Obesity Surgery

, Volume 29, Issue 4, pp 1281–1286 | Cite as

Unexpected Intraoperative Findings, Situations, and Complications in Bariatric Surgery

  • Paul Joo
  • Lizbeth Guilbert
  • Elisa M. Sepúlveda
  • Cristian J. Ortíz
  • Gianluca Donatini
  • Carlos ZerrweckEmail author
Original Contributions



Bariatric surgery is considered a safe therapy to treat obesity. Postoperative complications are well known; however, there is a lack of data describing intraoperative complications and/or unexpected findings, and if there is further impact on outcomes.


Retrospective study with patients operated between 2013 and 2016 at a single institution. All operative information was collected prospectively and aimed to analyze the incidence and causes of unexpected intraoperative findings, complications, change in surgical plan, extra surgeries, and procedure interruption in patients submitted to bariatric surgery. Secondarily, a morbidity analysis was performed, correlating intraoperative complications with postoperative complications and length of stay.


Four-hundred and five patients were included. Female sex comprised 82% of cases, and a median age of 38 years old was observed; almost 90% were gastric bypass. In 29.3% of cases, there were intraoperative findings, mainly adhesions, abdominal wall hernias, positive methylene blue test, hiatal hernias, and gastrointestinal stromal tumors. Associated surgeries were performed in 8.6% cases, and intraoperative adverse events reported in 7.1%, where organ injury and anastomosis problems were the most frequent. A change in the operative plan was done in 0.9% and surgery interruption in 1.2% of the cases. Early complications were observed in 6.6%. There was no correlation between intraoperative complications and length of stay or early complications.


Unexpected intraoperative findings/complications are common in bariatric surgery, but without increasing morbidity or length of stay. Surgery suspension, change in the planned technique, or adding extra (non-bariatric) procedures may occur.


Bariatric surgery complications Laparoscopic gastric bypass Postoperative complications Intraoperative complications Unexpected findings Laparoscopic sleeve gastrectomy Obesity Morbid obesity Intraoperative adverse events 


Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institution and/or national research committee and with 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained for all individual participants included in the study.


