Laparoscopy and Bariatrics: Treating Big Problems with Small Incisions

Caroline Jadlowiec, MD, Nissin Nahmias, MD. University of Connecticut, Department of Surgery and The Hospital of Central Connecticut, Department of Bariatric Surgery

Introduction

After its introduction in the early 1990s, laparoscopic gastric bypass (LGB) quickly emerged as the preferred choice for most bariatric surgeons thereby replacing traditional open bariatric surgery. As the number of LGBs increased, there were several notable changes in post-operative outcomes. LGB has shown a diminished frequency of wound infection and ventral hernia formation, faster recovery, and better cosmetic results; it has, likewise, demonstrated an increased incidence of small bowel obstruction (SBO). Internal hernias and adhesions are, by far, the most common etiologies of post-bypass acute SBO.

In keeping with this evolving paradigm in bariatrics, laparoscopic techniques for the treatment of acute SBO have also undergone transformation over the last decade. Laparoscopy, once considered strictly contraindicated in the emergency setting, has become progressively more accepted. And while there has been literature documenting its safety and efficacy for the treatment of acute SBO in the non-bariatric patient, there have been few, if any, reviews of its role in treating the post-bypass acute SBO.

Here, we report our experience with laparoscopic management of acute post-bypass SBO in a small case series of two patients. SBO etiologies were secondary to mesenteric internal hernia and adhesions. From our observations, we feel that laparoscopy is a safe and effective procedure for the treatment of acute SBO in the bariatric patient and should be a consideration when initiating treatment.

Cases

Patient 1: A 33 year-old female five months status-post a LGB who presented with complaints of abdominal pain; CT imaging showed evidence of SBO. The patient underwent diagnostic laparoscopy, and was found to have an internal hernia at her jejunojejunostomy. This defect was repaired primarily. The post-operative course was uneventful with discharge home on post-operative day two.

Patient 2: A 46 year-old female one year status-post an open gastric bypass who presented with complaints of nausea; CT imaging confirmed an SBO. The patient underwent diagnostic laparoscopy. Two thick adhesive bands were found within the area of the jejunojejunostomy, connecting the Roux limb to the distal common channel. These were treated with laparoscopic lysis of adhesions. The post-operative course likewise was uneventful with discharge home on post-operative day three.

Results

Conclusions

Our study is the first to our knowledge to examine the laparoscopic treatment of acute SBO in the bariatric patient. We feel it is an attractive alternative to the open approach for many of the same reasons applied to LGB. Similar to LGB, it reduces the risk of ventral hernia and wound infection in a population already more prone to these complications. Laparoscopy likewise allows for quicker post-operative recovery, decreased duration of ileus, and decreased length of hospital stay. In experienced hands, it is an excellent diagnostic tool that, in our practice, has also proven to be therapeutic. As in all laparoscopic surgery, a low threshold for conversion should always be maintained.

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