Cost advantages of open gastric bypass surgery and technical details of left subcostal incision
**Increased Costs**
Laparoscopic surgeons believe patients can be discharged faster after laparoscopic surgery. Some published data seem to support this, suggesting a discharge time of approximately two days after laparoscopic surgery compared to three days after open surgery, saving one day and roughly $1,000. However, anastomotic leakage typically doesn't occur within the first 72 hours post-surgery. If a patient is discharged one to two days after surgery and returns home hundreds of miles away, anastomotic leakage can be disastrous. I compared the cost of equipment and instruments for laparoscopic and open RYGB procedures at one of the two hospitals where I work and found that laparoscopic equipment costs approximately $5,200, while open suture equipment costs approximately $1,700, a difference of $3,500. Hospitals typically double their medical costs to make a profit, so the difference can reach approximately $7,000. When we assume an operating room usage fee of $1,250 per hour, the total cost for a patient undergoing laparoscopic RYGB can be $8,000 to $10,000 more than that for open surgery.
Our Obesity Treatment Surgery Center at Christus Schumpert Medical Center in Shreveport, Louisiana, is an ASBS-certified Center of Excellence. Patients undergoing laparoscopic RYGB have almost the same hospital stay as those undergoing open surgery, averaging 3.2 days, while the surgery itself takes nearly twice as long. Anesthesiologists note that there is virtually no difference in pain experienced by either procedure. From a rather practical standpoint, since the reimbursement from health insurance companies is only slightly different for the two methods, if each patient's surgery takes only half the time of laparoscopic surgery, I will be able to perform more surgeries in the same amount of time, thus significantly increasing my healthcare revenue.
**Left subcostal incision**
When we compared laparoscopic and open RYGB procedures again, we found that while it's generally believed that open surgery is performed through a midline abdominal incision, Alvarez-Cordero and I both used a left subcostal incision (LSI) for open surgery. When others compared our clinical data with published data, it was easy to see that our incisional hernia incidence was only one-third that of other large midline incisions. Why? Simply put, the muscles at the LSI have a better blood supply than the fascia at the midline incision, thus healing faster.
Some may ask, given the high rate of loss of follow-up among patients undergoing open bariatric surgery, how can I be so certain that my incisional hernia incidence is so low? I addressed this issue using sampling techniques. For example, I used a subset of patients who had undergone four months of observation in 1996. These patients presented for various reasons, primarily for follow-up 1–10 years after RYGB surgery. We examined 173 consecutive patients and found no hernias. My incisional hernia incidence was 0.4% (5/1367), and the anastomotic leakage incidence was 0.4% (5/1367). The incidence of other surgical incision-related complications was 2.2%. These figures are relatively consistent.
Comparing the incidence of wound-related complications in some laparoscopic surgery cases with those of my left subcostal incision makes it easy to see that the incidence of incisional hernia and other related complications is indeed lower with the left subcostal incision. I often tell my patients that, aside from the high complication rate and cost of laparoscopic RYGB, the trauma to the abdominal wall is 7 inches whether the surgery is performed through one 7-inch incision or seven 1-inch incisions.
In addition, we should emphasize to beginners in bariatric surgery that they should perform more open surgeries before their first laparoscopic procedure. The ASBS guidelines recommend performing 10 open surgeries before laparoscopic bariatric surgery. As an ASBS instructor, both of my students are proficient in laparoscopic surgery; however, in the initial stages, I had them perform open RYGB (Reverse Rupture-Brain) procedures. They agreed with me that laparoscopic surgery has no real advantages and many potential drawbacks. In the 476 surgeries they performed, their leakage rate was only 1.3%, compared to an average leakage rate of 3% and a hernia rate of 7.6%, and the incidence of left subcostal hernia was only 1.5%.
**technology**
My surgical procedure was based on a modification of the OcaTorres procedure, with the following improvements: ① a left subcostal incision; ② the use of a TA-90B four-row Autosuture stapler, released twice, and then reinforced at both ends with Ligaclips sutures; ③ without severing the gastric pouch and residual stomach, establishing a vertical gastric pouch and using continuous suturing; ④ retrocolic-gastric-anterior gastrojejunostomy, double-layered hand sutures, using a 38-gauge Bougie (13mm in diameter); ⑤ according to the recommendations of Brolin et al., using linear cutting and suturing instruments for enteroenterostomy, with gastrojejunal loops shorter than 150cm and biliary-pancreatic-enterostomy loops shorter than 100cm, depending on the patient's BMI.