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

Abstract

K (2016). How to cope with insufficient pneumoperitoneum and exposure when performing laparoscopic gastric bypass surgery. Langenbeck's Archives of Surgery, 401(3) AbstractObjective: 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 kg vs. 127 kg, p<0.001), with 79% a BMI >50 kg/m 2 . The patients lost a median of 11 kg after two months of conservative treatment, and the mean BMI decreased from 55.7 to 52.6 kg/m 2 . All 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 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 undergoing 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/m 2 ) for surgery at our hospital.

Low-pressure pneumoperitoneum with deep neuromuscular blockade in metabolic surgery to reduce postoperative pain: a randomized pilot trial

“…The optimal intraabdominal pressure for metabolic (fast-track) surgery has not yet been determined. Other studies that address the optimal IAP in metabolic surgery describe a wide range of used IAP from 14 to 18 mmHg [8,11,12,16,17] which points to large practice variation.…”

Prolonged postoperative ileus in gastric surgery: Is there any difference between laparoscopic and open surgery?

“…The operational advantage of laparoscopic surgery on gastrectomy has been identified, including decreased blood loss, shorter time to ambulation and faster recovery of bowel function, leading to a reduced rate of PPOI. However, anastomotic leakage and pneumoperitoneum‐related complications seemed more likely to occur after using the laparoscopic approach, leading to an increased rate of PPOI. To our knowledge, no study to date focused explicitly on the impact of laparoscopic vs open surgery for PPOI after gastric cancer surgery.…”