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Why
Laparoscopic Bariatric Surgery?
The goal of bariatric
surgery is to live better, healthier, and longer.
The technically advanced, experienced surgeons
at Bluegrass Bariatrics feel strongly that surgery
for the debilitating, chronic disease of morbid
obesity should be performed in the safest, least
invasive means possible. That is why we perform
all of our bariatric procedures laparoscopically,
a technically challenging minimally invasive method
proven to have less complications than traditional
“open” bariatric surgical procedures.
During the laparoscopic procedure,
a tiny video camera and surgical instruments are
inserted into the abdomen through several very
small incisions. The surgeon performs the entire
procedure via observation through the camera.
The laparoscope, which is connected to the video
camera, provides the surgeon with a magnified,
more precise view of the patient’s abdominal
area.
Patients who undergo laparoscopic
surgery typically experience far fewer complications
than those that undergo open surgery. They report
less pain, fewer side effects, and quicker return
to normal activities and work than with the open
procedures.
We bring experience in
performing hundreds of these procedures exclusively
laparoscopically with minimal complications and
no deaths. We can almost always perform your surgery
laparoscopically (minimally invasively) even if
another bariatric surgeon has told you that you
are not a candidate for laparoscopic bariatric
surgery. You owe it to yourself to seek a second
opinion with Bluegrass Bariatrics before proceeding
with an open surgery known to have increased complications
and longer hospital stays. We have heard all types
of misleading reasons that open or inexperienced
laparoscopic bariatric surgeons give for why you
cannot have your surgery done laparoscopically.
These include such excuses as “you’re
too big”, “you’re too short
or tall”, “they can’t see as
well laparoscopically”, “you have
too much scar tissue”, “you’ve
had a previous open or laparoscopic procedure”
and “we would need to use too much gas to
inflate your abdomen”. Be aware that in
most instances, none of these statements are true
for advanced laparoscopic bariatric surgeons,
and once again, you owe it to yourself to talk
to us before you proceed with an open procedure
based on one of these false assumptions. Previous
open or laparoscopic surgeries such as gallbladder
surgery, C-section, hysterectomy, appendectomy,
splenectomy, and pelvic surgery (such as on the
ovaries, fallopian tubes, or for endometriosis)
are generally NOT contraindications to laparoscopic
bariatric surgery in our hands.
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Post-Operative
Care
In addition to the importance
of an experienced, highly skilled technical surgeon,
is the surgeon’s post-operative care. If
your surgeon is not willing to take full responsibility
for your care after surgery and manage any complications
quickly and decisively, you run the risk of unnecessary
and bad outcomes. For example, if you have bleeding,
your surgeon should address it quickly and appropriately
hopefully avoiding the need for or limiting the
amount of blood transfused. Another example would
be a “leak” – if addressed quickly,
the amount of peritonitis is decreased and the
outcome improved. If your surgeon blames post-operative
problems on medications, anesthesia, or other
issues and does not come in and take care of the
problem, you could suffer unnecessary and potentially
serious complications. This could turn a minor
complication into a major one. Be sure your surgeon
is conscientious, diligent, compassionate, and
accepts responsibility for your care. In general,
nurses in the operating rooms, intensive care
units and on the post-op care floors, as well
as previous patients, can give you this information.
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History
of “Open” Bariatric Surgery
The surgeons at Bluegrass Bariatrics
do not believe in elective open bariatric surgery.
Open bariatric surgery has been around for years,
and has a storied past. Everyone has heard the
horror stories of liver failure, deaths, hernias,
and other serious complications. A few years ago,
very few surgeons were interested in bariatric
surgery. Although generally a lucrative field,
most surgeons shunned this field because of the
high complication rate. Almost every general surgeon
has had to manage the complications of other bariatric
surgeons, including multiply recurrent incisional
hernias, bowel obstructions, reversal of failed
procedures, and chronic pain to name a few. Why
the sudden interest in bariatric surgery? The
answer is multi-fold, but includes factors such
as declining reimbursements and managed care,
the obesity epidemic, and the rise of laparoscopy.
Laparoscopy is clearly the safest, least invasive
method so why aren’t all surgeons doing
it this way? Unfortunately, it is very technically
demanding and beyond the skills of the vast majority
of general surgeons, especially those who trained
without being exposed to advanced laparoscopy.
