Overview of Laparoscopic Gastric Bypass
Gastric Bypass is a popular procedure that helps severely overweight individuals lose weight. This surgery was first formulated in the 1960s by doctors Mason and Ito, who noticed a patient losing considerable weight after a partial gastrectomy – a surgery for stomach ulcers. Initially, this procedure was performed with the help of open surgery. However, like all open surgeries, this approach had some drawbacks. There was a 20% chance of developing an incisional hernia (a bulge through an incision made during surgery) and an 8% chance of wound complications.
To improve the results after surgery, doctors began using a technique known as laparoscopic surgery. This method involves making smaller incisions, reducing surgery-related complications. Drs. Wittgrove and Clark first successfully demonstrated this approach in 1994. The most prominent evidence of success came from a trial led by Nguyen and colleagues in 2001.
Multiple studies have shown that gastric bypass surgery is more successful when performed laparoscopically. This method results in shorter hospital stays, less blood loss during surgery, reduced discomfort after surgery, fewer lung complications, and a lower risk of wound infections. However, there’s also evidence suggesting a slightly higher risk of a postoperative internal hernia – a potentially serious condition that requires immediate attention. But overall, the benefits of laparoscopic surgery make it a safer and more affordable choice when compared to traditional open surgery.
Today, more than 90% of gastric bypass surgeries for weight loss are performed laparoscopically. Despite being one of the most intricate minimally invasive procedures, it is the most common stomach operation conducted in the United States. There are various ways to perform this surgery, but the primary principle for each method remains consistent.
Anatomy and Physiology of Laparoscopic Gastric Bypass
When a doctor performs a type of weight loss surgery called a laparoscopic gastric bypass, they need to understand all aspects of the abdomen’s internal area which contains many different organs. This specific surgery focuses mainly on organs like the stomach, small intestine, liver, spleen, transverse colon, its ligament, and diaphragm.
The stomach is key to understand in this process. It’s essentially a muscular tube shaped like a reversed ‘C’. It starts at the lower part of the esophagus (the tube that connects your throat and stomach) and ends where it continues as the first section of the duodenum (the first part of the small intestine). The stomach has several parts including the cardia (just after the esophagus enters the stomach), fundus (near the left side of the diaphragm), body, antrum, and pylorus (the section that enters the duodenum). The stomach’s smaller inside curve lies beneath the middle sections of the liver and is connected to it by a ligament called the gastrohepatic ligament. The spleen, located in the upper left section of the abdomen, is linked to the stomach’s larger curve by the gastrosplenic ligament, which contains the short gastric vessels.
The duodenum is split into four sections. The second part has the duodenal papilla, which is the opening on the inside edge of the duodenum that allows substances from the liver and pancreas to drain into the digestive system. The final section of the duodenum leaves the space behind the abdominal cavity and crosses the transverse mesocolon (the ligament connecting the transverse colon to the back of the abdominal wall) at the ligament of Treitz to become the jejunum. The jejunum is located in the abdominal cavity and transitions into the ileum, which eventually leads to the large intestine at the ileocecal valve. On average, the small intestine is about 500 cm long, but it can vary from roughly 200 cm to 800 cm.
Why do People Need Laparoscopic Gastric Bypass
Laparoscopic gastric bypass is a type of weight loss surgery that isn’t used very often today. It might be considered in rare situations, like when the stomach can’t properly empty food due to tumors or peptic ulcer disease, which is a type of sore in the stomach lining.
The main reason people have weight loss surgery though is due to obesity and related health problems. To be considered as a candidate for this kind of surgery, you typically must have either:
- A body mass index (BMI), which is a measure of body fat based on your weight and height, of 40 or above, OR
- A BMI of 35 or above and at least one health problem related to obesity such as high blood pressure, diabetes or serious musculoskeletal issues which impact your ability to move around.
Before surgery, you should have tried non-surgical ways to lose weight without success, have mental health clearance, no issues with alcohol or drug abuse, and there should be no medical reasons why you shouldn’t have the surgery.
The most common weight loss surgery is the sleeve gastrectomy. Recent studies have shown that sleeve gastrectomy and laparoscopic gastric bypass have similar results in terms of weight loss and improvement of health problems related to obesity after 5 years. However, nearly a third of patients who have sleeve gastrectomy can experience worsening of gastroesophageal reflux disease (GERD), a condition where acid from the stomach comes up into the throat, causing a burning sensation and other symptoms. Some of these patients may need to switch to a laparoscopic gastric bypass due to relentless symptoms of GERD. So, if you’re considering weight loss surgery and have GERD, this could be a reason to choose laparoscopic gastric bypass instead of a sleeve gastrectomy.
