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Morbid Obesity : Surgeries

Weight loss surgery is not a magical cure for morbid obesity that requires no effort on the part of the patient in order to achieve weight reduction and subsequent improved health. In fact, the benefits of the surgery can be overcome if dietary and exercise regimens are not adhered to. Weight loss surgery is best thought of as a major push in the right direction in order to achieve reduced weight and subsequent improved health. It is often the push that is needed to overcome years of physiological and psychological barriers that prevent people from losing and keeping off excess weight. Patients after having lost a significant amount of weight often find it easier to get around and therefore have an easier time starting and staying with a regular exercise regimen.

Categories of Surgeries

The 3 categories of types of surgeries one can undergo for weight loss (not plastic surgery or liposuction as these procedures have no health benefit) are classified as:

  1. Restrictive (Vertical Banded Gastroplasty for example)
  2. Malabsorptive (Jejunoileal Bypass for example)
  3. A combination of both (Roux-en-Y Gastric Bypass for example)

Restrictive procedures reduce the size of the stomach so that the amount of food that can be eaten at one time is greatly reduced. There is no bypassing of any intestine so the food that is eaten will "see" the entire intestinal tract. Restrictive procedures are relatively easier to perform, however the average amount of weight loss is less for restrictive procedures than for malabsorptive procedures or combination procedures. There is also a greater chance of regaining some of the lost weight over a long period of time if dietary regimens are not adhered to (eating high calorie syrups, cookies, sugary substances). The most common restrictive procedure done today is the Vertical Banded Gastroplasty or VBG. This operation is described below. There is a relatively newer restrictive procedure called adjustable banding and this is often done through the laparoscopic approach. It is also known as "lap banding." Both these procedures are purely restrictive, meaning that the upper stomach is made smaller and is the only part of the intestine that is altered.

Malabsorptive procedures do not restrict the size of the stomach to any great extent, however the food is diverted away from most of the intestinal tract and therefore nutrients are absorbed to a much lesser extent than in the normal digestive system, thus achieving weight loss. Pure malabsorptive procedures such as the Jejuno-ileal bypass have higher rates of malnutrition and other complications such as liver failure and are not performed anymore in this country. The malabsorptive procedures that are currently being done are the bilio-pancreatic diversion and the duodenal switch. These procedures do not bypass as much intestine as in the jejuno-ileal bypass and therefore have less malnutrition and liver failure complications however they have the highest rates of these complications out of all the bariatric procedures that are currently being done.

Combination procedures, such as the Roux-en-y gastric bypass, restrict the size of the stomach and at the same time a part of the intestine is bypassed. The amount of intestine bypassed is not to the extent that is done in the malabsorptive procedures so the complication rates of malnutrition are much less. With part of the intestine being bypassed, there is less of a chance of non-adherence to dietary regimens causing regaining of weight, as seen with purely restrictive procedures. This is the advantage of the Roux-en-Y gastric bypass over the purely restrictive procedures. One must also understand that there is a higher complication rate with revision surgery. This means that if one has had a previous VBG and has regained the weight, converting that operation to a Roux-en-Y gastric bypass will have a higher rate of complication than having done the Roux-en-Y the first time. The majority of bariatric surgeons in the U.S. today recommends and performs the Roux-en-Y Gastric Bypass as their weight loss surgery of choice.

(diagrams of types of surgeries)

Jejuno-ileal bypass Gastroplasty
VBG Banding Roux-en-Y

Approaches to Surgeries

All of the above operations can be accomplished thru a number of different approaches. These approaches differ mainly in the size of the incision. They are:

  1. Traditional open surgery
  2. Minimally invasive surgery
    1. Laparoscopic
    2. Minimal incision

In traditional open surgery a large incision is made down the middle of the abdomen to accomplish the operation. The length of the incision is generally 10 â° inches. Most bariatric operations are accomplished through the traditional open technique. As more bariatric surgeons are trained in minimally invasive techniques, traditional open surgery will be done much less commonly.

The Minimal incision approach falls within the category of minimally invasive surgery, as does Laparoscopic surgery. Both approaches minimize the incision length reducing trauma and therefore minimizing recovery time and post-operative pain. In minimal incision bariatric surgery, the same operation is accomplished as with traditional open surgery, however the incision size is greatly reduced, and is on the order of about 4 inches or 10 cm. The total length of the multiple small incisions used for laparoscopy and the length of the single small incision used for minimal incision surgery are about the same, and therefore the amount of pain and recovery time from both approaches are comparable.

Laparoscopic surgery is accomplished by filling the belly up with air, which creates a space between the abdominal organs and the abdominal wall. A camera and thin instruments can then be passed thru the abdominal wall and into this created space, through multiple small incisions, to accomplish the operation. As stated above, the total of all the small incisions is usually about the same length as the one incision made for the minimal incision technique.

Different Approaches
Open Laparoscopic Minimal Incision
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