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The laparoscopic Roux-en-Y gastric bypass (known commonly as "gastric bypass," "stomach bypass," or "Roux-en-Y surgery") (LRYGB) is the most commonly performed operation for morbid obesity in the United States.
This operation is both a restrictive procedure and a mildly malabsorptive procedure. A small stomach pouch restricts food intake, while the "Roux-en-Y" intestinal connection provides malabsorption of calories and nutrients.
The characteristics necessary for adequate weight loss include the size of the opening between the pouch and the Roux limb which should be 12 millimeters, and the size of the pouch, which should be 15-30 milliliter (1-2 tablespoons). Therefore, the new stomach pouch is smaller than a golf ball. The final anatomy of the laparoscopic operation is identical to the final anatomy of the open operation.
Five or six small incisions are used for this operation. Two of the incisions are 3/4 inch long and the other incisions are 1/4 inch in length.
Effectiveness of the Laparoscopic Gastric Bypass
Mean excess weight loss ranges from about 70 to 80% within 1 year after surgery. This means that patients who are 100 pounds overweight would lose an average of about 70-80 pounds in the first year after surgery. Long-term reports extending to 14 years and more after open RYGB have demonstrated at least 50% mean excess weight loss.
Most co-morbidities were improved or eradicated, including diabetes mellitus (resolved in 84%), hypertension (resolved in 68%), sleep apnea (resolved in 68%), and hypercholesterolemia (improved in 95%). Quality of life improves significantly.
It is routine to stay in the hospital for two days. On the day of surgery patients are encouraged to walk around on the afternoon and evening after surgery. Walking around right after surgery helps to break up clots which form in the legs.
Pain is controlled with narcotic medications like morphine, which are started in the recovery room. The administration of pain control is typically controlled by a button that the patient can press. It is important for patients to work with a nurse to make sure that pain is adequately under control. The nurses will call the doctors if more pain medication is needed. While receiving pain medication, breathing will be monitored by a pulse oximeter, which is placed on the patient's finger.
Patients will receive blood thinning medications two or three times each day while in the hospital as long as this is considered safe by the surgeons. Patients will be encouraged to take deep breaths and practice coughing to help expand their lungs.
A routine swallow study (Upper GI) is obtained on the day after surgery to assess the stomach connection. Clear liquids are then started after the radiologist decides that the Upper GI is satisfactory. IV fluids are then stopped, the bladder catheter is removed, and oral pain and other routine oral medications are started.
Clear liquids are typically started slowly with only 2 tablespoons per half hour for 12 hours and then 4 tablespoons per half hour for the next 12 hours. All juices are diluted.
On the second day after surgery, skin staples will be removed and replaced with steri-strips by the nurses or the doctors.
Patients will be required to have a bowel movement before discharge. This should not be difficult after having barium from the swallow study, although it might require additional medications to help induce a bowel movement.
Patients will be discharged home on postoperative day 2 (48 hours after surgery) when pain has been controlled with oral medication, there is no nausea or vomiting, they are tolerating a post-gastric bypass clear liquid diet, and when they are walking and urinating without difficulty.
Patients must have someone available to help take care of them at home when they are discharged.
Surgery clinic follow-up is in about a week. These appointments are typically made before the operation
Complications of the Laparoscopic Roux-en-Y Gastric Bypass
Mortality after Roux-en-Y gastric bypass has been reported as 0.5% (1 in 200). A recent analysis of thousands of operations in high volume centers indicates that mortality after laparoscopic Roux-en-Y gastric bypass is actually closer to 0.16% (1 in 600).
Postoperative complications include the following: anastomotic or GJ leak (0-5.1%), pulmonary embolism or deep venous thrombosis (0 to 1.3??, bleeding (0.6-4%), narrowing or stenosis of the GJ anastomosis (1.6-11.4%), bowel obstruction (0.6-10%), incisional hernia (0-1.8%), wound infection (0-5%), internal hernia (0-3.3%), symptomatic gallstone disease (0-3.8%), marginal ulcer (0-10%), and stomach perforation (0-0.9%).
Advantages of the Laparoscopic Approach
With the laparoscopic Roux-en-Y gastric bypass, there is less postoperative pain, a lower postoperative stress response, and better cosmetic results. Patients recover rapidly and have a shorter hospital stay.
There is no large midline incision which is required for the open operation, and this markedly reduces the incidence of postoperative wound infection and incisional hernia. There is also a significant improvement in lung function after surgery with the laparoscopic procedure compared to the open gastric bypass.
The laparoscopic gastric bypass in well-trained hands is safe and feasible. If our surgeons think that the operation can be safely approached laparoscopically, our success in performing surgery via this route is approximately 99%.
However, the laparoscopic gastric bypass is a technically challenging, advanced procedure that is not taught in surgical residency and is associated with a steep learning curve.
The laparoscopic approach may be more difficult in super-obese patients (BMI > 50) and in patients who have an enlarged liver. This is one of the reasons that our surgeons ask that all patients lose some weight prior to surgery. Moreover, we ask that all patients who have had prior surgery should have their old operative reports made available to our surgeons.
There are four stages of dietary advancement after surgery. Please click here to review our dietary handbook.
The laparoscopic RYGB was first described by an American surgeon (Wittgrove) in 1994 and first performed by a member of the University of Minnesota surgical team (Ikramuddin) in 1997.
It is essential to make sure that the surgeon makes a very small gastric pouch in order for the operation to be successful. Too large of a pouch size is one of the most common reasons that we have had to revise a first time operation when physicians have sent their patients to us after failed weight loss surgery.
We routinely ask patients to start a clear liquid diet and preoperative bowel preparation during the two days before surgery. In order to prevent deep venous thrombosis at the time of surgery and immediately afterward, a blood thinner is given in the preoperative area to all patients.
Five or six small incisions are used for this operation. Two of the incisions are 3/4 inch long and the other incisions are 1/4 inch in length. We use a liver retractor through one of the incisions and this moves the liver out of the way and provides a view of the upper stomach, which is critical for us to perform the operation.
We start the operation by making the very small stomach pouch, which is slightly smaller than a golf ball. The rest of the stomach is left inside the abdomen and remains connected to the blood supply, but less active.
Then we measure out a piece of intestine about 3 feet (100 cm) in length and attach this to the stomach and one side of this loop becomes the Roux limb. The connection between the stomach pouch and the Roux limb is called the "gastrojejunostomy" or "G-J" anastomosis.
We test for leaks at this connection by having an endoscope inside the stomach pouch and blowing air into the stomach with the G-J anastomosis under water. We can see if there is a leak in the same way that one tests a bicycle tire for a leak because there would be bubbling at the site of a leak. We fix the leaks immediately in the rare event (~1%) that they occur and these types of leaks would never cause a patient to become sick afterwards since they have already been corrected.
Next, the intestine connected to the bile and pancreatic juices (the "BP" limb) is disconnected from the Roux limb. We measure about 4-5 feet (150 cm) down the Roux limb and connect the Roux limb to the BP limb at this location. This is called the "jejunojejunostomy" or "J-J" anastomosis. Then we close the window under this connection, which is where internal hernias can occur. Occasionally a drain is left near the GJ anastomosis, but this is not routine. We don't routinely place tubes in the nose for laparoscopic Roux-en-Y gastric bypass.