What is laparoscopic surgery?

Laparoscopic surgery for obesity is for people who are severely overweight. Laparoscopy involves using a specialized telescope (laparoscope) to view the stomach, which typically allows smaller abdominal incisions.

What is severe (morbid) obesity?

Severe obesity, sometimes known as “morbid obesity”, is defined as being approximately 100 pounds (45.5 kg) or 100% above ideal body weight. Between 3-5% of the United States adult population has severe obesity. This condition is associated with the development of life-threatening complications such as hypertension, diabetes and coronary artery disease, to name a few.

Numerous therapeutic approaches to this problem have been advocated, including low calorie diets, medication, behavioral modification and exercise therapy. However, the only treatment proven to be effective in long-term management of morbid obesity is surgical intervention.

What Causes Severe Obesity?

he cause of severe (morbid) obesity is poorly understood. There are probably many factors involved. In obese persons, the set point of stored energy is too high. This altered set point may result from a low metabolism with low energy expenditure, excessive caloric intake, or a combination of the above. There is scientific data that suggests obesity may be an inherited characteristic.

 

Severe obesity is most likely a result of a combination of genetic, psychosocial, environmental, social and cultural influences that interact resulting in the complex disorder of both appetite regulation and energy metabolism. Severe obesity does not appear to be a simple lack of selfcontrol by the patient

What Are the Treatment Options?

Medical Treatment: In 1991, the National Institutes of Health Conference concluded that non-surgical methods of weight loss for patients with severe (morbid) obesity, except in rare instances, are not effective over long periods of time. It was shown that nearly all participants in any non-surgical weightloss program for severe (morbid) obesity regained their lost weight within 5 years. Although prescriptions and non-prescription medications are available to induce weight loss, there does not appear to be a role for long-term medical therapy in the management of morbid obesity.

Medications that reduce appetite can result in 11 to 22 pound weight reduction. However, weight gain is rapid once medication is withdrawn. Various professional weight loss programs use behavior modification techniques in conjunction with low caloric diets and increased physical activity. Weight loss of one to two pounds per week has been reported, but nearly all the weight loss is regained after 5 years.Surgical Treatment: A number of weight loss operations have been devised over the last 40-50 years. The operations recognized by most surgeons include: vertical Sleeve Gastrectomy, Adjustable gastric banding , Roux-en-Y gastric bypass.

Choosing between the different operative procedures involves many factors to be considered. Visit “Choosing a Procedure”.

What Are the Advantages of Laparoscopic Obesity Surgery?

Advantages of the laparoscopic approach include:

  • Reduced post-operative pain
  • Shorter hospital stay
  • Faster return to work
  • Improved cosmesis

Who is a Candidate for Bariatric Surgery?

Qualifications for bariatric surgery in most areas include:

  • BMI ≥ 40, or more than 100 pounds overweight.
  • BMI ≥35 and at least two obesity-related co-morbidities such as type II diabetes (T2DM), hypertension, sleep apnea and other respiratory disorders, non-alcoholic fatty liver disease, osteoarthritis, lipid abnormalities, gastrointestinal disorders, or heart disease.
  • Inability to achieve a healthy weight loss sustained for a period of time with prior weight loss efforts.

The NIH, as well as the American College of Surgeons (ACS) and the American Society for Metabolic and Bariatric Surgery (ASMBS) also recommend that surgery be performed by a board certified surgeon with specialized experience/Fellowship training in bariatric and metabolic surgery, and at a center that has a multidisciplinary team of experts for follow-up care. This may include a nutritionist, an exercise physiologist or specialist, and a mental health professional. In addition, some insurance companies require that the surgery be performed at a facility that meets the ASMBS-approved quality standards (MBSAQIP). Facilities which meet high standards or quality, like those outlined in MBSAQIP, are preferable choices for patients.

 

What Preparation Is Required?

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.
  • Around 7-10 day prior to surgery, you will begin a special diet.
  • 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  should not be used for the two weeks prior to surgery.
  • Quit smoking and arrange for any help you may need at home.

How Is Laparoscopic Obesity Surgery Performed?

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.

What Happens if the Operation Cannot Be Performed by the Laparoscopic Method?

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.

What Should I Expect the Day of Surgery?

  • You will arrive at the hospital the morning of the operation.
  • 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.
  • 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.

How does the surgery Work?

Bariatric surgery, such as gastric bypass, gastric sleeve, and laparoscopic adjustable gastric banding, work by changing the anatomy of your gastrointestinal tract (stomach and digestive system) or by causing different physiologic changes in your body that change your energy balance and fat metabolism. Regardless of which bariatric surgery procedure you and your surgeon decide is best for you, it is important to remember that bariatric surgery is a “tool.” Weight loss success also depends on many other important factors, such as nutrition, exercise, behavior modification, and more.

By changing your gastrointestinal anatomy, certain bariatric procedures affect the production of intestinal hormones in a way that reduces hunger and appetite and increases feelings of fullness (satiety). The end result is reduction in the desire to eat and in the frequency of eating.

