3D laparoscopy – use in bariatric surgery
Dr. med. Mirko Otto, Acting Senior Physician, Surgical Clinic, Mannheim University Medical Center
Mannheim University Medical Center, as a maximum care hospital, provides a wide range of diagnostic and therapeutic services. Including part-time staff, around 4,800 employees at around 30 clinics and institutes care for around 76,000 inpatient and day-care patients as well as approximately 210,000 outpatients annually.
The surgical clinic offers the complete range of visceral, chest and vascular surgery as well as bariatric surgery. With 136 beds, over 40 physicians and a comprehensive diagnostic and therapeutic service, the surgical clinic is the largest department at Mannheim University Medical Center. Since 2003 we have been carrying out more and more bariatric operations and endoscopic procedures. Annually, we perform around 100 bariatric procedures.
The number of bariatric operations is increasing worldwide, in particular due to the lower mortality rate in operated patients compared to non-operated obese patients.  There is also growing evidence of a beneficial effect on concomitant diseases such as diabetes and hypertension. , 
As a global comparison, the number of operations per 100,000 inhabitants in Germany is only 11, compared to approx. 130 in the USA. Even in Sweden, a country with a significantly lower average BMI among the general population, approximately 90 operations / 100,000 inhabitants are carried out. In this context, there seems to be a clear need to increase the number of bariatric operations in Germany. , 
The bariatric operations performed fall mainly into two types: laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (RYGB). The currently available data shows that the two procedures are equivalent to one another, at least in the initial post-operative years.  There is currently no long-term data for the subsequent years. There is a loss of around 60-70% of the overweight and a clear improvement in concomitant diseases.
These two procedures also account for the majority of the bariatric operations performed at our clinic as well, as we can achieve good results with lower morbidity with these procedures. Based on the available longterm data (over 10 years), we first recommend the RYGB if there are no contraindications. Contraindications include chronic inflammatory bowel diseases, conditions following kidney transplantation with significant medication dependency and prior major intestinal surgery.
The number of additional procedures with evidence of good effectiveness is increasing. So, the single-anastomosis gastric bypass (omega loop), the biliopancreatic diversion with a duodenal switch (BPDDS) and even the gastric band should not be left unmentioned.
The omega loop is a real alternative for patients with a BMI of 50-60 kg/m2 as it leads to better weight loss compared to the two traditional procedures. Unfortunately, the development of a gastric stump carcinoma cannot be ruled out, which is why young patients should be advised against undergoing this procedure. 
For very heavy patients (BMI > 65 kg/m2), often only one multistage process is considered. After initial sleeve gastrectomy, BPDDS seems to the have the best weight loss results with a concomitant excellent effect on any possible diabetes. Quality of life, measured using a questionnaire (BAROS) on physical, social and psychic effects is significantly improved after the operation, despite the malnutrition caused by the operation. 
The gastric band provided excellent data in an Australian study. However, the requirement for intensive follow-up care, which is not paid for in Germany, is problematic. Therefore, this procedure is rare both in Germany and at our clinic. 
Different methods can also be combined in individual cases, e.g. the fitting of a gastric band to an existing gastric bypass (laparoscopic banded Roux-en-Y-gastric bypass). However, this should be a strictly exceptional indication as there is no long-term data available, there are no prospective randomized superiority studies and the negative effects of a foreign body are already known about from the traditional gastric band.
Every indication and each surgical procedure requires an individual decision, agreed with the patient. From our perspective, the good long-term data and good tolerability of LSG and RYGB support the use of these procedures. A general recommendation for the other methods cannot be given due to the lack of evidence regarding their equivalence.
Laparoscopic Roux-en-Y gastric bypass
65% of our patients undergo an RYGB. First of all, we insert a 12 mm camera trocar under visual control without prior creation of a pneumoperitoneum. Then two 12 mm trocars and two 5 mm trocars are introduced by sight and we start the measurement of the biliary limb (section of the small intestine from the duodenum to the subsequent Roux-en-Y anastomosis), which is marked 60 cm after the ligament of Treitz.
The limb lengths are still being discussed as current studies seem to show that there are advantages to a longer biliary loop. However, we are still waiting for prospective, randomized long-term data. 
A 6-7 cm long and narrow gastric pouch with a fill capacity of 20 ml is formed. To do this, a linear stapler is applied from the small curvature at a right angle. Then two further magazines are applied longitudinally up to the angle of His.
The posterior wall of the gastrojejunostomy is also attached using a linear stapler and the anterior wall suture is made using a continuous suture technique, with a gastric probe (28 Charrière) inserted for anastomosis calibration. We the check that the anastomosis and the stapled suture is tight by filling the stomach with indigo carmine.
The alimentary limb (section of the small intestine from the gastric limb to the Roux-Y anastomosis) is set at 150 cm. We always close the jejunojejunal defect with non-absorbable suture material. Various studies  show the superiority of closing both this defect as well as Petersen’s space (between the colon and the pulled down alimentary limb).
The jejunojejunal anastomosis is created with three linear stapler magazines. First, two magazines are applied in opposing directions. These create a sufficiently large anastomosis, which is then closed transversely with an additional magazine. A fascial suture is not used and after the draining of the capnoperitoneum, the trocar accesses are cutaneously sealed.
3D technology (EinsteinVision®)
Using 3D technology we have been able to significantly shorten the duration of the operation in recent years. Laparoscopic suturing is made significantly easier and leads to less surgeon fatigue. The three-dimensional imaging enables threads, needles and tissue to be reached quickly and unerringly. The stitch direction and the angle of the clamped needle can be seen clearly. Procedures with a significant suturing aspect, such as RYGB and BPDDS, benefit in particular from the 3D system.
As the currently available data shows, the surgical bariatric procedures are clearly superior to conservative treatment of overweight. Therefore, the number of these operations is also increasing in Germany. New technologies, like the 3D technologies, that simplify these operations and have a positive effect on the cost-benefit ratio and a lower surgical risk for patients due to the shorter operating time, are also contributing to this increase in case numbers.
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