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Laparoscopic or Minimally
Invasive Surgery
For the last decade, laparoscopic procedures have been used in a variety of general surgeries. Many people mistakenly believe that these techniques are still "experimental." In fact, laparoscopy has become the predominant technique in some areas of surgery and has been used for weight loss surgery for several years. Although few bariatric surgeons perform laparoscopic weight loss surgeries, more are offering patients this less invasive surgical option whenever possible.
When a laparoscopic operation is performed, a small video camera is inserted into the abdomen. The surgeon views the procedure on a separate video monitor. Most laparoscopic surgeons believe this gives them better visualization and access to key anatomical structures.
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The camera and surgical instruments are inserted through small incisions made in the abdominal wall. This approach is considered less invasive because it replaces the need for one long incision to open the abdomen. A recent study shows that patients having had laparoscopic weight loss surgery experience less pain after surgery resulting in easier breathing and lung function and higher overall oxygen levels. Other realized benefits with laparoscopy have been fewer wound complications such as infection or hernia, and patients returning more quickly to pre-surgical levels of activity.
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Laparoscopic procedures for weight loss surgery employ the same principles as their "open" counterparts and produce similar excess weight loss. Not all patients are candidates for this approach, just as all bariatric surgeons are not trained in the advanced techniques required to perform this less invasive method. The American Society for Bariatric Surgery recommends that laparoscopic weight loss surgery should only be performed by surgeons who are experienced in both laparoscopic and open bariatric procedures. |
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LAP Band |
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Approved by the FDA in June 2001, the BioEnterics ® LAP-BAND ® Adjustable Gastric Banding System is the newest and the only adjustable surgical treatment for morbid obesity in the United States. It induces weight loss by reducing the capacity of the stomach, which restricts the amount of food that can be consumed.
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Minimally Invasive Approach
During the procedure, surgeons usually use laparoscopic techniques (using small incisions and long-shafted instruments rather than a large incision), to implant an inflatable silicone band into the patient's abdomen. Like a wristwatch, the band is fastened around the upper stomach to create a new, tiny stomach pouch that limits and controls the amount of food you eat. It also creates a small outlet that slows the emptying process into the stomach and the intestines. As a result, patients experience an earlier sensation of fullness and are satisfied with smaller amounts of food. In turn, this results in weight loss.
Least Traumatic Procedure
Since there is no cutting, stapling or stomach rerouting involved in the LAP-BAND System procedure, it is considered the least traumatic of all weight loss surgeries. The laparoscopic approach to the surgery also offers the advantages of reduced post-operative pain, shortened hospital stay and quicker recovery. If for any reason the LAP-BAND System needs to be removed, the stomach generally returns to its original form.
Adjustable Treatment
The LAP-BAND System is also the only adjustable weight loss surgery available in the United States . The diameter of the band is adjustable to meet your individual needs, which can change as you lose weight. For example, pregnant patients can expand their band to accommodate a growing fetus, while patients who aren't experiencing significant weight loss can have their bands tightened.
To modify the size of the band, its inner surface can be inflated or deflated with saline solution. The band is connected by tubing to a reservoir, which is placed well under the skin during surgery. After the operation, the surgeon can control the amount of saline in the band by entering the reservoir with a fine needle through the skin.
Caution: This device is restricted to use by or on the order of a physician.
The BioEnterics LAP-BAND System and accessories contain no latex or natural rubber materials.
The LAP-BAND System is Patented and Copyrighted by BioEnterics. For more information, visit:
http://www.lap-band.com/about.html
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Laparoscopic Sleeve Gastrectomy |
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Sleeve gastrectomy is a partial gastrectomy that results in removal of most of the stomach. The procedure is sometimes called "partial gastrectomy," "sleeve gastrectomy," "longitudinal gastrectomy" or "vertical gastrectomy."
The common denominator of this procedure is that a smaller stomach size decreases the distention of the stomach and helps the patient to become full faster. It increases the sensation of fullness and decreases the sensation of appetite. Increased satiety may also result from decreased ghrelin , secreted by the fundus , which sleeve gastrectomy resects.
