title: Hand-assisted laparoscopic gastric bypass does not improve outcome and increases costs when compared to open gastric bypass for the surgical treatment of obesity.
abstract: BACKGROUND
  Hand-assisted laparoscopic Roux-en-Y gastric bypass (Hand-Lap GB) has been adopted by some surgeons to treat morbid obesity because it is easier to perform than the total laparoscopic procedure, but to date no study has compared the outcomes of patients undergoing the Hand-Lap GB to those obtained with the open procedure (Open GB). We hypothesized that patients undergoing Hand-Lap GB would lose a similar amount of weight when compared to Open GB patients, while experiencing no increase in complications, a shorter hospital stay, and lower overall costs of care, in part as a result of fewer incisional hernias requiring subsequent surgery.
  
  
  METHODS
  Nonrandomized, prospective data were collected on all patients undergoing proximal GB via Hand-Lap or open approaches between May 1998 and July 1999. Our first 25 Hand-Lap GB procedures, performed in selected patients (with no extensive previous abdominal surgery) referred to two of us (E.J.D, M.A.S), were compared to all other (n = 62) concurrent open proximal GB performed by the group during this period of time in patients with body mass index (BMI) <50 kg/m2.
  
  
  RESULTS
  Preoperatively, Hand-Lap GB patients did not differ from Open GB patients in age (40 +/- 11 vs 43 +/- 11 years), gender (92% female vs 81% female), incidence or type of preoperative comorbid conditions, preoperative weight (282 +/- 33 vs 280 +/- 37 lb), or BMI (45.5 +/- 5.4 vs 44.1 +/- 3.3 kg/m2). (Data given as mean +/- standard deviation). Although length of hospital stay did not differ between groups (3.6 +/- 1.3 vs 4.2 +/- 4.6 days), total hospital costs were significantly higher for Hand-Lap GB ($14,725 +/- 3089 vs. $10,281 +/- 3687, p <0.01 ANOVA). One patient in the Open GB group developed an anastomotic leak from the gastrojejunostomy. Follow-up revealed that Hand-Lap GB patients had a similar risk of postoperative complications as the Open GB group, including marginal ulcer (16% vs 14.5%), stomal stenosis (24% vs 23%), and, most notably, incisional hernia (20% vs 27%). There were no major wound infections or deaths in either group. One patient in each group developed a postoperative small bowel obstruction. Loss of excess weight in Hand-Lap GB patients at 12 months postoperatively was 66 +/- 14% vs 77 +/- 14% in the Open GB group.
  
  
  CONCLUSIONS
  The Hand-Lap GB yielded good weight reduction in a population of morbidly obese patients, but at a higher cost for hospital care than Open GB. There was no decrease in the incidence of incisional hernias with the Hand-Lap GB procedure. Although Hand-Lap GB appears to be safe and effective, its failure to provide a decrease in hospital stay or risk of incisional hernia requiring subsequent surgical repair is significant. The primary role for the Hand-Lap GB procedure should therefore be to aid surgeons in developing skills to climb the steep learning curve for total laparoscopic gastric bypass, since Hand-Lap GB does not improve patient outcome and increases cost in comparison to the open GB procedure.
authors.affiliation: Department of Surgery, Center for Minimally Invasive Surgery, Medical College of Virginia Campus of Virginia Commonwealth University, MCV Box 980519, 1200 Broad Street, Richmond, VA 23298, USA. edemaria@hsc.vcu.edu
authors.forename: E J
authors.initials: EJ
authors.lastname: DeMaria
authors.forename: M A
authors.initials: MA
authors.lastname: Schweitzer
authors.forename: J M
authors.initials: JM
authors.lastname: Kellum
authors.forename: J
authors.initials: J
authors.lastname: Meador
authors.forename: L
authors.initials: L
authors.lastname: Wolfe
authors.forename: H J
authors.initials: HJ
authors.lastname: Sugerman
mesh_terms: D000328:Adult; D000713:Anastomosis, Roux-en-Y / Q000191:economics / Q000379:methods / Q000706:statistics & numerical data; D001835:Body Weight; D003362:Cost-Benefit Analysis / Q000706:statistics & numerical data; D005260:Female; D015390:Gastric Bypass / Q000191:economics* / Q000379:methods* / Q000706:statistics & numerical data; D006801:Humans; D010535:Laparoscopy / Q000191:economics* / Q000379:methods* / Q000706:statistics & numerical data; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D009765:Obesity / Q000601:surgery*; D011183:Postoperative Complications; D011300:Preoperative Care / Q000706:statistics & numerical data; D011446:Prospective Studies; D012306:Risk; D016896:Treatment Outcome