title: How to cope with insufficient pneumoperitoneum and exposure when performing laparoscopic gastric bypass surgery.
abstract: OBJECTIVE
  Despite following international guidelines and conducting routine preoperative dietary counseling, every bariatric surgeon will encounter technical challenges in laparoscopic gastric bypass surgery. We present a series of patients in whom the bariatric procedure was stopped after encountering insufficient exposure during diagnostic laparoscopy. These patients were sent back for dietary counseling and underwent surgery after conservative weight loss. The data from this two-step procedure are analyzed and discussed.
  
  
  METHODS
  This concept was applied and studied in 14 patients from a series of 620 bariatric procedures. Patients who underwent a primary laparoscopic gastric bypass (n = 593) were used as references.
  
  
  RESULTS
  The patients in the study group were significantly heavier than those in the reference group (165 vs. 127 kg, p < 0.001), with 79 % having a BMI >50 kg/m(2). The patients lost a median of 11 kg after 2 months of conservative treatment, and the mean BMI decreased from 55.7 to 52.6 kg/m(2). All the patients in the study group underwent laparoscopic surgery for the second procedure with no need for conversion. The complication rate was not elevated in the study group. Overall hospital costs were higher for the study group compared with those for the primary laparoscopic bypass group (27,136 vs. 19,601 USD, p = 0.034).
  
  
  CONCLUSIONS
  The primary laparoscopic procedure can be stopped in patients with insufficient exposure instead of having them undergo conversion to open surgery. These patients may undergo successful laparoscopic procedures after conservative weight loss with no increased risk and with all of the possible benefits of a laparoscopic approach. As a result of this study, we have established a fixed, preoperative lower limit of 10 % excess weight reduction before accepting superobese patients (BMI >50 kg/m(2)) for surgery at our hospital.
authors.affiliation: Department of Surgery, Stadtspital Waid, 8000, Zürich, Switzerland.
authors.forename: Hella
authors.initials: H
authors.lastname: Scotland
authors.affiliation: Department of Surgery, Bariatric Reference Centre, Kantonsspital Frauenfeld, 8500, Frauenfeld, Switzerland.
authors.forename: Jeannette D
authors.initials: JD
authors.lastname: Widmer
authors.affiliation: Department of Surgery, Stadtspital Waid, 8000, Zürich, Switzerland.
authors.forename: Stefan
authors.initials: S
authors.lastname: Wildi
authors.affiliation: Department of Visceral and Transplantation Surgery, University Hospital, 8000, Zürich, Switzerland.
authors.forename: Marco
authors.initials: M
authors.lastname: Bueter
authors.affiliation: Department of Surgery, Stadtspital Triemli, 8000, Zürich, Switzerland.
authors.forename: Markus
authors.initials: M
authors.lastname: Weber
authors.affiliation: Department of Surgery, Bariatric Reference Centre, Kantonsspital Frauenfeld, 8500, Frauenfeld, Switzerland. markus.k.mueller@stgag.ch.
authors.forename: Markus K
authors.initials: MK
authors.lastname: Muller
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D061887:Conversion to Open Surgery; D015390:Gastric Bypass; D006801:Humans; D010535:Laparoscopy; D008875:Middle Aged; D009767:Obesity, Morbid / Q000150:complications / Q000601:surgery*; D018579:Patient Selection; D011028:Pneumoperitoneum, Artificial; D012086:Reoperation; D012189:Retrospective Studies; D015431:Weight Loss; D055815:Young Adult
keywords: Bariatric surgery; Dietary counseling; Laparoscopic gastric bypass; Morbid obesity; Preoperative weight reduction; Superobesity; Technique; Two-step procedure