From Laparoscopy to Lap-Band

After more than seven months of planning, practice and patience, Namir Katkhouda, M.D., completed a complex Roux-en-Y gastric bypass without a long incision. Instead, he performed the surgery using slender instruments and a tiny camera, or scope, threaded through small cuts in the skin. Since this USC first, he has performed succesfully in the last year a large number of these procedures.

In minimally invasive procedures, patients experience smaller scars, quicker recovery time and less pain than in open procedures.

Dr. Katkhouda, Professor of Surgery and Director of the Department of Surgery's Laparoscopy Program, honed his technique by observing surgeries, consulting with pioneering colleagues in the United States and Europe, reviewing publications, taking an American Bariatric Society course and practicing in his lab.

"This is an incredible surgery on the complexity scale of laparoscopic procedures," says Katkhouda. He is a laparoscopic leader, pioneering the technique in operations and teaching other surgeons. He has written books on laparoscopy, and designed instruments used in the procedures.

In the laparoscopic bariatric procedure, Dr Katkhouda performs a Roux-en-Y gastric bypass considered to be the gold standard in the US.

He makes five small incisions and threads a tiny camera into the abdomen. He inserts long tools through tubes placed into the incisions, and watches the organs on a screen as he operates.

Katkhouda creates a 150 cm segment of the small intestine and sutures it to the tiny gastric pouch that he creates using laparoscopic techniques. The small intestine absorbs nutrients from food, but with less intestine, the body absorbs fewer calories.

He resects much of the stomach, leaving it a small pouch about the size of a plum. One of the critical parts of the operation is the suture of the small newly created pouch to the intestinal limb. Dr Katkhouda uses hand-sutured laparoscopic techniques instead of using stapling thus minimizing the risks of leaks.

"It is more complex to do it this way but it is safer; it is like a hand made versus a machine made suit: you wait longer and it is more difficult to fabricate but the suit is impeccable and will last longer".

The communication between the stomach and the intestine is purposely kept small to provide for a "funnel effect". This contributes to the sensation of fullness and limits food intake.

In summary, patients loose weight following laparoscopic gastric bypass because of the tiny pouch ( restriction) , the small communication (fullness) and the Roux en Y intestinal limb ( limited malabsorption).

Although dumping has been described following this operation, very few of Dr Katkhouda's patients have experienced this. Also, problems with flatulence and gas are virtually absent because of the limited malabsorption.

Patient Tony Matta left USC University Hospital just three days after his laparoscopic bariatric surgery, sooner than the four-to-six-day recovery time that typifies open procedures.

Matta went back to work 10 days after surgery. Six weeks after surgery, the once-320-pound Matta had dropped 47 pounds, reversed his diabetes and lowered his blood pressure to normal. He lost the drive to eat, resumed normal sleep patterns and bucked his depression.

Katkhouda is excited about the surgery's potential but warns that only surgeons with proven laproscopic skills should perform the surgery. He expects that in the coming years, surgeons will offer weight loss solutions to morbidly obese patients tailored to their unique needs. For now, he will continue to perform the laparoscopic Roux-en-Y, but does not exclude-with improvement of the technique and instrumentation-that the duodenal switch could be offered laparoscopically.

"In the coming years, there will be an operation for each situation," Katkhouda says. Understanding each patient's history and eating habits-whether sweet-eater, snacker or binge eater, for example-can guide choices.

And as society has accepted morbid obesity as a serious problem, attempts to combat obesity have grown.

Witness the Lap-band

First standardized in the 1990s in Belgium and Italy, the laparoscopic adjustable gastric banding procedure squeezes closed the upper part of the stomach with an inflatable belt. Patients quickly feel full after eating a little.

"Over the past seven years in Europe, thousands of Lap-bands have been placed," Katkhouda says. "And now they can place a band in one hour, with a one-day hospital stay, and through only three small incisions. This does not mean that this operation is devoid of risks; careful patient selection and technique is required."

Only recently approved in the U.S. by the Food and Drug Administration, the Lap-band can be inflated or deflated through a catheter under the skin. Surgery can be reversed by removing the band, says Katkhouda, one of the few surgeons in Los Angeles approved to offer the procedure.

"While the laparoscopic gastric bypass is good for the morbidly obese patient, the Lap-band may help those who are morbidly obese, under 20 years old," he says. "It also is an option for those over 60, or at high risk for complications."

Dr. Katkhouda agrees with his colleagues that obesity treatment does not end when the patient leaves the hospital. "These patients have a radical change in their lives," Katkhouda observes. "Without food for comfort, depression sets in. Support groups and nutritional counseling are key."