Initially , partial gastrectomy was used to resect stomach cancers. It became part of the bariatric arsenal after it was shown to induce weight loss. Because no one believed the weight loss would be exceptional , sleeve gastrectomy or partial gastrectomy was traditionally considered to be a first-stage procedure for either biliopancreatic diversion , which was performed very successfully , or as a first stage for gastric bypass. Nowadays, sleeve gastrectomy is recognized as a first and single procedure for weight loss because it can achieve more than 50% excess weight loss in as little as 18 months.
Advantages
- The stomach is reduced without loss of function.
- Pyloric preservation prevents " dumping syndrome." The syndrome is the result of rapid emptying of stomach contents into the small intestine. This is sometimes triggered when too much sugar or large amounts of food are consumed.
- Discharge from the hospital occurs within one day.
- It is an effective first-stage procedure for super-obese patients who are not ready to undergo laparascopic Roux-en-Y gastric bypass.
- It is useful in circumstances such as anemia and Crohn's disease that preclude intestinal bypass.
- It can be performed laparoscopically , even in patients who weigh over 500 lbs.
- No band adjustment is required.
- There are virtually no problems with malabsorption.
- Excess weight loss greater than 50% in approximately 18 th months
Risks
- There is an increased risk due to stapling complications (0.5% incidence)
- Unlike the Lap-band procedure, the sleeve-gastrectomy is irreversible.
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Laparoscopic Gastric Banding and Partial Gastrectomy (GBSR) |
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Advantages
- Shorter hospital length of stay compared to bypass and biliopancreatic diversion.
- Better weight-loss at six months when compared with either LGB or SG alone.
- Decreased risk of malabsorption compared to GBP or biliopancreatic diversion.
- Decreased risk of post-operative complications.
- Outpatient adjustment of the band.
- Decreased need for a second procedure.
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Laparascopic Radio-Frequency Ablation of Liver Tumors |
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Liver metastasis remains a concern for surgeons and oncologists. The treatment for liver metastasis has been liver resection. Some of the matastases that were resected responded better to chemotherapy than others without. Colorectal cancer has an increased incidence of survival of 30% over 5 years. Not much is known about some of the cancers except that survival is not as good, and this includes breast cancer and the new endocrine tumor.
The problem that remains in dissecting metastatic tumor to the liver is the cirrhosis that can preclude liver resection. The relation between radiofrequency ablation and liver resection has been well established so that the liver resection remains the gold standard. Therefore, with a single mass of 5 cm or 7 cm, the radiofrequency ablation can actually create a good alternative. When the masses are involved on more than one side of the lobe and require a trisegmentectomy or bilateral part of the liver that is not going to be resectable, this can create an impasse of the indication for liver resection; therefore, we believe that the role of radiofrequency ablation can be expanded by taking care of multiple masses.
In a patient with an advanced disease, the goal of radiofrequency ablation is to reduce the cells that are present so that chemotherapy and all other therapies work better to give better survival for the patient affected.
Our tecnique involves a RFA performed laparoscopically with a 24 hours hospital stay. Laparoscopy decreases hospital stay, pain and wound infection risk. Radiofrequency ablation with secondary cytoreduction can improve treatment with chemotherapy. The concept of cytoreduction and debulking of the tumor with RFA, particularly in patients who have multiple site matastasis or bilateral metastasis, is important and will allow the chemotheraphy to work better.
Additional information on this tecnique can be found at:
www.liver.org
www.rita.org |
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Gastroesophageal Reflux Treatment including Stretta Procedure |
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Gastroesophageal acid reflux is secondary to incompetancy of the lower esophageal sphincter (LES) mechanism. Nissen's fundoplication, first described in 1956, involved the creation of a complete ring of fundus about the gastroesophageal junction. Dealing with the understanding of the problems of the lower esophageal sphincter for treatment of GERD, not much consideration was given to the fact that there was an increased production of acid, which actually is creating the symptomatology of GERD, and can be associated with peptic ulcer or gastritis. Some surgeons explored the possibility of using truncal vagotomy to decrease the acidity production, but gastrointestinal dysmotility precluded the use of this approach. The problem remains because between 6% and 15% of those with GERD also have a duodenal ulcer. Studies have shown that selective vagotomy is effective in ameliorating GERD. The combination of Nissen fundoplication and highly selective vagotomy (NFHSV) seems logical at this point.
