For treating morbid obesity a number of weight loss operations have been devised over the last 40-50 years. The morbid obesity surgical treatments recognized by most surgeons include: vertical banded gastroplasty, gastric banding (adjustable or non-adjustable), Roux-en-Y gastric bypass, and malabsorbtion procedures (biliopancreatic diversion, duodenal switch).
The vertical banded gastroplasty involves the construction of a small pouch that restricts the outlet to the lower stomach. The outlet is reinforced with a piece of mesh (screen) to prevent disruption and dilation
The laparoscopic gastric band involves placing a 1/2 inch belt or collar around the top portion of the stomach. This creates a small pouch and a fixed outlet into the lower stomach. The adjustable band, which was approved by the FDA in June 2001, can be filled with sterile saline. When saline is added, the outlet into the stomach is made smaller which further restricts food from leaving the pouch.
The gastric bypass procedure involves dividing the stomach and forming a small gastric pouch. The new gastric pouch is connected to varying lengths of your own small intestine constructed into a Y-shaped limb (Roux-en-Y gastric bypass).
The malabsorbtion operations cause weight loss by decreasing absorption of calories from the intestines. These operations involve reducing the stomach size and bypassing most of the intestines.
Choosing between the different operative procedures involves the surgeon’s preference and consideration of the patient’s eating habits.
Advantages of the laparoscopic approach include:
Reduced post-operative pain
Shorter hospital stay
Faster return to work
Who can undergo in for a Laparoscopic Obesity Surgery
The following guidelines for selecting patients for obesity surgery were established by the National Institute of Health:
Patients should exceed ideal body weight by approximately 100 pounds (45.5 kg) or 100% above ideals body weight.
Patients should have no known metabolic (chemical breakdown of food into energy) or endocrine (hormone) causes for the morbid obesity.
Patients should have an objectively measurable complication (physical, psychological, social, or economic) that might benefit from weight reduction. This includes hypertension (high blood pressure), diabetes (too much sugar in the blood), heart disease, breathing problems or lung disease, sleep apnea (snoring) and arthritis, just to name a few.
The patient should understand the full importance of the proposed surgical procedure including suspected risks and complications.
The patient should be willing to be observed and followed by a medical professional for many years.
The patient should have attempted weight reduction using medical treatment without success.
In some instances, a patient who is not quite 100 pounds or 100% above the ideal body weight is a candidate for surgical intervention. This patient should have a significant medical problem(s) that could benefit from weight reduction.
Preparation required for a Laparoscopic Surgery
A thorough medical evaluation to determine if you are a candidate for laparoscopic obesity surgery by your physician. Supplemental diagnostic tests may be necessary, including a nutritional evaluation.
A psychiatric or psychological evaluation may be required to determine the patient’s ability to adjust to changes after the operation.
Consultation from specialists, such as cardiologist, pulmonologist or endocrinologist may be needed depending on your own specific medical condition.
Continued participation in Obesity Support Group is encouraged A written consent for surgery will be needed after the surgeon reviews the potential risks and benefits of the operation.
The day prior to surgery, you will begin a clear liquid diet. Blood transfusion and/or blood products such as platelets may be needed depending on your condition.
Your surgeon may request that you completely empty your colon and cleanse your intestines prior to surgery.
It is recommended that you shower the night before or morning of the operation.
After midnight the night before the operation, you should not eat or drink anything except medications that your surgeon has told you are permissible to take with a sip of water the morning of surgery.
Drugs such as aspirin, blood thinners, anti-inflammatory medications (arthritis medications) and Vitamin E will need to be stopped temporarily for several days to a week prior to surgery.
Diet medication or St. John’s Wort should not be used for the two weeks prior to surgery.
Quit smoking and arrange for any help you may need at home.
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How Laparoscopic Surgery performed for morbid obesity
In a laparoscopic procedure, surgeons use small incisions (1/4 to 1/2 inch) to enter the abdomen through cannulas (narrow tube-like instruments). The laparoscope, which is connected to a tiny video camera, is inserted through the small cannula. A picture is projected onto a TV giving the surgeon a magnified view of the stomach and other internal organs. Five to six small incisions and cannulas are placed for use of specialized instruments to perform the operation.
The entire operation is performed inside the abdomen after expanding the abdomen with Carbon dioxide (CO2) gas. The gas is removed at the completion of the operation.
In a small number of patients the laparoscopic method cannot be performed. Factors that may increase the possibility of choosing or converting to the "open" procedure may include a history of prior abdominal surgery causing dense scar tissue, inability to visualize organs or bleeding problems during the operation.
The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather sound surgical judgment. The decision to convert to an open procedure is strictly based on patient safety.
On the day of the surgery
You will arrive at the hospital the morning of the operation. Preparation before surgery often includes changing into a hospital gown.
A qualified medical staff member will place a small needle/catheter (IV) in your vein to dispense medication during your surgery.
