Single Incision LRYGB

Abstract

Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) has emerged as a gold standard bariatric procedure. In the pursuit of scarless surgery, the concept of single incision laparoscopic surgery (SILS) was born and implicated in bariatric surgery. To hide the scar, umbilicus serves as the main orifice for entry of all ports in SILS. However, this small incision leads to change of basic laparoscopic principles of port placement and makes procedure exceptionally difficult. To perform single incision transumbilical (SITU) LRYGB, proper case selection important. Extremely obese patients (BMI >50 kg/m²) and very tall patients (>180 cm in height) should be avoided because of abundant visceral fat and the long distance between umbilicus and gastric pouch. Previous abdominal surgery is a relative-contraindication because of lost advantage of cosmesis. During early learning curve stage, the 4.5 cm skin incision can be enlarged to 6 cm omega shaped incision, to get extra room for instrument maneuverability. Umbilicoplasty can be done to decrease this to 3.5 cm at the end of the procedure. Furthermore, in morbidly obese patients, the hypertrophic liver usually hinders the surgeon’s view of upper stomach and liver retraction plays a pivotal role in the success of surgery. Liver suspension technique provides good exposure. After adequate experience, all steps of multi-port LRYGB can be readily replicated in SITU-LRYGB, without increased complication rate but with improved cosmetic result.

This chapter describes the technique of SITU-LRYGB, along with variations in technique, complications and some technical tips.