  1. 1.
    Arroyo-Johnson C, Mincey KD. Obesity epidemiology worldwide. Gastroenterol Clin N Am. 2016;45(4):571–9.Google Scholar
  2. 2.
    Ogden CL, Carroll MD, Fryar CD, et al. Prevalence of obesity among adults and youth: United States, 2011–2014. NCHS Data Brief. 2015;219:1–8.Google Scholar
  3. 3.
    Belle SH, Berk PD, Courcoulas AP, et al. Safety and efficacy of bariatric surgery: longitudinal assessment of bariatric surgery. Surg Obes Relat Dis. 2007 Mar-Apr;3(2):116–26.Google Scholar
  4. 4.
    Gloy VL, Briel M, Bhatt DL, et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:f5934.Google Scholar
  5. 5.
    Nguyen NT, Varela JE. Bariatric surgery for obesity and metabolic disorders: state of the art. Nat Rev Gastroenterol Hepatol. 2017;14(3):160–9.Google Scholar
  6. 6.
    De La Cruz-Munoz N, Lopez-Mitnik G, Arheart KL, et al. Effectiveness of bariatric surgery in reducing weight and body mass index among Hispanic adolescents. Obes Surg. 2013;23(2):150–6.Google Scholar
  7. 7.
    Nandan AR, Bohnen JD, Chang DC, et al. The impact of major intraoperative adverse events on hospital readmissions. Am J Surg. 2017;213(1):10–7.Google Scholar
  8. 8.
    Chang SH, Stoll CR, Song J, et al. The effectiveness and risks of bariatric surgery: an updated systematic review and meta-analysis, 2003–2012. JAMA Surg. 2014;149(3):275–87.Google Scholar
  9. 9.
    Falk V, Twells L, Gregory D, et al. Laparoscopic sleeve gastrectomy at a new bariatric surgery centre in Canada: 30-day complication rates using the Clavien-Dindo classification. Can J Surg. 2016;59(2):93–7.Google Scholar
  10. 10.
    Lee SK, Heo Y, Park JM, et al. Roux-en-Y gastric bypass vs. sleeve gastrectomy vs. gastric banding: the first multicenter retrospective comparative cohort study in obese Korean patients. Yonsei Med J. 2016;57(4):956–62.Google Scholar
  11. 11.
    Bohnen JD, Mavros MN, Ramly EP, et al. Intraoperative adverse events in abdominal surgery: what happens in the operating room does not stay in the operating room. Ann Surg. 2017;265(6):1119–25.Google Scholar
  12. 12.
    Eisendrath P, Deviere J. Major complications of bariatric surgery: endoscopy as first-line treatment. Nat Rev Gastroenterol Hepatol. 2015;12(12):701–10.Google Scholar
  13. 13.
    Brethauer SA, Kim J, el Chaar M, et al. Standardized outcomes reporting in metabolic and bariatric surgery. Surg Obes Relat Dis. 2015;11(3):489–506.Google Scholar
  14. 14.
    Leuratti L, Alfa-Wali M, Bonanomi G. Intraoperative findings during a gastric bypass necessitating the removal of the gastric remnant to proceed or not with the elective plan? Surg Obes Relat Dis. 2013;9(5):e69–71.Google Scholar
  15. 15.
    Brolin RE, Bradley LJ, Taliwal RV. Unsuspected cirrhosis discovered during elective obesity operations. Arch Surg. 1998;133(1):84–8.Google Scholar
  16. 16.
    Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin Nutr. 1992;55(2 Suppl):615S–9S.Google Scholar
  17. 17.
    Zerrweck-Lopez C. The origin of the “simplified gastric bypass”. Cir Cir. 2015;83(1):87–8. Origen del “bypass gastrico simplificado”Google Scholar
  18. 18.
    Mavros MN, Bohnen JD, Ramly EP, et al. Intraoperative adverse events: risk adjustment for procedure complexity and presence of adhesions is crucial. J Am Coll Surg. 2015;221(2):345–53.Google Scholar
  19. 19.
    Kaafarani HM, Mavros MN, Hwabejire J, et al. Derivation and validation of a novel severity classification for intraoperative adverse events. J Am Coll Surg. 2014;218(6):1120–8.Google Scholar
  20. 20.
    Skroubis G, Karamanakos S, Sakellaropoulos G, et al. Comparison of early and late complications after various bariatric procedures: incidence and treatment during 15 years at a single institution. World J Surg. 2011;35(1):93–101.Google Scholar
  21. 21.
    Coblijn UK, Karres J, de Raaff CAL, et al. Predicting postoperative complications after bariatric surgery: the bariatric surgery index for complications, BASIC. Surg Endosc. 2017;31(11):4438–45.Google Scholar
  22. 22.
    Finnell CW, Madan AK, Ternovits CA, et al. Unexpected pathology during laparoscopic bariatric surgery. Surg Endosc. 2007 Jun;21(6):867–9.Google Scholar
  23. 23.
    Greenbaum D, Friedel D. Unanticipated findings at bariatric surgery. Surg Obes Relat Dis. 2005;1(1):22–4.Google Scholar
  24. 24.
    Beltran MA, Pujado B, Mendez PE, et al. Gastric gastrointestinal stromal tumor (GIST) incidentally found and resected during laparoscopic sleeve gastrectomy. Obes Surg. 2010;20(3):393–6.Google Scholar
