Laparoscopic Staged Roux-en-Y: A Staged Procedure for Super-Super Obese Patients

Laparoscopic Roux-en-Y gastric bypass in the super-super obese (BMI >60 kg/m2) population can be challenging. Factors that contribute to the technical difficulty include male gender, android body habitus, and high BMI. Men often have an android body habitus with high content of visceral fat, which increases intra-abdominal pressure and reduces intraoperative laparoscopic visualization. In addition, android body habitus and high BMI are often associated with fatty liver disease and enlarged liver lobes that may obscure visualization of the gastroesophageal junction. All of these factors can contribute to the degree of intraoperative technical difficulty and should be weighed in the selection of appropriate patients to undergo laparoscopic gastric bypass.

Although a high BMI is not in itself a contraindication to surgery, laparoscopic gastric bypass in the super-super obese can be associated with a higher morbidity and mortality. In an effort to minimize perioperative morbidity, the concept of a two-stage operation was developed. The initial two-stage procedure consists of a sleeve gastrectomy (first stage) followed by an interval Roux-en-Y gastric bypass or duodenal switch. However, the sleeve gastrectomy can still be challenging in the super-super obese, particularly in patients with an enlarged liver from nonalcoholic steatohepatitis or liver cirrhosis obscuring visualization of the gastroesophageal junction near the angle of His. The alternative two-stage procedure is the staged Roux-en-Y, which consists of a modified Roux-en-Y operation with construction of a larger gastric pouch and a low gastrojejunal anastomosis. Construction of a large gastric pouch avoids the difficult dissection of the angle of His. The construction of a low gastrojejunal anastomosis minimizes tension on the anastomosis and hence reduces the chance for leaks. In the second stage, 6 to 12 months later, the volume of the gastric pouch is reduced by performing a sleeve gastrectomy of the gastric fundus.