Throughout many medical centers in the United States, laparoscopy has become the preferred strategy for performing a variety of bariatric surgical procedures. Advanced laparoscopic skills are required for these surgeries, but laparoscopic gastric bypass (LGB) is one of the most difficult to learn and master. A steep learning curve has been associated with LGB because of longer operative times and higher complication rates during early experiences with the procedure. Even after LGB is mastered, surgeons must still be cautious because major morbidity or mortality risks remain considerable.
As bariatric surgery continues to become an increasingly important component of training programs for surgical residents and postgraduate fellows, academic medical centers often struggle between optimizing patient safety and outcomes with mandates to train surgical residents in advanced laparoscopic techniques. In many facilities, this has limited the ability of surgical trainees to perform or assist in these procedures. In addition, surgical techniques for LGB vary widely. The choice of technique must safely accommodate the varying levels of knowledge and skill of participating residents.
“Utilizing our S-LGB approach, we were able to decrease operative times by 45%.”
S-LGB: A Simplified Technique
In May 2008, a group of surgeons at Madigan Army Medical Center developed and introduced a new simplified technique for performing LGB (S-LGB). We eliminated the circular stapler and converted to a totally stapled linear gastrojejunostomy. This created the anastomosis before pouch formation and simplified the jejunojejunostomy and mesenteric defect closures.
In the September 2010 Archives of Surgery, my colleagues and I prospectively studied S-LGB in a residency training program in 140 operations. Utilizing our S-LGB approach, we were able to decrease operative times by 45% when additional concurrent procedures were performed. For those undergoing S-LGB only, the operative time reduction was 56%. The mean operative times with S-LGB compare favorably with those in other research studies of the procedure that are being performed by fully trained bariatric surgeons. Among patients receiving S-LGB and undergoing concurrent procedures, the mean operative time was 116 minutes, which was significantly shorter than reported times for LGB in other studies. Furthermore, these short operative times were achieved with full resident participation.
The S-LGB technique offers a number of significant improvements and advantages over circular stapled techniques. Application and use of articulating linear staplers during LGB were much easier for residents to grasp than use of circular staplers or advanced suturing techniques. We also found a decrease in the incidence of anastomotic strictures with the S-LGB technique. The short- and midterm outcomes in patients who received S-LGB have been excellent. Patients have benefited with short hospital stays, minimal complications, and postoperative weight loss that compares favorably with reported standards.
Surgeon Preferred for S-LGB Technique
Resident and attending surgeons also believed that the S-LGB technique reduced the difficulty of the operation. Additionally, they reported that it was a more satisfying technique than the previous standard technique. All residents and staff surgeons who completed the survey and who perform or plan to perform LGB chose the S-LGB technique as their preferred method. Although more research is needed on longer-term outcomes and the durability of S-LGB, our results suggest that the S-LGB technique is safe, effective, and beneficial for performing LGB, even for training residents.
Readings & Resources (click to view)
Martin MJ, Eckert MJ, Eggebroten WE, Beekley AC. A new and simplified technique for laparoscopic gastric bypass in a residency training program decreased resource utilization and enhanced training.Arch Surg. 2010;145:844-851. Available at: http://archsurg.ama-assn.org/cgi/content/full/145/9/844.
Ballantyne GH, Ewing D, Capella RF, et al. The learning curve measured by operating times for laparoscopic and open gastric bypass: roles of surgeon’s experience, institutional experience, body mass index and fellowship training. Obes Surg. 2005;15:172-182.
Keller P, Romain B, Nicolae MA, Perrin P, Meyer C. Is laparoscopic gastric bypass a dangerous procedure during the early phase of the learning curve? A prospective study of the first 50 cases. J Chir(Paris). 2009;146:373-381.
Shikora SA, Kim JJ, Tarnoff ME, Raskin E, Shore R. Laparoscopic Roux-en-Y gastric bypass: results and learning curve of a high-volume academic program. Arch Surg. 2005;140:362-367.