Chapter 9. Surgical Therapies for Morbid Obesity

• Body mass index (BMI) > 40.
• BMI between 35 and 40 and presence of such comorbid conditions as severe obstructive sleep apnea, pickwickian syndrome, obesity-related cardiomyopathy, degenerative joint disease, diabetes mellitus, hypertension, and hyperlipidemia.
• Failed dietary attempts at weight loss.

Absolute

• Active substance abuse.
• Severe psychiatric disorders.
• Pregnancy.
• Untreated esophagitis.

Relative

• BMI < 35.
• Age younger than 18 years.
• Age older than 60 years.
• Desire to become pregnant within 2 years.

Expected Benefits

• Loss of 50–80% of excess weight.
• Improvement of comorbid factors.

Potential Risks

• Overall mortality < 1%.
• Anastomotic leak (1%).
• Anastomotic stricture (5–10%).
• Wound complications (infection, hernia) more common with open surgery (15–20%) than with laparoscopic procedure (2–5%).
• Systemic complications of major surgery (pneumonia, venous thromboembolism, and cardiovascular events).

• Operating table capable to accommodate the morbidly obese patient.
• Extra-large sequential compression device (SCD) stockings.
• For laparoscopic surgery, video telescopic equipment with two monitors and extra-long instruments (laparoscope, graspers, staplers, ultrasonic dissector, suction/irrigator).
• For gastric bypass procedure, end-to-end anastomosis (EEA) stapler.

• Upper endoscopy if indicated by symptoms (heartburn, regurgitation, dysphagia, epigastric pain, anemia).
• Right upper quadrant ultrasound to rule out cholelithiasis if indicated by symptoms.
• Cardiovascular evaluation.
• Psychiatric evaluation.
• Nutritionist evaluation.

Open Operation

• The patient should be supine with arms abducted and extended.

Laparoscopic Operation

• The patient should be supine with arms abducted and extended.
• Split-leg position is preferable.
• Contact and pressure points should be padded.
• The patient must be well secured to the operating table.

Roux-en-Y Gastric Bypass: Open and Laparoscopic

• Figure 9–1: The typical port placement for a laparoscopic approach.
• Following port placement, the abdomen is explored.
• The jejunum is divided approximately 30–40 cm from the ligament of Treitz and the alimentary (Roux) limb is tagged with Penrose drain.
• Figure 9–2: Creation of a side-to-side stapled enteroenterostomy 100–150 cm from the stapled end of the alimentary limb.
• The mesenteric defect is closed with permanent sutures.
• The omentum is divided with an ultrasonic dissector.
• A Nathanson liver retractor is used to elevate the left lateral segment, exposing the proximal stomach.
• The patient is placed into steep reverse Trendelenburg position.
• Peritoneal attachments between the diaphragm and the cardia at the angle of His are bluntly divided.
• The lesser omentum is incised at the pars flaccida portion and divided up to the proximal lesser curvature with an endoscopic stapler.
• A gastrotomy is made in the body of the stomach with an ultrasonic dissector. This will be closed with an endoscopic stapler after anvil introduction.
• The anvil from a 25-mm EEA stapler is introduced through the 15-mm port site and inserted into the gastrotomy. The anvil tip is brought out through the proximal stomach, near ...