad, tales como funcio ´n respiratoria alterada, elevada presio ´n intraabdominal, grosor de la pared abdominal y esteatosis hepa´tica. En este artı´culo describimos el desarrollo de los pro-

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cedimientos de gastroplastia de “banding” vertical (GBV) y de “bypass” ga´strico y se discuten interrogantes tales como factibilidad, comparabilidad con los procedimientos abiertos, problemas en relacio ´n con el procedimiento y recuperacio ´n. Tambie´n se informa una actualizacio ´n del resultado clı´nico luego de la GBV y del “bypass” ga´strico practicados por el me´todo laparosco ´pico. La pe´rdida de peso registrada luego de estos procedimientos concuerda con la registrada en los procedimientos abiertos. Se describen en detalle las complicaciones. Nuestra conclusio ´n es que la cirugı´a baria´trica laparosco ´pica continuara´ ocupando un lugar de importancia tanto en la pra´ctica clı´nica como en la investigacio ´n y el desarrollo. References 1. Belachew, M., Legrand, M.J., Defechereux, T.H., Burtheret, M.P., Jacquet, N.: Laparoscopic adjustable silicone gastric banding in the treatment of morbid obesity: a preliminary report. Surg. Endosc. 8:1354, 1994 2. Wittgrove, A.C., Clark, G.W., Tremblay, L.J.: Laparoscopic gastric bypass Roux-en-Y: preliminary report of five cases. Obes. Surg. 4:353, 1994 3. Catona, A., Gossenberg, M., Mussini, G., La Manna, L., De Bastiani,

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4. 5.

6. 7. 8. 9. 10. 11. 12.

T., Armeni, E.: Videolaparoscopic vertical banded gastroplasty. Obes. Surg. 5:323, 1995 Chua, T.Y., Mendiloa, R.M.: Laparoscopic vertical banded gastroplasty: the Milwaukee experience. Obes. Surg. 5:77, 1995 Lo ¨nroth, H., Dalenba¨ck, J., Haglind, E., Josefsson, K., Olbe, L., Fagevik Olse´n, M., Lundell, L.: Vertical banded gastroplasty by laparoscopic technique in the treatment of morbid obesity. Surg. Laparosc. Endosc. 6:102, 1996 National Institutes of Health Consensus Development Conference draft statement on gastrointestinal surgery for severe obesity. Obes. Surg. 1:257, 1991 Mason, E.E., Ito, C.: Gastric bypass. Ann. Surg. 170:329, 1969 Griffen, W.O., Jr., Young, V.L., Stevenson, C.C.: A prospective comparison of gastric and jejunoileal bypass procedures for morbid obesity. Ann. Surg. 186:500, 1977 Lo ¨nroth, H., Dalenba¨ck, J., Haglind, E., Lundell, L.: Laparoscopic gastric bypass: another option in bariatric surgery. Surg. Endosc. 10:636, 1996 Wittgrove, A.C., Clark, G.W.: Laparoscopic gastric bypass, Rouxen-Y: experience of 27 cases, with 3–18 months follow-up. Obes. Surg. 6:54, 1996 Cleator, I.G.M., Litwin, D., Phang, P.T., Brosseuk, D.T., Rae, A.J.: Laparoscopic ileogastrostomy for morbid obesity. Obes. Surg. 4:358, 1994 Mason, E.: Ten years of vertical banded gastroplasty for severe obesity. Probl. Gen. Surg. 9:280, 1992.