OBES SURG (2009) 19:1711–1715 DOI 10.1007/s11695-009-9900-0
CASE REPORT
Single Incision Transumbilical Laparoscopic Roux-en-Y Gastric Bypass: A First Case Report Chih-Kun Huang & Jer-Yiing Houng & Chen-Ju Chiang & Yaw-Sen Chen & Po-Huang Lee
Received: 9 March 2009 / Accepted: 2 June 2009 / Published online: 24 June 2009 # Springer Science + Business Media, LLC 2009
Abstract Roux-en-Y gastric bypass, which is based on the dual mechanisms of restriction and mal-absorption, is considered to be one of the gold standard surgeries for treatment of morbid obesity. However, the classic laparoscopic approach requires five to seven incisions for multiple trocar placement. Recently, single incision laparoscopic surgery has been adopted for performing appendectomies, cholecystectomies, sleeve gastrectomies, and adjustable gastric band surgeries. Here, we described the first case of a patient receiving laparoscopic Roux-en-Y gastric bypass through a single transumbilical incision. The operative time was 170 min. There were no intra-operative complications; the patient did very well postoperatively and was discharged 2 days later. Single incision laparoscopic surgery has been viewed as an alternative to natural orifice transluminal endoscopic surgery. When performed via the transumbilical route, it can make the abdominal wound scarless and cosmetically more acceptable. Keywords Roux-en-Y gastric bypass . Minimally invasive surgery . Bariatric surgery . Single laparoscopic incision transabdominal surgery C.-K. Huang (*) : Y.-S. Chen : P.-H. Lee Department of General Surgery, E-Da Hospital/I-Shou University, 1, E-Da Rd, Jian-Shu Tsuen, Yan-Chau Shiang, Kaohsiung 824, Taiwan e-mail:
[email protected] C.-K. Huang : J.-Y. Houng Department of Chemical Engineering, Institute of Biotechnology and Chemical Engineering, I-Shou University, Kaohsiung, Taiwan C.-J. Chiang Postgraduate Programs in Management, I-Shou University, Kaohsiung, Taiwan
Introduction Roux-en-Y gastric bypass is one of the emerging approaches for bariatric surgery in Asia. Regarding its efficacy, most investigators have reported a 60–70% loss of excess body weight using this technique, with the effects being maintained for >10 years [1–4]. However, among the various bariatric surgeries, this technique is considered to be the most complex surgical process with a steep learning curve. Nevertheless, since Wittgrove et al. introduced the laparoscopic technique in 1993, the number of operations performed has expanded rapidly, and this has been accompanied by a gradual reduction in the number of complications [5]. Our results using laparoscopic Roux-enY gastric bypass (LRYGB) have also demonstrated an acceptable learning curve, proven efficacy, and a reduced complication rate in the Chinese population [6]. However, the classic laparoscopic approach still requires five to seven incisions in order to facilitate placement of multiple trocars. In the concept of no-scar operation, natural orifice transluminal endoscopic surgery (NOTES) has been considered as a new landmark of laparoscopic advancement. Since the introduction of NOTES in 2004, numerous reports have been published describing different surgical interventions [7–9]. Although it has attracted the attention of surgeons worldwide, the techniques and instruments of this new minimally invasive procedure are still very much in the developmental phase. Recently, an emerging procedure, single incision laparoscopic surgery (SILS), has been applied to cholecystectomy, appendectomy, adjustable gastric banding, and sleeve gastrectomy [10–15]. In bariatric surgeries, adjustable banding and sleeve gastrectomy have been selected for application of the SILS technique since these procedures require extension of one of the trocar incisions for placement of a subcutaneous port
1712
or for extraction of a resected gastric specimen [13–15]. If SILS is performed using an umbilical incision, it will be more beneficial in terms of cosmetic outcome since the wound can be hidden in the umbilicus, thereby leaving no visible abdominal scars [14]. However, the small umbilical incision will make trocars “crowed” and “small angle” for instruments to operate in. Furthermore, in morbidly obese patients, a hypertrophic left liver lobe invariably hinders a view of the whole stomach. Consequently, traction of the liver during the manipulation of instruments will be a major concern in the course of an operation. In this report, we describe the first case of single incision transumbilical laparoscopic Roux-en-Y gastric bypass (SITU-LRYGB). In addition, a novel intra-operative traction method for the liver will be described.