The tecnique consists of adding the highly selective vagotomy after creating the fundoplication. The illustration in this section shows a patient's anatomy just after the completion of the HSV. The surgery is all done laparoscopically.
A study has shown that only 4.7% of patients who underwent highly selective vagotomy had recurrent symptoms and endoscopic evidence of esophagitis. As laparascopic gastric surgery becomes increasingly available, NFHSV may well become more common as a surgical treatment for GERD.
For additional information on the stretta procedure see www.gerd-institute.org |
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 Gastric Bypass Roux-en-Y |
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In recent years, better clinical understanding of procedures combining restrictive and malabsorptive approaches has increased the choices of effective weight loss surgery for thousands of patients. By adding malabsorption, food is delayed in mixing with bile and pancreatic juices that aid in the absorption of nutrients. The result is an early sense of fullness, combined with a sense of satisfaction that reduces the desire to eat.
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According to the American Society for Bariatric Surgery and the National Institutes of Health, Roux-en-Y gastric bypass is the current gold standard procedure for weight loss surgery. It is one of the most frequently performed weight loss procedures in the United States . In this procedure, stapling creates a small (15 to 20cc) stomach pouch. The remainder of the stomach is not removed, but is completely stapled shut and divided from the stomach pouch. The outlet from this newly formed pouch empties directly into the lower portion of the jejunum, thus bypassing calorie absorption. This is done by dividing the small intestine just beyond the duodenum for the purpose of bringing it up and constructing a connection with the newly formed stomach pouch. The other end is connected into the side of the Roux limb of the intestine creating the "Y" shape that gives the technique its name. The length of either segment of the intestine can be increased to produce lower or higher levels of malabsorption.
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Advantages
- The average excess weight loss after the Roux-en-Y procedure is generally higher in a compliant patient than with purely restrictive procedures.
- One year after surgery, weight loss can average 77% of excess body weight.
- Studies show that after 10 to 14 years, 50-60% of excess body weight loss has been maintained by some patients.
- A 2000 study of 500 patients showed that 96% of certain associated health conditions studied (back pain, sleep apnea, high blood pressure, diabetes and depression) were improved or resolved.
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Risks
- Because the duodenum is bypassed, poor absorption of iron and calcium can result in the lowering of total body iron and a predisposition to iron deficiency anemia. This is a particular concern for patients who experience chronic blood loss during excessive menstrual flow or bleeding hemorrhoids. Women, already at risk for osteoporosis that can occur after menopause, should be aware of the potential for heightened bone calcium loss.
- Bypassing the duodenum has caused metabolic bone disease in some patients, resulting in bone pain, loss of height, humped back and fractures of the ribs and hip bones. All of the deficiencies mentioned above, however, can be managed through proper diet and vitamin supplements.
- A chronic anemia due to Vitamin B12 deficiency may occur. The problem can usually be managed with Vitamin B12 pills or injections.
- A condition known as "dumping syndrome" can occur as the result of rapid emptying of stomach contents into the small intestine. This is sometimes triggered when too much sugar or large amounts of food are consumed. While generally not considered to be a serious risk to your health, the results can be extremely unpleasant and can include nausea, weakness, sweating, faintness and, on occasion, diarrhea after eating. Some patients are unable to eat any form of sweets after surgery.
- In some cases, the effectiveness of the procedure may be reduced if the stomach pouch is stretched and/or if it is initially left larger than 15-30cc.
The bypassed portion of the stomach, duodenum and segments of the small intestine cannot be easily visualized using X-ray or endoscopy if problems such as ulcers, bleeding or malignancy should occur. |
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