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How to cope with insufficient pneumoperitoneum and exposure when performing laparoscopic gastric bypass surgery

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Abstract

Objective

Despite following international guidelines and conducting routine preoperative dietary counseling, every bariatric surgeon will encounter technical challenges in laparoscopic gastric bypass surgery. We present a series of patients in whom the bariatric procedure was stopped after encountering insufficient exposure during diagnostic laparoscopy. These patients were sent back for dietary counseling and underwent surgery after conservative weight loss. The data from this two-step procedure are analyzed and discussed.

Methods

This concept was applied and studied in 14 patients from a series of 620 bariatric procedures. Patients who underwent a primary laparoscopic gastric bypass (n = 593) were used as references.

Results

The patients in the study group were significantly heavier than those in the reference group (165 vs. 127 kg, p < 0.001), with 79 % having a BMI >50 kg/m2. The patients lost a median of 11 kg after 2 months of conservative treatment, and the mean BMI decreased from 55.7 to 52.6 kg/m2. All the patients in the study group underwent laparoscopic surgery for the second procedure with no need for conversion. The complication rate was not elevated in the study group. Overall hospital costs were higher for the study group compared with those for the primary laparoscopic bypass group (27,136 vs. 19,601 USD, p = 0.034).

Conclusion

The primary laparoscopic procedure can be stopped in patients with insufficient exposure instead of having them undergo conversion to open surgery. These patients may undergo successful laparoscopic procedures after conservative weight loss with no increased risk and with all of the possible benefits of a laparoscopic approach. As a result of this study, we have established a fixed, preoperative lower limit of 10 % excess weight reduction before accepting superobese patients (BMI >50 kg/m2) for surgery at our hospital.

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Author notes

    Authors and Affiliations

    1. Department of Surgery, Stadtspital Waid, 8000, Zürich, Switzerland

      Hella Scotland & Stefan Wildi

    2. Department of Surgery, Bariatric Reference Centre, Kantonsspital Frauenfeld, 8500, Frauenfeld, Switzerland

      Jeannette D. Widmer & Markus K. Muller

    3. Department of Visceral and Transplantation Surgery, University Hospital, 8000, Zürich, Switzerland

      Marco Bueter

    4. Department of Surgery, Stadtspital Triemli, 8000, Zürich, Switzerland

      Markus Weber

    Authors
    1. Hella Scotland
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    2. Jeannette D. Widmer
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    3. Stefan Wildi
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    4. Marco Bueter
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    5. Markus Weber
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    6. Markus K. Muller
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    Corresponding author

    Correspondence to Markus K. Muller.

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    The authors declare that they have no conflict of interest.

    Ethical approval

    All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of retrospective study formal consent is not required.

    Informed consent

    Informed consent was obtained from all individual participants included in the study.

    Additional information

    Hella Scotland and Jeannette D. Widmer contributed equally to this work.

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    Scotland, H., Widmer, J.D., Wildi, S. et al. How to cope with insufficient pneumoperitoneum and exposure when performing laparoscopic gastric bypass surgery. Langenbecks Arch Surg 401, 299–305 (2016). https://doi.org/10.1007/s00423-016-1379-2

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    • DOI: https://doi.org/10.1007/s00423-016-1379-2

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