When a Person Should Avoid Laparoscopic Gastric Bypass
There are a few reasons why someone might not be able to undergo this type of procedure, which is often similar to other laparoscopic surgeries. Laparoscopic surgeries use smaller incisions and a camera to guide the surgery. Some reasons someone might not be able to undergo this surgery include:
If a person cannot tolerate having their stomach filled with gas (pneumoperitoneum), which is done to make the operation area more visible during the laparoscopic surgery.
If a person has an issue with their blood clotting, which makes it difficult to stop bleeding, known as uncorrectable coagulopathy, surgery can be too risky.
People who have had previous surgeries in the abdomen might also have a higher risk with these types of procedures.
In addition, people who have conditions where doctors need to regularly check on them using a long telescope-like instrument inserted into their body (endoscopic surveillance), or individuals with severe abnormal cell growth in the lining of their food pipe (Barrett esophagus with severe dysplasia), are both not recommended for a specific type of laparoscopic surgery called gastric bypass. Gastric bypass is a weight-loss surgery which reduces the size of the stomach.
Equipment used for Laparoscopic Gastric Bypass
For this type of operation, some basic tools needed are things to pump the body with carbon dioxide gas (what we call ‘insufflation with CO2’), sheets to protect the area (these are ‘drapes’), screens to see what’s happening inside (‘monitors’), special instruments for the surgery (‘laparoscopic instruments’), a tool to cut through tissues (‘electrocautery’), and tools for making small holes where the instruments enter the body (‘trocars’).
When working with people who have larger bodies (these are our ‘bariatric patients’), we have to switch up our method a bit. Because they have a thicker layer of fat on their stomach, we need to use longer trocars and instruments.
There are many ways to perform a weight-loss surgery called a ‘gastric bypass’. Yet, quite a few of the steps and tools needed remain the same. Here is what we usually need:
- Five trocars (which are tools that make small holes for instruments, usually between 5-12 millimeters in size)
- A retractor to move the liver aside (something we call a ‘liver retractor’)
- A laparoscope that is 10 millimeters in size and can angle 30 degrees to get a good look inside. A laparoscope is a tiny camera that lets us see inside the body during surgery.
- An endoscopic stapler to cut and seal off parts of your stomach or gut. Some methods also require a circular stapler.
- An endoscope, which is long, flexible tube that has a light and a camera to see inside your body.
- An ultrasonic energy device, which is a special instrument using sound waves to cut tissue and stop bleeding during surgery.
Who is needed to perform Laparoscopic Gastric Bypass?
Before you can have bariatric surgery (a type of surgery that helps with weight loss), you must see a team of health professionals. This team will work together to make sure you are a good fit for the surgery and that you’ll get the best possible care. The team is made up of a nutritionist, a mental health expert, a surgical team, and your everyday doctor.
When it’s time for the surgery, there’ll be a couple of key people to help you on the day. These people will include: an anesthesiologist, who will ensure you’re asleep and don’t feel any pain during the procedure; a primary surgeon who will be the one performing the surgery; a scrub technician who assists by passing instruments and other supplies to the surgeon; a first assistant who directly aids the surgeon; along with a circulating nurse who helps everyone communicate and manages the nursing care in the operating room.
Preparing for Laparoscopic Gastric Bypass
Before surgery, all patients should undergo several tests. These include an upper endoscopy to check the condition of the digestive tract, a test for a bacterium called Helicobacter pylori, a type of stomach ultrasound to get a clear picture of the abdomen, pulmonary function tests for lung health, and basic lab tests for overall health assessment.
Prior to the operation, the patient receives antibiotics to prevent infections. These are given half an hour before starting the surgical procedure. Along with this, a medication to prevent blood clotting (known as venous thromboembolism prophylaxis) is also given. Any hair on the abdomen region is carefully clipped in the pre-surgery area to ensure hygiene and prevent any complications.
Once the patient is under anesthesia, two more procedures take place. A Foley catheter, which is a tube, is inserted to drain urine during the operation. Additionally, an orogastric tube (a special tube inserted through the mouth into the stomach) is positioned to help keep the stomach empty during the surgery.
