Bariatric Surgery (also called Weight Loss Surgery) is performed on obese patients for reduction of weight & also for relief from co-morbidities like diabetes, hypertension and obstructive sleep apnoea. This weight loss is usually achieved by reducing the size of the stomach with an implanted medical device (gastric banding); or through removal of a portion of the stomach (sleeve gastrectomy); or by resecting and re-routing the small intestines to a small stomach pouch (Roux en y gastric bypass/Minigastricbypasssurgery).
Types of Bariatric Surgery
Laparoscopic Adjustable Gastric Banding:
The adjustable gastric band is only a restrictive and reversible procedure. The small intestine is not altered during this procedure. The adjustable silicone ring is placed around the stomach 1-2 cm centimeters below the oesophagus (see figure). This ring is attached to tubing, which is threaded under the skin to a round "port". One can feel this port just under the skin in the center of the abdomen. This is how the surgeon adds or subtracts water to make the band smaller or bigger. Weight loss is predominantly due to the restriction of nutrient intake that is created by the small gastric pouch and the narrow outlet. The stomach needs to heal from surgery before the first fill. So the first adjustment won't occur until around six weeks after surgery. Gastric bands need to be adjusted an average of four to six times in the first year after surgery. These fills are done to make sure the band is not too tight or too loose and/or to encourage continued weight loss. Band adjustments are painless, and are usually done in the Radiology department under direct vision so the surgeon can see how tight to make the band in order to restrict food intake, but not make it so tight that one can't eat or drink anything. The patient can lose 40 to 50% of excess weight on average. It is considered one of the safest procedures performed today with a mortality rate of 0.05% (one in 2,000).
Laparoscopic Sleeve Gastrectomy
Laparoscopic Sleeve Gastrectomy (or Gastric Sleeve) is a surgical weight-loss restrictive and irreversible procedure in which the stomach is reduced to about 15% of its original size, by surgical removal of a large portion of the stomach, following the major curve. The open edges are then attached together (typically with surgical staples, sutures, or both) to leave the stomach shaped more like a tube, or a sleeve, with a banana shape. The procedure permanently reduces the size of the stomach. The gastric sleeve is a restrictive procedure only. Unlike a roux-en-y gastric bypass or the duodenal switch, there is no bypass of the small intestines with the gastric sleeve, so all nutrients are absorbed and unlike gastric banding surgeries, no foreign objects are left in the body during the procedure. The patient can lose 60 to 70% of excess weight. The leakage (< 1%) in Sleeve gastrectomy may require another operation or insertion of stent.
Laparoscopic Roux-en-Y Gastric Bypass:
A common form of gastric bypass surgery is the Roux-en-Y gastric bypass. Here, a small stomach pouch (25-30 ml) is created with a stapler device, and connected to the distal small intestine. The upper part of the small intestine is then reattached in a Y-shaped configuration. The patient can lose about 70 to 80% of excess weight and motivated patients can achieve ideal body weight with resolution of their co morbidities. The patients need to know that they have to take vitamins and minerals and iron supplements for a long time (lifelong). Dumping Syndrome, mineral and vitamin deficiencies and marginal ulcer at anastomotic site are few of the complications associated with this procedure.
Laparoscopic Mini Gastric Bypass:
Laparoscopic Mini Gastric Bypass consists of forming a long gastric tube and attaching it 200 cm down to small bowel with single anastomosis. Unlike conventional gastric bypass it has fewer early and long term complications and can achieve weight loss similar to it. The disadvantage is bile reflux which is mentioned but practically very few patients observe it.
Laparoscopic Gastric Plication
Laparoscopic Adjustable Gastric Banded Plication
What is Minimal Access Surgery or Keyhole Surgery?
Minimal Access Surgery is an advanced technique for doing all types of surgical procedures. A thin telescope known as laparoscope and working instruments are inserted through small incisions (3-12mm) in the abdominal wall. The laparoscope is connected to a tiny video camera which projects the inside view of patient's body to a high resolution monitors in the operating room. These incisions are usually covered with surgical glue/ closed with absorbable sutures and after a few weeks are barely visible thus avoiding any follow-up visit for suture removal.
Benefits of Minimal Access Surgery
There are numerous benefits of MAS over Open surgery: Faster recovery, shorter hospital stay, minimal pain, minimal scarring, early resumption of normal activity to name a few.
Who are the candidates for Bariatric/Weight Loss surgery? (Am I a Candidate?)
BMI > 37.5 kg/m2.
BMI > 32.5Kg/m2 & co-morbidities like Hypertension, Diabetes, etc.
Failed supervised medical weight-loss program.
Age between 18 to 65 years.
Committed and motivated.
If you are fit enough to undergo an anesthetic procedure and surgery.
How can I lose weight?
Mild form of obesity can be treated with Diet, Exercise & Medication, however for people who are severely obese after conventional approaches to weight loss such as diet and exercise - have failed, or for patients who have obesity - related complications, surgery may be the best treatment option and life saving at times.
When can I start walking after surgery?
Same day after surgery doctors will require you to get up and move about when you have recovered fully from anesthesia. Patients are asked to walk or stand at the bedside on the night of surgery, take several walks the next day and thereafter.
When do I get discharged from the hospital and resume work?
In a good surgical set-up and excellent team patient may be discharged 2nd day after surgery. Most patients go home after 3 days and some with preop co morbidities may need few more days to settle their co morbidities. You could start your office/desk work after 7 days of surgery.
What about the post surgery scars?
Scars like any other laparoscopic surgery are almost invisible in patients with good healing and also we use absorbable sutures so there is no need of stitch removal. Patients can bath the next day after surgery.
Can I get pregnant after surgery?
Yes, of course but it is strongly advised that pregnancy should be postponed for at least one year after surgery, as by then your body will be fairly stable and nutritional status in place with that you should be able to carry a normal healthy foetus. However, you should consult your surgeon and get evaluated before you plan for pregnancy.
When can I resume my normal sexual activity?
As early as you are pain free and once you resume your normal activity. Vigorous sexual activity should be avoided till 2 months after surgery.
When can I start to drive?
You could start driving from third day of surgery. However, it is recommended that you dont take a long drive as it increases the chances of DVT (Deep Vein Thrombosis).
Will my Diabetes be corrected with weight loss surgery?
It is known that type 2 Diabetes Mellitus is strongly associated with Obesity and with weight loss surgery patients become Euglycaemic and also it depends on duration of diabetes, family history and duration of use of insulin. It is observed that those patients who don't get remission from diabetes have better glycemic control after surgery.