Technical pearls of laparoscopic bariatric surgery

Surgery on the morbidly obese presents many challenges. Problematically, except for its extremes, weight or body mass index (BMI) alone does not predict the challenges that lie ahead in any bariatric procedure. Since the inception of laparoscopic bariatric surgery in 1993 all of the modern bariatric procedures have been performed laparoscopically with some modifications based on the limitations of the existing stapling equipment. The path, however, has not been without pitfalls for many surgeons. The learning curve has been steep, particularly for procedures that involve gastrointestinal tract reconstruction such as the laparoscopic Roux-en-Y gastric bypass (LRYGBP) or the biliopancreatic diversion/duodenal switch (BPD/DS) procedure. In the case of the LGB, Schauer et al. (1,2) have reported the learning curve to be as high as 100 cases. In the case of adjustable gastric banding, the technical challenges may lie less in the procedure and more in the details of band adjustment in the postoperative period. This chapter addresses some of the techniques used in bariatric surgery that facilitate the routine case as well as those that can be used to facilitate more challenging cases.