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INDICATIONS

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is indicated for patients who meet the 1991 NIH Consensus criteria for bariatric surgery. These indications include a body mass index (BMI) of 40 kg/m2 or greater or 35 kg/m2 or greater and the presence of serious obesity-related comorbidities. Additionally, patients must have failed attempts at nonsurgical weight loss such as supervised medical weight loss programs, behavioral therapy, or pharmacologic therapy. Comorbidities that are frequently associated with morbid obesity (and improve or resolve after gastric bypass) include obstructive sleep apnea, obesity hypoventilation syndrome, hypertension, diabetes, hyperlipidemia, degenerative joint disease, and gastroesophageal reflux disease. Other obesity-related comorbidities include venous stasis disease, migraine headaches, pseudotumor cerebri, asthma, infertility or menstrual problems, stress urinary incontinence, gout, and skin infections related to a pannus or skin folds.

PREOPERATIVE PREPARATION

Bariatric surgery patients require an extensive preoperative evaluation to determine their anesthetic risk, to define the severity of known comorbidities, and to identify occult comorbid conditions such as sleep apnea, obesity hypoventilation syndrome, and coronary artery disease. This evaluation requires a multidisciplinary approach. The bariatric team should include dieticians, psychologists, and medical subspecialists who can optimize the patient’s cardiovascular, pulmonary, and endocrine status prior to surgery. Patients with active substance abuse problems or uncontrolled psychiatric disorders are not candidates for bariatric surgery. Strong family and social support for the patient is important to achieving a successful outcome.

Patients who are preparing for bariatric surgery must be fully informed about all of the available surgical options. The choice of laparoscopic bariatric operations today include laparoscopic adjustable gastric banding, sleeve gastrectomy, gastric bypass, or a malabsorptive procedure such as biliopancreatic diversion (BPD) or BPD with duodenal switch. The risks and benefits of LRYGB should be discussed in detail with the patient and put into context with the other available bariatric procedures and other major laparoscopic operations performed today.

ANESTHESIA

Laparoscopic RYGB requires a general anesthetic. The anesthesiologist must be prepared for a difficult airway in this patient population. The surgeon should be available during induction, intubation, and extubation should a surgical airway become necessary. Patients with sleep apnea and obesity hypoventilation syndrome are at particularly high risk for airway problems and should be continued on their continuous positive airway pressure (CPAP) devices postoperatively in the hospital. Antiemetics should be started in the operating room during the case and continued as needed postoperatively. Pain control is achieved with narcotic patient-controlled anesthesia for 1 or 2 days postoperatively and transitioned to oral pain medication in elixir form prior to discharge.

POSITION

The patient is placed supine on the operating table with legs together and arms abducted. The weight limit for the operating room table should be confirmed with the manufacturer and should be sufficient for bariatric patients. A padded footboard is placed on the foot of the bed, and the ...

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