Single Incision Bariatric Surgery
Saturday, May 07, 2011
Since the first laparoscopic bariatric procedure was performed in the mid-1990’s, weight loss surgery has become much more accepted and is now a mainstay in surgery in the United States. The outcomes with weight loss surgery and the health benefits enjoyed by the morbidly obese population are overwhelming.
Photo: Leena Khaitan, MD, MPH, FACS
As more is being learned about the benefits of obesity surgery, it is becoming clear that obesity compromises every organ system. Patients who have bariatric surgery have a 23 percent overall reduced mortality compared to those who try to lose weight by diet and exercise alone. (Diabetes related mortality reduced by 92 percent; cancer related mortality decreased by 60 percent). (1) A patient who undergoes weight loss surgery can be assured that sleep apnea, diabetes, hypertension and coronary artery disease will improve significantly or resolve completely. One of the newest interesting findings is that cancer incidence also decreases in those who have weight loss surgery. (2)
Although initially thought to be high risk, weight loss surgery procedures can now be done with extremely low morbidity and mortality (<1 percent). (3) With over 100,000 weight loss surgeries now being performed annually in the US, physicians have become extremely skilled in the care of the obese patient. Over 60 percent of the US remains overweight and over 30 percent are obese. The trends are not decreasing. Physicians in every field face challenges with their obese patients.
Just as laparoscopy revolutionized surgery in the early 90’s, single incision laparoscopic surgery (SILS) represents one of the greatest advances in minimally invasive surgery in the last several years. This novel surgical approach was born out of the quest for scarless surgery. With this approach, surgeons perform many procedures with a single incision through which multiple ports are placed. This incision can be placed at the umbilicus so that the patient is ultimately left with almost no scar or one that is cleverly hidden.
Bariatric procedures are technically challenging procedures when done with the traditional laparoscopic approach and require advanced minimally invasive skills. The single incision approach requires even more surgical skills from the surgeon. For the patient this technique provides the potential benefit of no scar, less pain and quicker recovery time.
The gastric banding procedure, gastric sleeve procedure and gastric bypass procedure have all been successfully performed using the SILS approach. Both the gastric banding procedure and the gastric sleeve are restrictive-only procedures and result in the patient having a decreased appetite and less volume capacity for food. These procedures are particularly well-suited for the SILS approach as the procedure is focused in one area of the abdomen.
The Roux-en Y gastric bypass procedure (RYGBP) is a much more technically demanding procedure, even laparoscopically. The patient’s stomach is divided resulting in restriction of oral intake. A long limb of small bowel is bypassed resulting in malabsorption. Finally the procedure causes dumping syndrome when high sugar foods are ingested. Patients can expect 50-75 percent excess weight loss that is sustained for at least 14 years. This procedure is particularly well suited to diabetics and those who have an affinity for sweets. Patients have been highly satisfied with this procedure when performed with SILS. (4)
SILS procedures are very safe with risks similar to that of traditional laparoscopic surgery. The technique does have limitations— because all of the instruments are being placed through a single port, the ability to triangulate (as with traditional laparoscopy) is lost. Therefore flexible tipped instrumentation has been developed to facilitate this technique.
SILS is considered an enhancement of laparoscopic surgery in that multiple ports are reduced to one small single port. Patients not only are benefited by the improved cosmesis but also have the potential for faster recovery time, less pain and greater satisfaction.
Dr. Leena Khaitan is Director of University Hospitals Digestive Health Institute’s Bariatric Surgery & Nutrition Center. She is the Director of Bariatric and Minimally Invasive Surgery at UH Geauga Medical Center and has offices at UH Case Medical Center in Cleveland and UH Geauga Medical Center in Chardon, Ohio.
References
1. Sjöström L, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007 Aug 23;357(8):741-52.
2. Sjöström L, et al. Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish Obese Subjects Study): a prospective, controlled intervention trial. Lancet Oncol. 2009 Jul;10(7):653-62. Epub 2009 Jun 24.
3. Nguyen NT, et al. Result of a national audit of bariatric surgery performed at academic centers: a 2004 University HealthSystem Consortium Benchmarking Project. Arch Surg. 2006 May;141(5):445-9; discussion 449-50.
4. Saber AA, El-Ghazaly TH, Minnick DB.Single port access transumbilical laparoscopic Roux-en-Y gastric bypass using the SILS Port: first reported case. Surg Innov. 2009 Dec;16(4):343-7. Epub 2009 Dec 22.
MD News April/May 2011, Northeastern Ohio/Western Pennsylvania