Laparoscopic Gastric Bypass RYGB for Morbid Obesity

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Laparoscopic Gastric Bypass (RYGB) for Morbid
Obesity
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Morbid Obesity

• Major health problem
• 30.5 (1999) USA overweight vs. 22.9 (1980)
• Currently, 50 million Americans obese
• 12 million Americans morbidly obese
• Definition
• Body Mass Index kg/m2
• BMI 35 with comorbidity or BMI 40
• BMI 30 obese
• BMI 25 overweight

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Comorbidities

• Diabetes
• Asthma
• Sleep Apnea
• Obesity Hypoventilation
• Hypertension
• GERD
• DJD

• Gout
• Infertility
• Urinary incontinence
• Depression
• Malignancies
• Soft tissue infections
• Cholelithiasis
• Atherosclerosis

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Comorbidities

• Hyperlipidemia
• Accidents
• Focal segmental glomerulosclerosis

• Pseudotumor cerebri
• Hypercoagulable States
• NAFLD

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Surgical Management

• Roux-en-Y Gastric Bypass

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Roux-en-Y Bypass

• Patient Selection requires consultation
• Endocrinology
• Psychology
• Drug and EtOH dependence, manic/depressive,
  noncompliant behavior
• Nutrition
• postop diet and exercise

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Laparoscopic Management

• Patient Positioning
• Supine
• No Esophageal tubes
• Foley
• Arms out or right arm tucked
• Padding
• Footboard

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Forming the Roux Limb

• After placing the ports
• The small bowel is fashioned to formed a 100 or
  150cm Roux limb
• Once the Roux limb is formed, a small bowel
  anastomosis or hook up must be performed to
  transport the bile and pancreatic fluid

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Anastomosis for Small Bowel

• Staplers used to hook up or anastomosis for
  small bowel

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Anastomosis
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Small Bowel Anastomosis

• Remaining enterostomy, hole, is closed with
  sutures

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Creating Gastric Pouch

• Place anvil into proximal stomach
• Staple horizontally 2-3cm below the cardiac fat
  pad
• Extend superiorly to the Angle of His
• Goal--remove the fundus to avoid receptive
  relaxation of stomach

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Pouch to Roux Limb

• Once the pouch is formed around the anvil
• The Anvil is stapled to the Roux limb

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GASTRIC POUCH
ROUX
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Alternative Method

• The gastric pouch can be formed without the anvil
• Once formed, a linear stapler is used to staple
  the Roux limb to the pouch

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Finishing Anastomosis

• After the Roux is stapled to the gastric pouch
• The remaining hole, enterostomy, is closed with
  sutures

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Pouch
Anastomosis
Roux
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Remnant
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Post op Day 1

• An upper GI study is performed on POD 1
• Rule out a leak

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Length of Stay

• Open 4.60 days
• Laparoscopic 2.89 days
• Converted 3.87 days

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Weight Loss

• 0.5-1.0lb per day first 1-2 months
• Weight loss is maximal at 2 years
• Goal 75-80 excess weight loss, 35-40 total
  body weight loss, BMI 25

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Mean Postoperative BMI
months
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Percent Total Weight Loss
N214
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Mean Postoperative BMI