How is Laparoscopic Gastric Bypass performed
What we want to discuss here are some common procedures that doctors might carry out during your surgery. This list includes steps like preparing for the surgery, making the Roux-limb, joining the jejunum a second time, creating a small stomach pouch, creating a passage between the stomach and jejunum, endoscopy and finally, closing up the wounds.
To give you a clear idea, let’s go through each step. Initially, you would be safely secured to the operating table in a position that allows the doctor easy access to your abdomen. Then, the abdominal area is prepared and cleaned in a sterile manner to avoid any infections. Usually, the doctor will stand on your right side during the operation.
The first step will be entering the abdominal cavity. This is achieved by using a sharp, thin instrument with or without camera (12mm optical trocar or veress insufflation). Then, the doctor will pump in some carbon dioxide gas into your abdomen. This is done to temporarily create more space for the doctor to work.
After securing a safe entry, other ports or connecting points, will be made. These will enable the doctors to use various instruments during the procedure. One key procedure involves the creation of a Roux-limb, a portion of the small intestine (jejunum) which is reshaped and connected to a newly made pouch of the stomach. The doctor achieves this by using a special kind of stapler that can work inside your body.
After creating the Roux-limb, the doctor connects another section of the small intestine to itself – this is known as the ‘jejunojejunal anastomosis’. Once that’s done, a small stomach pouch is created. This is a significant step of the surgery as it helps in reducing your overall food intake.
Moving on, the newly created stomach pouch is connected with the Roux-limb to allow food to pass through. The exact method to do this can differ based on individual cases, but it will involve using devices called staplers and suture materials.
Subsequently, the doctor uses an endoscope for an internal inspection to confirm the connections and keeping a check for any unexpected conditions like bleeding. Once everything is confirmed, closure of all the wounds using absorbable sutures is carried out to wrap up the procedure.
During these procedures, variables like the length and volume of several parts may differ depending upon the individual case. For instance, the Roux-limb length and the gastric pouch volume are determined based on factors such as severity of obesity. These specifics and best measures are often backed by research to provide the most efficient and effective results. Always remember, your doctor will carefully customize these steps according to your health condition, making this procedure as safe and beneficial as possible for you.
Possible Complications of Laparoscopic Gastric Bypass
The chance of passing away within 90 days after gastrectomy, a type of stomach surgery, is extremely low (less than 0.5%). However, there can be some complications related to the procedure. These issues can be categorised into two types: early and late complications.
Early complications are problems that occur within the first 30 days after surgery. They include:
* VTE: a condition called venous thromboembolism, where blood clots form in the veins and can potentially travel to the lungs.
* Anastomotic leak: a rare but serious complication where a leak occurs at the surgical connection between two parts of the digestive system.
* Infection: this can happen at the site of surgery or elsewhere in the body.
* Intestinal obstruction: this is when something blocks the intestines and prevents waste from passing through.
* GJ stenosis: a condition where the connection point between the stomach and the small intestine narrows and can cause difficulty swallowing, heartburn, and other symptoms.
Late complications are problems that occur more than 30 days after surgery. They include:
* Intestinal obstruction: which is the same as introduced above.
* Dumping syndrome: this happens when food moves too quickly from the stomach to the small intestine, causing symptoms like nausea, sweating, and diarrhoea.
* Marginal ulcer: a type of peptic ulcer that develops at the surgical connection site within the stomach or small intestine.
* Gastrogastric fistula: an abnormal connection that forms between the stomach and the surgical pouch.
* Gallstones: hard, pebble-like deposits that form in the gallbladder.
* Incisional hernia: a type of hernia that develops at the site of the surgical incision.
* Nutritional deficiencies: these can occur due to changes in the way the body absorbs nutrients after surgery.
Please note that the details and specifics of these complications involves complex medical processes and are beyond the scope of this summary. Each type of complication has its unique causes, effects on the body, and possible treatments.
What Else Should I Know About Laparoscopic Gastric Bypass?
Laparoscopic gastric bypass is a type of weight loss surgery that is quite popular in the United States. This procedure is now commonly preferred over the traditional open approach for several reasons including cost-effectiveness and higher patient satisfaction. The results are equally successful with patients typically losing around 60% of their excess weight and seeing a great improvement in health conditions related to obesity.
The skills required for performing this type of surgery might be somewhat challenging to acquire initially, as there is a learning curve involved. However, once a surgeon becomes adept in performing this procedure, a laparoscopic gastric bypass surgery can safely be carried out with low risk of complications and excellent results.
