LAS VEGAS (EGMN) – A novel, single-incision transumbilical approach to laparoscopic Roux-en-Y gastric bypass led to a quick recovery, excellent weight loss, and minimal scarring in morbidly obese patients, according to a study comparing this approach with conventional five-port LRYGB surgery.
Because of the “less than ideal” cosmetic results associated with conventional LRYGB, which requires five to seven incisions to facilitate multiple trocar placement, “we developed this new, single-incision approach to achieve a more cosmetically acceptable scar,” said Dr. Chih-Kun Huang. Significantly greater wound satisfaction was observed in patients undergoing this procedure, compared with those who opted for the classic, multiple-incision procedure, Dr. Huang said at the annual meeting of the American Society for Metabolic and Bariatric Surgery.
Although single-incision laparoscopic surgery (SILS) has been used to perform adjustable banding and sleeve gastrectomy, some aspects of the technique have made it impractical for LRYGB. Specifically, Dr. Huang said, “the small [4-cm] umbilical incision crowds the trocars, leaving the surgeon with only a small angle in which to work.” Additionally, the hypertrophic left liver lobe in morbidly obese patients obstructs the surgeon’s view of the stomach, necessitating liver traction during surgery, he noted.
In contrast, the single-incision transumbilical approach developed by Dr. Huang and his colleagues at E-Da Hospital, Kaohsiung, Taiwan, improves workspace during surgery by extending the omega wound to 6 cm (with a subsequent umbilicoplasty to hide the scar) and optimizes visualization for jejunostomy repair by using a liver-suspension tape to achieve and maintain liver traction intraoperatively, Dr. Huang said.
In an earlier report on the first case in which this surgical method was used, Dr. Huang and his colleagues observed an “acceptable operation time” of 170 minutes and better cosmetic results, compared with those of the conventional procedure (Obes. Surg. 2009;19:1711-15).
For the current study, the investigators compared the surgical results and satisfaction scores of 40 morbidly obese patients who underwent the single-incision procedure with those of 100 morbidly obese patients who opted for the conventional, five-port LRYGB surgery, Dr. Huang said, noting that superobese patients – those with body mass indexes (BMIs) greater than 60 kg/m2 – were excluded from the analysis.
Preoperatively, patients in the five-port group were more obese than were those the single-incision group, with mean weights of 120.8 kg and 108.9 kg, respectively, and their rate of hypertension was higher, Dr. Huang said. The mean surgical times were 101.1 minutes for the single-incision procedure vs. 81.1 minutes for the five-port group, he said.
After surgery, there were no significant differences in the lengths of hospitalization or rates of morbidity between the two groups, Dr. Huang said. Additionally, the percent excess weight loss (EWL) was similar at all five time points evaluated. The percents EWL for the single-incision and five -port groups, respectively, were as follows: 21.17% and 20.85% at 1 month; 40.39% and 39.39% at 3 months; 54.99% and 52.18% at 6 months; 64.84% and 75.22% at 9 months; and 75.41% and 78.2% at 12 months, he reported.
Responses to a wound satisfaction questionnaire given to patients 3 months after surgery showed that the single-incision patients were significantly more pleased with the outcome of their incisions, Dr. Huang stated.
There were no differences in postsurgical complications between the two groups. However, because of the need for more tension during closure, the period of wound care was longer for the single-incision group than for the five-port group, Dr. Huang said.
Careful patient selection and surgeon experience are critical for achieving good outcomes with the single-incision procedure, Dr. Huang stressed. “The surgery is not well suited to superobese patients or very tall patients [taller than 180 cm]. The abundant fat in the abdomen and the very long distance between the umbilicus and the gastric pouch make the surgery very difficult.”
He added that because of the steep learning curve, “we recommend that the procedure be performed only by experienced bariatric surgeons who have completed more than 400 laparoscopic Roux-en-Y gastric bypasses.”
While the findings indicate that the single-incision approach is a safe, technically feasible, and reproducible procedure for gastric bypass, the results are limited by the fact that the study was not randomized, Dr. Huang stated.
“The patients were able to choose which procedure they wanted,” he said, acknowledging the possibility of selection bias since patients who were more concerned with cosmetic outcomes may have chosen the single-incision approach. For this reason, the investigators have initiated prospective, randomized studies to compare the single-incision approach with the five-port procedure, he said.
Dr. Huang reported having no financial conflicts of interested related to this investigation.