Case Study and Surgical Technique A 53-year-old female patient, with a body mass index of 35.9 kg/m2 and a history of hypertension and osteoarthritic change in the knees, underwent SITU-LRYGB. The patient was placed in the supine position with the arms extended laterally. The surgeon stood on the right side of the patient with an assistant on the left side. A 4-cm omega-shaped incision was made around the upper half of the umbilicus (Fig. 1). We deepened the incision to the linea alba, where a 15-mm VersaStep bladeless trocar (Covidien) was inserted at the cephalic site after the creation of pneumoperitoneum. The step trocar can effectively prevent the leakage of air and loosening of the fascia defect. Carbon dioxide insufflation with a pneumoperitoneum pressure of 15 mm Hg was then performed, followed by insertion of a long, 5-mm, rigid, 30° video laparoscope. Under direct visualization, two Versaport™ V2 5-mm trocars bladed with fixation cannula (Covidien) were placed through the
Fig. 1 A 4-cm omega-shaped skin incision for SITU-LRYGB
OBES SURG (2009) 19:1711–1715
Fig. 2 The triangular position of trocars
“bilateral arms” of the incision (Fig. 2). We then placed a self-designed “liver suspension tape” into the peritoneal cavity (Fig. 3). One needle was held by a needle holder and penetrated the left liver lobe near the falciform ligament and was then brought out from the midline abdominal wall. Another needle penetrated the lateral edge of the left liver lobe and was then brought out from the left subcostal abdominal wall. The liver was then suspended in the correct position and the sutures were fixed with Kelly clamps (Fig. 4). We subsequently introduced an ultrasonic coagulation instrument (AutoSonix™ Ultra Shears™ Long; Covidien) to dissect the perigastric vessels, and then created a 20-ml proximal gastric pouch using a laparoscopic stapler (Endo GIA Roticulator™ 60–3.5 mm SULU, Covidien). The proximal jejunum was then traced and measured 50 cm distal to the Treitz ligament. It was then raised to create a
Fig. 3 Design for “liver suspension tape”: We measured the length of the left liver lobe intra-operatively and then cut the Jackson–Pratt drain tube near the drainage hole site to the same length. We penetrated it with a 2-0 Prolene suture (Monofilament Polypropylene Suture W8400; Ethicon). The needles were left in both sides for further liver puncture
OBES SURG (2009) 19:1711–1715
1713
Fig. 4 a One needle was held by a needle holder and penetrated the left liver lobe near the falciform ligament and was then brought out from the midline abdominal wall. b Another needle penetrated the lateral edge of left liver and was then brought out from the left upper
quadrate abdominal wall. c The liver was suspended in the correct position and the sutures were fixed with Kelly clamps. d Extracorporeal fixation of “liver suspension tape”: The tape was fixed with Kelly clamps after liver suspension
3.0-cm-long gastrojejunostoma using a laparoscopic stapler (Endo GIA Roticulator™ 30–3.5 mm SULU; Covidien) at the antecolic position. The proximal jejunum was then transected using a laparoscopic stapler (Endo GIA Roticulator™ 45–2.5 mm SULU; Covidien) adjacent to the gastrojejunostoma, and then lowered to perform a side-toside jejunojejunostomy (alimentary limb measured 80 cm) using a laparoscopic stapler (Endo GIA Roticulator™ 45–2.5 mm SULU; Covidien). We then applied two stay sutures for retraction of the jejunostoma and the stoma was closed using a laparoscopic stapler (Endo GIA Roticulator™ 60–3.5 mm SULU). The mesenteric defect was closed with a 2-0 Ethibond (W6977; Ethicon) suture, and the gastrojejunostoma was closed with one layer of 2-0 Vicryl (VCP333; Ethicon; Fig. 5). The liver suspension tape was then removed and homeostasis was established by cauterization if there was hemorrhage at the liver surface. All trocars were then removed and the fascia defect was closed with sutures. Dermabond topical skin adhesive (2-octyl cyanoacrylate; Ethicon) and dressing were applied to the skin incision (Fig. 6). The operative time was 170 min and blood loss was 75 ml. The patient did well postoperatively
and was discharged on postoperative day 2. There were no postoperative complications.
