++
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 35 kg/m2 with associated medical condition(s) or a BMI greater than 40 kg/m2 regardless of associated medical conditions. 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.
+++
PREOPERATIVE PREPARATION
++
A team approach is necessary for optimal care of patients with morbid obesity. Prior to the initial clinic visit, patients must provide evidence of a medically supervised diet, counseling and referral from a primary care physician, and attendance at a seminar that includes a comprehensive review of bariatric surgery, including the types of procedures, expected results, and possible complications. Preoperatively, patients undergo a medical and dietary evaluation and must attend nutrition classes to learn about the dietary changes necessary both pre- and postoperatively for long-term success. Additional testing may include a full psychological evaluation, upper endoscopy, a sleep study, and specialty medical evaluation, including cardiac and/or pulmonary assessment. 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.
+++
OPERATIVE PREPARATION
++
Preoperative antibiotics are administered, venous thromboembolism prophylaxis is employed, and an orogastric tube is positioned. Additionally, hair on the abdominal wall may be removed with a clipper, and a Foley catheter may be placed depending on the practice. Then a time-out is performed.
+++
INCISION AND DETAILS OF THE OPERATION
++
The abdomen is prepared and draped in 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 and viscera are inspected to ensure that there is no evidence of port insertion injury. Next, a supraumbilical 10-mm port, a ...