Key technical points of laparoscopic bariatric surgery: initiation and optical techniques
**Key Techniques of Minimally Invasive Surgical Treatment for Obesity**
Sayeed Ikramuddin
Surgical treatment of morbid obesity presents numerous challenges. The problem is that, except in cases of extreme obesity, weight or body mass index (BMI) does not predict the difficulty of bariatric surgery. Laparoscopic bariatric surgery began in 1993, and since then, all related procedures have been performed laparoscopically, with continuous refinement of surgical techniques thanks to advancements in anastomotic devices. However, laparoscopic techniques are not mastered by all surgeons. This learning process is arduous, especially for surgeries requiring gastrointestinal reconstruction, such as laparoscopic Y-shaped gastric bypass (LRYGB) or bile-pancreatic diversion/duodenal transposition (BPD/DS). For example, Schauer et al. reported a learning curve of up to 100 cases for laparoscopic adjustable gastric banding (LGB). For adjustable gastric banding, the key technical points may not lie in the surgical procedure itself, but rather in the numerous details requiring attention during postoperative banding adjustments. This chapter aims to highlight key technical points applicable to both routine and complex cases.
**starting point**
Patient positioning varies. During surgery, many surgeons prefer to stand between the patient's legs, while others tend to stand on the patient's right, the latter being our preference. In principle, surgeons should be accustomed to a particular stance to facilitate coordination with other personnel in the operating room. Choosing the surgical position also places high demands on the operating table, requiring it to be able to support a weight of 800 pounds and withstand a relatively steep head-up, feet-down position.
Access to the abdomen is a fundamental step in laparoscopic surgery. Undoubtedly, thinner patients are easier to access. Access is one of the most challenging parts of the entire procedure. Even the commonly used Hasson cutdown technique is time-consuming and laborious in extremely obese patients, partly due to the thick layer of subcutaneous fat. For this reason, we chose to establish pneumoperitoneum in the left subcostal region. We used the standard 150mm Veress needle. We were initially very careful to lift the abdominal wall during the initial puncture, but later found this to be less crucial during the procedure. Inflation requires the inflator to be turned up to maximum flow. Typically, using an S-shaped retractor or thick sutures to pull the skin can significantly simplify this process. Many devices on the market can assist in accessing the abdominal cavity regardless of whether pneumoperitoneum is established. These devices offer no clear advantage when pneumoperitoneum is already in place. Without pneumoperitoneum, they can pose certain risks to internal organs or blood vessels. These devices also have a learning curve. Training on the methods and risks before using these devices is crucial.
The key points after entering the abdomen are choosing the best location for the operating port and retracting the liver.
**Optics**
Over the past decade, a major advancement in minimally invasive surgery has been the improvement in light sources, a trend also seen in the digital camera market. Three-chip cameras are now widely used, a configuration that enhances color reproduction. The application of high-fidelity imaging systems allows even the finest details to be displayed exceptionally clearly during surgery. Top-tier optics are irreplaceable. More vivid and detailed images increase the precision of the surgery. Surgical teams need to understand the serious consequences of accidental bowel damage. From the outset, performing surgical treatment for obesity requires a team and a well-planned allocation of resources and equipment.
Besides camera quality, the angled lens is also crucial during surgery. A 45° scope is most commonly used in the surgical treatment of obesity. Although a 0° scope can theoretically be used, it is generally not. Using an angled scope allows the surgeon to obtain a wider surgical field by manually moving the optical cable. Adjusting the lens by rotating the tip is more cumbersome than adjusting the lens by rotating the optical cable to achieve the desired field of view. Sometimes, even slight movement of the optical cable can be very helpful during suturing. In addition to the traditional 10mm scope, a 5mm 45° scope is also necessary. This scope can be entered into the abdominal cavity through any puncture site to ensure adequate observation of the surgical field. This type of lens is helpful for releasing adhesions at the beginning of surgery and for closing incisions postoperatively. This type of lens is often used in extremely obese male patients.
The laparoscope lens can become blurry as the surgery progresses, sometimes due to leaking carbon dioxide mixing with cold carbon dioxide. The key is to identify the cause of the leak. Once found, it is easily corrected. If the leak is at the fascia level, the fascia can be sutured. In some cases, it's best to avoid using this puncture site, as it can worsen the leak.