Discussion Recently, the technique of single incision laparoscopic surgery has been developed and is gradually being applied in bariatric surgery. Saber et al. have reported the first series of single incision laparoscopic sleeve gastrectomies [14]. Since this technique utilizes the transumbilical route, the incision scar can be almost completely hidden inside the umbilicus and becomes scarless after surgery. Further, this surgical technology is an acceptable alternative to NOTES, which is still experimental and a subject of considerable ethical discussion [16]. Moreover, in addition to yielding satisfactory cosmetic results, we can expect the procedure to decrease the postoperative pain and discomfort experienced in traditional multi-incision laparoscopic surgery and also to result in a shorter recovery time. With further improvements and a greater understanding of this technique, we can start to consider performing more advanced
1714
OBES SURG (2009) 19:1711–1715
Fig. 5 a We created a 20-ml proximal gastric pouch. b A 3.0-cm-long gastrojejunostoma was created at the antecolic position. c The proximal jejunum was then transected adjacent to the gastrojejunostoma. d Side-to-side jejunojejunostomy was performed using an Endo
GIA 45–2.5 mm laparoscopic stapler. e We applied two stay sutures for retraction of the jejunostoma, and the stoma was closed using a laparoscopic stapler. f The gastrojejunostoma was closed with the hand-sewn technique
surgeries, which require anastomosis of the gastrointestinal tract. To the best of our knowledge, this is the first report in the literature describing a SITU-LRYGB. Previously, the main impediment to performing this type of surgery has been the finite number of trocars that can be used in a very limited surgical field. The resulting small degree of instrument triangulation and lack of tissue retraction by the assistant surgeon tended to make the procedure very stressful for the surgeons. The omega-shaped incision
described in this paper can create an additional 5-mm space between trocars and allow the surgeon to manipulate these instruments more easily. The ability to handle hypertrophic livers is also a very critical aspect in the surgery of morbidly obese patients. The novel technique of using liver suspension tape for intra-operative liver retraction will make the operation process easier by facilitating approach without the necessity of another hand to “push” the liver. The gastrojejunostomy was performed using the linear GIA
OBES SURG (2009) 19:1711–1715
1715
References
Fig. 6 Excellent cosmetic result was obtained for the umbilical wound
anastomosis method. In our experience, this method is less time-consuming and easier to manipulate at smaller angles, as compared to the totally hand-sewn technique. Also, it does not require counter traction in order to preserve the integrity of the sutures. Using these modifications, we completed this first operation within a reasonable time of 170 min without specially designed flexible articulating instruments or endoscope. We still have a strong belief that single incision transumbilical laparoscopic surgery is safe, technically feasible, and reproducible for this procedure. However, we anticipate certain limitations for the use of this technique in severely obese (BMI≥50 kg/m2) patients or those taller than 180 cm. In such patients, the position of the umbilicus is lower; hence, its distance from the gastric pouch is greater. This inadequate positioning and fat abundance could make the umbilical approach difficult and harder to reconstruct. Overall, with the rapid development of more flexible articulating instruments, endoscopes, and robotic assistance, this approach is set to expand and will achieve wider application in the near future.
1. Sugerman HJ, Kellum JM, Engle KM, et al. Gastric bypass for treating severe obesity. Am J Clin Nutr. 1992;55:560S–6S. 2. Benotti PN, Forse RA. The role of gastric surgery in the multidisciplinary management of severe obesity. Am J Surg. 1995;169:361–7. 3. Pories WJ, MacDonald KG Jr, Morgan EJ, et al. Surgical treatment of obesity and its effect on diabetes: 10-year follow up. Am J Clin Nutr. 1992;55:582S–5S. 4. Demaria EJ, Jamal MK. Surgical options for obesity. Gastroenterol Clin North Am. 2005;34(1):127–42. 5. Wittgrove AC, Clark GW, Tremblay LJ. Laparoscopic gastric bypass, Roux-en-Y: preliminary report of five cases. Obes Surg. 1994;4(4):353–7. 6. Huang CK, Lee YC, Hung CM, et al. Laparoscopic Roux-en-Y gastric bypass for morbidly obese Chinese patients: learning curve, advocacy and complications. Obes Surg. 2008;18(7):776– 81. 7. de la Fuente SG, Demaria EJ, Reynolds JD, et al. New developments in surgery: natural orifice transluminal endoscopic surgery (NOTES). Arch Surg. 2007;142(3):295–7. 8. McGee MF, Rosen MJ, Marks J, et al. A primer on natural orifice transluminal endoscopic surgery: building a new paradigm. Surg Innov. 2006;13(2):86–93. 9. Flora ED, Wilson TG, Martin IJ, et al. A review of natural orifice transluminal endoscopic surgery (NOTES) for intra-abdominal surgery: experimental models, techniques, and applicability to the clinical setting. Ann Surg. 2008;247(4):583–602. 10. Martínez AP, Bermejo MA, Cortś JC, et al. Appendectomy with a single trocar through the umbilicus: results of our series and a cost approximation. Cir Pediatr. 2007;20(1):10–4. 11. Tacchino R, Greco F, Matera D. Single-incision laparoscopic cholecystectomy: surgery without a visible scar. Surg Endosc. 2009;23(4):896–9. 12. Cuesta MA, Berends F, Veenhof AA. The “invisible cholecystectomy”: a transumbilical laparoscopic operation without a scar. Surg Endosc. 2008;22:1211–3. 13. Reavis KM, Hinojosa MW, Smith BR, et al. Single-laparoscopic incision transabdominal surgery sleeve gastrectomy. Obes Surg. 2008;18(11):1492–4. 14. Saber AA, Elgamal MH, Itawi EA, et al. Single incision laparoscopic sleeve gastrectomy (SILS): a novel technique. Obes Surg. 2008;18(10):1338–42. 15. Nguyen NT, Hinojosa MW, Smith BR, et al. Single laparoscopic incision transabdominal (SLIT) surgery-adjustable gastric banding: a novel minimally invasive surgical approach. Obes Surg. 2008; 18:1628–31. 16. Mintz Y, Horgan S, Savu MK, et al. Hybrid natural orifice transluminal surgery (NOTES) sleeve gastrectomy: a feasibility study using an animal model. Surg Endosc. 2008;22:1798– 802.