Significant weight loss is also associated with a number of other changes in your body that help to reduce defects in fat metabolism. With increased weight loss, you will find yourself engaging in more physical activity. Individuals who find themselves on a weight-loss trend often engage in physical activity, such as walking, biking, swimming, and more. Additionally, increased physical activity combined with weight loss may often improve your body’s ability to burn fat, lead to a positive personal attitude, and decrease stress levels. Massive weight loss, as a result of bariatric surgery, also reduces hormones such as insulin (used to regulate sugar levels) and cortisol (stress hormone) and improves the production of a number of other factors that reduce the uptake and storage of fat into fat storage depots. Physical activity is also a very important component of combating obesity.

Bariatric surgery may improve a number of conditions and result in  biological actions (hormonal changes) to reverse the progression of obesity. Studies find that more than 90 percent of bariatric patients are able to maintain a long-term weight loss of 50 percent excess body weight or more.

Bariatric surgery can be a useful tool to help you break the vicious weight gain cycle and help you achieve long term weight loss and improve your overall quality of health and life.

How Can Bariatric Surgery Help Me?

When combined with a comprehensive treatment plan, bariatric surgery may often act as an effective tool to provide you with long term weight-loss and help you increase your quality of health. Bariatric surgery has been shown to help improve or resolve many obesity-related conditions, such as type 2 diabetes, high blood pressure, heart disease, and more. Frequently, individuals who improve their weight find themselves taking less and less medications to treat their obesity-related conditions.

Significant weight loss through bariatric surgery may also pave the way for many other exciting opportunities for you, your family, and most importantly – your health.

Long Term Weight Loss Success

Bariatric surgeries result in long-term weight-loss success. Most studies demonstrate that more than 90 percent of individuals previously affected by severe obesity are successful in maintaining 50 percent or more of their excess weight loss following bariatric surgery. Among those affected by super severe obesity, more than 80 percent are able to maintain more than 50 percent excess body weight loss.

Improved Longevity

Several large population studies find that individuals affected by severe obesity who have had bariatric surgery have a lower risk of death than individuals affected by obesity who do not have surgery. One of these studies found up to an 89 percent greater reduction in mortality throughout a 5-year observation period for individuals who had bariatric surgery when compared to those who did not. Another large population study comparing mortality rates of bariatric and non-bariatric patients found a greater than 90 percent reduction in death associated with diabetes and a greater than 50 percent reduction in death from heart disease.

The mortality rate for bariatric surgery  is similar to that of a gallbladder removal and considerably less than that of a hip replacement. The exceptionally low mortality rate with bariatric surgery is quite remarkable considering that most patients affected by severe obesity are in poor health and have one or more life-threatening diseases at the time of their surgery. Therefore, as regards mortality, the benefits of surgery far exceed the risks.

Improvement/Resolution of Coexisting Diseases

Bariatric surgery is associated with massive weight-loss and improves, or even resolves (cures), obesity-related co-morbidities for the majority of patients. These co-morbidities include high blood pressure, sleep apnea, asthma and other obesity-related breathing disorders, arthritis, lipid (cholesterol) abnormalities, gastroesophageal reflux disease, fatty liver disease, venous stasis, urinary stress incontinence, pseudotumor cerebri, and more.

Bariatric surgeries also lead to improvement and remission of Type II diabetes mellitus (T2DM). In the past, diabetes was considered to be a progressive and incurable disease. Treatments include weight loss and lifestyle changes for those who are overweight or obese and antidiabetic medication, including insulin. These treatments help to control T2DM but rarely cause remission of the disease. However, there is now a large body of scientific evidence showing remission of T2DM following bariatric surgery.

Causes of improvement or remission of diabetes have not been completely identified. Improvement of T2DM with AGB is related to weight loss. However, with other surgeries, such as the LSG or RYGB, diabetes remission or improvement occurs early after surgery – well before there is significant weight reduction. In fact, some bariatric patients with T2DM leave the hospital with normal blood sugar and without the need for antidiabetic medication.

Changes in Quality of Life and Psychological Status with Surgery

In addition to improvements in health and longevity, surgical weight-loss improves overall quality of life. Measures of quality of life that are positively affected by bariatric surgery include physical functions such as mobility, self-esteem, work, social interactions, and sexual function. Singlehood is significantly reduced, as is unemployment and disability. Furthermore, depression and anxiety are significantly reduced following bariatric surgery.

 

What Complications Can Occur?

Although the operation is considered safe, complications may occur as they may occur with any major abdominal operation.

Though not common, serious 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 occur. In the post-operative period complications such as leaks or obstruction may require additional surgeries.

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 bariatric surgery, nutritional deficiencies such as Vitamin B-12, folate,Calcium,Vitamin D 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.

 

What to Expect After Surgery

You will usually be in the hospital 1 to 3 days after a laparoscopic procedure.

You should be out of bed, sitting in a chair the night of surgery and walking the same day. You will need to participate in breathing exercises. You will receive pain medication when you need it.

On the first day after surgery you may have an X-ray of your stomach.  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. 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.

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.

 

Arch Bariatrics LLC before and after weight-loss surgery
Arch Bariatrics LLC before and after weight loss surgery
Arch Bariatrics LLC before and after weight loss surgery

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