Selection of patients for bariatric procedures is based on evidence-based guidelines. Patients must have failed dietary therapy and have a body mass index (BMI) greater than 40 kg/m2 without associated medical conditions or a BMI greater than 35 kg/m2 with associated medical condition(s). In addition, practical considerations for the patient to be a candidate for the procedure include psychiatric stability, a motivated attitude, and comprehension of the nature of the procedure and the changes in eating that will follow the procedure.
A team approach is necessary for the optimal care of the patient with morbid obesity. Prior to the initial clinic visit, the patient must provide evidence of a medically supervised diet, counseling and referral from a primary care physician, and completion of a reading assignment to include a comprehensive review of bariatric surgery including the types of procedures, expected results, and possible complications or attendance at a seminar regarding the same. At the initial visit the patient is expected to attend a group session on bariatric surgery and a presentation by the nutritionalist on dietary issues preoperatively and postoperatively. In addition, the patient has individual assessment and counseling with the surgical team and the dietician. Subsequent evaluations may include, as indicated, a full psychological evaluation, specialty medical evaluation, ultrasound of the gallbladder, and a pulmonary evaluation including baseline arterial blood gases. Finally, preoperative assessment by anesthesiology is warranted.
General endotracheal tube anesthesia is required for the procedure. The anesthesiologist should be prepared for the potential of a difficult intubation including the availability of flexible bronchoscopy to assist placement of the endotracheal tube.
The patient is transferred to the operating room table with a lateral transfer device. The patient is placed in the supine position and secured to the operating room table with Velcro leg straps and a spindle sheet for the pelvis. The arms are placed on arm boards, and sometimes the left arm is tucked at the side. Additional securing of the patient to the table with tape may be appropriate. Figure 1a shows the room setup.
Preoperative antibiotics are administered and venous thromboembolism prophylaxis is employed. Hair on the abdominal wall is removed with a clipper. A Foley catheter is placed and an orogastric tube is positioned.
INCISION AND DETAILS OF THE OPERATION
The abdomen is prepared and draped in the standard surgical fashion. A small transverse skin incision is made in the left upper quadrant through which a Veress needle is inserted and pneumoperitoneum is established to a maximum pressure of 15 mm Hg. The Veress needle is withdrawn and a 12-mm port is placed. A 10-mm 30-degree laparoscope is inserted into the abdominal cavity and the peritoneal cavity ...