Often pre-operative medications are necessary.
You will meet the anesthesiologist and discuss the anesthesia. You will be under general anesthesia (asleep) during the operation, which may last for several hours.
Following the operation you will be sent to the recovery room until you are fully awake. Then you will be sent to your hospital room.
Most patients stay in the hospital the night of surgery and may require additional hospital days to recover from the surgery.
After the Laparoscopic Surgery for Morbid Obesity
The success rate for weight loss is reported as being slightly higher with gastric bypass operation than the gastroplasty or gastric banding, but all techniques show good to excellent results. Most reports show a 40-50% loss of excess weight for the gastric banding and vertical banded gastroplasty and a 65-70% loss of excess body weight for the gastric bypass after 1 year. The malabsorbtive operations generally achieve an average body weight loss of 70-80% after a year. Weight loss generally continues for all the procedures for 18-24 months after surgery. Some weight gain is common about two to five years after surgery.
Effect of surgery on associated medical conditions
Weight reduction surgery has been reported to improve conditions such as sleep apnea, diabetes, high blood pressure and high cholesterol. Many patients report an improvement in mood and other aspects of psychosocial functioning after surgery. Because the laparoscopic approach is performed in a similar manner to the open approach, the long-tern results appear to be similarly good.
Can any complications occur
Although the operation is considered safe, complications may occur as they may occur with any major operation.
The immediate operative death rate for any of the laparoscopic obesity procedures is relatively low in the reported case series (less than 2%). On the other hand, complications such as wound infections, wound breakdown, abscess, leaks from staple-line breakdown, perforation of the bowel, bowel obstruction, marginal ulcers, pulmonary problems and blood clots in the legs may be as high as 10% or more. In the post-operative period other problems may arise that may require more surgery. These problems include pouch dilatation, persistent vomiting, heartburn or failure to lose weight. In a rare individual, reversal of the operation is necessary due to a complication of surgery. Complication rates with secondary surgery are higher than after the first operation.
Gallstones are a common finding in the obese patient. Symptoms from these gallstones are a common occurrence with weight loss. Many physicians either treat patients with bile lowering medication (Actigall or URSO) or recommend gallbladder removal at the time of the operation. This should be discussed with your surgeon and physician.
After gastric bypass, nutritional deficiencies such as Vitamin B-12, folate, and iron may occur. Taking necessary vitamin and nutrient supplements can generally prevent them. Another potential result of gastric bypass is “Dumping Syndrome”. Abdominal pain, cramping, sweating, and diarrhea characterize dumping Syndrome after eating drinks and foods that are high in sugar. Avoiding high sugar foods can prevent these symptoms. After the malabsorbtive operations, the same nutritional deficiencies that occur after gastric bypass may occur, as well as protein deficiencies. Diarrhea or loose “stools” are also common after malabsorbtion operations depending on fat intake.
Women who become pregnant after any of these surgical procedures need special attention from their doctors and clinical care team. In general, complication rates of the laparoscopic approach are equal to or less than the conventional, open operations. Following obesity surgery, patients must re-orient themselves and adjust to the effect of a changing body image.
As with any operation, there is a risk of a complication. However, the risk of one of these complications occurring is no higher than if the operation was done with the open technique.
After the surgery
You will usually be in the hospital 1 to 3 days after a laparoscopic procedure. You may have a tube through your nose and not be permitted to eat or drink anything until it is removed. You should be out of bed, sitting in a chair the night of surgery and walking by the following day. You will need to participate in breathing exercises. You will receive pain medication when you need it.
On the first of second day after surgery you may have an X-ray of your stomach. The X-ray is a way for the surgeon to know if the stapling of the stomach is okay before beginning to allow you to eat. If no leakage or blockage is seen (the usual case) then you will be permitted to have one ounce of liquids every hour. The volume of liquid you drink will be gradually increased. Some surgeons allow you to eat baby food or a “puree” type of food. You will remain on a liquid or puree diet until your doctor evaluates you approximately 1-2 weeks after you return home.
Patients are encouraged to walk and engage in light activity. It is important to continue the breathing exercises while at home after surgery. Pain after laparoscopic surgery is generally mild although some patients may require pain medication. At the first follow-up visit the surgeon will discuss with you any dietary changes.
After the operation, it is important to follow your doctor’s instructions. Although many people feel better in just a few days, remember that your body needs time to heal. You will probably be able to get back to most of your normal activities in one to two weeks time. These activities include showering, driving, walking up stairs, and work and light exercise.
You should call and schedule a follow-up appointment within 2 weeks after your operation.
Be sure to call your doctor if you develop any of the following: Persistent fever over 101F (39 C)
Increased abdominal swelling or pain
Persistent nausea or vomiting
Persistent cough and shortness of breath
Difficulty swallowing that does not go away within a few weeks
Drainage from any incision
Calf swelling or leg tenderness