  25. 25.
    Sanchez BR, Morton JM, Curet MJ, et al. Incidental finding of gastrointestinal stromal tumors (GISTs) during laparoscopic gastric bypass. Obes Surg. 2005;15(10):1384–8.Google Scholar
  26. 26.
    Viscido G, Signorini F, Navarro L, et al. Incidental finding of gastrointestinal stromal tumors during laparoscopic sleeve gastrectomy in obese patients. Obes Surg. 2017;27(8):2022–5.Google Scholar
  27. 27.
    Cazzo E, de Almeida de Saito HP, Pareja JC, et al. Gastric mesenchymal tumors as incidental findings during Roux-en-Y gastric bypass. Surg Obes Relat Dis. 2018;14(1):23–8.Google Scholar
  28. 28.
    Pagotto U, Gambineri A, Vicennati V, et al. Plasma ghrelin, obesity, and the polycystic ovary syndrome: correlation with insulin resistance and androgen levels. J Clin Endocrinol Metab. 2002;87(12):5625–9.Google Scholar
  29. 29.
    Silfen ME, Denburg MR, Manibo AM, et al. Early endocrine, metabolic, and sonographic characteristics of polycystic ovary syndrome (PCOS): comparison between nonobese and obese adolescents. J Clin Endocrinol Metab. 2003;88(10):4682–8.Google Scholar
  30. 30.
    Engeland A, Tretli S, Bjorge T. Height, body mass index, and ovarian cancer: a follow-up of 1.1 million Norwegian women. J Natl Cancer Inst. 2003;95(16):1244–8.Google Scholar
  31. 31.
    Pan SY, Johnson KC, Ugnat AM, et al. Canadian Cancer Registries Epidemiology Research G. Association of obesity and cancer risk in Canada. Am J Epidemiol. 2004;159(3):259–68.Google Scholar
  32. 32.
    Gonzalez R, Haines K, Gallagher SF, et al. Management of incidental ovarian tumors in patients undergoing gastric bypass. Obes Surg. 2004;14(9):1216–21.Google Scholar
  33. 33.
    Armour Forse R. Comment on: prevalence of hiatal hernia in the morbidly obese. Surg Obes Relat Dis. 2013;9(6):924–5.Google Scholar
  34. 34.
    Khorgami Z, Haskins IN, Aminian A, et al. Concurrent ventral hernia repair in patients undergoing laparoscopic bariatric surgery: a case-matched study using the National Surgical Quality Improvement Program Database. Surg Obes Relat Dis. 2017;13(6):997–1002.Google Scholar
  35. 35.
    Kumar SB, Hamilton BC, Wood SG, et al. Is laparoscopic sleeve gastrectomy safer than laparoscopic gastric bypass? A comparison of 30-day complications using the MBSAQIP data registry. Surg Obes Relat Dis. 2018;14(3):264–9.Google Scholar
  36. 36.
    Catarci M, Carlini M, Gentileschi P, et al. Major and minor injuries during the creation of pneumoperitoneum. A multicenter study on 12,919 cases. Surg Endosc. 2001;15(6):566–9.Google Scholar
  37. 37.
    Krishnakumar S, Tambe P. Entry complications in laparoscopic surgery. J Gynecol Endosc Surg. 2009;1(1):4–11.Google Scholar
  38. 38.
    Azevedo JL, Azevedo OC, Miyahira SA, et al. Injuries caused by Veress needle insertion for creation of pneumoperitoneum: a systematic literature review. Surg Endosc. 2009;23(7):1428–32.Google Scholar
  39. 39.
    Li RA, Fisher DP, Dutta S, et al. Bariatric surgery results: reporting clinical characteristics and adverse outcomes from an integrated healthcare delivery system. Surg Obes Relat Dis. 2015;11(5):1119–25.Google Scholar
  40. 40.
    Kelles SM, Barreto SM, Guerra HL. Mortality and hospital stay after bariatric surgery in 2167 patients: influence of the surgeon expertise. Obes Surg. 2009;19(9):1228–35.Google Scholar
  41. 41.
    Nguyen NT, Vu S, Kim E, et al. Trends in utilization of bariatric surgery, 2009–2012. Surg Endosc. 2016;30(7):2723–7.Google Scholar
  42. 42.
    Mavros MN, Velmahos GC, Larentzakis A, et al. Opening Pandora's box: understanding the nature, patterns, and 30-day outcomes of intraoperative adverse events. Am J Surg. 2014;208(4):626–31.Google Scholar
  43. 43.
    Wanjura V, Szabo E, Osterberg J, et al. Morbidity of cholecystectomy and gastric bypass in a national database. Br J Surg. 2018;105(1):121–7.Google Scholar
  44. 44.
    Pineda O, Maydon HG, Amado M, et al. A prospective study of the conservative management of asymptomatic preoperative and postoperative gallbladder disease in bariatric surgery. Obes Surg. 2017;27(1):148–53.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.The Obesity Clinic at Hospital General TláhuacMéxico CityMexico
  2. 2.Digestive and Endocrine Surgery DepartmentCentre Hospitalier Universitaire de PoitiersPoitiersFrance

Personalised recommendations