The laparoscopic Roux-en-Y gastric bypass for morbid obesity with a totally hand-sewn gastrojejunostomy can be safely performed by the bariatric surgeon with advanced laparoscopic skills in the community setting. Fixation and closure of all potential hernia sites with non-absorbable sutures is essential. Stenosis of the hand-sewn gastrojejunal anastomosis is amenable to endoscopic balloon dilation. Meticulous attention must be paid to the operative and perioperative care of the patient.

Internal hernias are more common following laparoscopic RYGBP than "open" RYGBP. Contrast radiographs alone are unreliable in ruling out this diagnosis. Early intervention is crucial; most repairs can be performed laparoscopically. This diagnosis should be entertained in all patients with unexplained abdominal pain following laparoscopic RYGBP. Meticulous closure of all potential internal hernia sites is essential to limit this potentially lethal complication.

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The laparoscopic gastric bypass is a viable alternative to traditional open techniques. It is as safe and effective and can be performed with equal or greater efficiency. Adoption of hand-suturing techniques helps to improve the surgeon's skill and ability to cope with the occasional stapler misfire or complication.

Hypothesis:A technique of the laparoscopic Rouxen-Y gastric bypass can be developed that is safe, effective, and practical in the community setting.Design: A case series of 400 morbidly obese and superobese individuals who underwent the laparoscopic Rouxen-Y gastric bypass over a 22-month period.Setting: Community private practice in Fresno, Calif.Patients: A consecutive sample of 400 patients (70 males and 330 females) who met National Institutes of Health criteria for recommendation of a bariatric procedure. Only patients who had a previous gastric or bariatric procedure were excluded from this sample.Intervention: Laparoscopic Roux-en-Y gastric bypass with a hand-sewn gastrojejunal anastomosis.Main Outcome Measures: Weight loss, complications, length of hospital stay, successful completion of the operation, and operative times were measured.Results: Open conversion was required in 12 patients (6 males and 6 females) and a secondary operation for incomplete division of the stomach was required in 2 patients early in the case series. Alternative exposure and fixation techniques greatly reduced these occurrences. There were 6 staple-line failures owing to a change in the manufacture of the instrument. There were no leaks at the gastrojejunal anastomosis, but 21 patients required endoscopic balloon dilation for significant stenosis. The average hospital stay was 1.6 days for the patients who underwent laparoscopy and 2.7 days for patients requiring open conversion. Average excessive weight loss was 69% at 12 months. Operative times are between 60 and 90 minutes. Other complications are described. Conclusion:The Roux-en-Y gastric bypass can be safely and effectively performed in the community setting using advanced laparoscopic techniques.