Options for interested surgeons are limited –
most attend a weekend course with a cadaver lab
and try and find an experienced surgeon to proctor
their first few cases. Fellowships are available,
but this would require a surgeon leave his practice
for at least a year to return to training, an
option rarely chosen by most surgeons because
(1) they are loathe to leave the practice they
have spent time building, (2) they have to take
a serious reduction in income, (3) it is hard
work with long hours, and (4) it is difficult
for a surgeon in practice to return to a role
as resident with limited authority. This has been
discussed at American Society of Bariatric Surgery
meetings, as the need is well recognized. In any
event, if your surgeon offers a laparoscopic approach,
be sure to find out how he or she was trained.
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If it is
better, why don’t all surgeons perform the
procedures laparoscopically?
If your surgeon is mostly or
completely an open bariatric surgeon, why doesn’t
he just refer you to an experienced laparoscopic
bariatric surgeon? In a perfect world, this would
be true, but surgeons cannot give up their livelihood.
Some might even rationalize why they feel an open
procedure is better for you, ignoring the published
data in respected medical journals.
For all the above reasons,
there are only a few centers in the country today
that can offer exclusive laparoscopic bariatric
surgery within a comprehensive program. We are
proud to offer this type of bariatric surgical
care in the central Kentucky area.
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What can
the experience with laparoscopic gallbladder surgery
tell us?
In 1989, the first laparoscopic
gallbladder surgery was performed in the United
States by a private practice general surgeon in
Georgia. This rapidly evolved into the treatment
of choice throughout the country and the world
for gallbladder disease because of its minimally
invasive nature with less pain, shorter recovery
times, and decreased complications. Initially,
obese patients were not done laparoscopically
because of concern with exposure and visualization
with the laparoscope. Now almost all gallbladder
surgery is done laparoscopically if possible,
and almost all surgeons agree that they prefer
this method for obese patients because of better
visualization! In other words, once surgeons gained
more experience with the laparoscope it became
the method of choice for removing the gallbladder
in all patients whether or not the patient is
obese, or has had previous surgery, etc. The same
principles apply to laparoscopic bariatric surgery
in the sense that it is relatively new and inexperienced
surgeons will prefer open methods as much as initially
inexperienced surgeons preferred open gallbladder
surgery.
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How much
does the procedure cost?
Whether your surgery is covered
by insurance or you are paying out of pocket,
you want the best laparoscopic bariatric surgeon(s)
operating within the best comprehensive program.
We feel strongly that the team of Bluegrass Bariatrics
and The Bariatric Center at Georgetown Community
Hospital offers a comprehensive bariatric surgical
program that rivals any in the world. Our surgeons’
training, experience and outcomes are impeccable
and Georgetown’s program receives rave reviews
by patients and in publications such as ObesityHelp
Magazine (top five in the nation in four categories.
See July 2003 issue for details.). With few quality
programs being available, we are also proud to
say patients are traveling great distances to
have their surgery done at our Center. Nevertheless,
we are able to keep our prices low, well below
national average, because our practice is located
within a community hospital setting in an area
of the country that has a low cost of living compared
to larger metropolitan cities such as New York
or San Diego.
The all inclusive fee for laparoscopic
gastric bypass is $23,203.25 with Advance payment. This amount includes:
a pre-operative evaluation by a nurse practitioner
and your surgeon (who will personally manage your
post-operative care), seminars, support groups,
dietary and exercise counseling, anesthesia, hospital
stay, surgeon’s fees, and one year of post-operative
follow up. Pre-Op laboratory testing, chest X-ray,
and EKG and medical evaluation (if needed) are
also included in this fee, but are usually covered
by insurance.
The all inclusive fee for the LAP-BAND® Adjustable Gastric Banding System is $17,939.25 with Advance payment and includes the banding device,
free lifetime adjustments (usually $250 each),
in addition to all the other inclusions mentioned
above for laparoscopic gastric bypass.
Prices include the hospital, surgeons and anesthesia fees, and a $250
program fee. The program fee is due at the time of your initial surgeon's
consultation. These prices do not cover the cost of complications.
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What
types of laparoscopic bariatric surgery do we
perform?
We offer both the laparoscopic
Roux-en-Y gastric bypass and the only FDA approved
adjustable silicone LAP-BAND® Adjustable Gastric Banding System. During your consultation,
we will personally meet with you to discuss your
options, the risks and complications involved,
realistic expectations and prepare you for surgery.
Whatever method you decide is best for you, you
can rest assure you are in experienced hands at
Bluegrass Bariatric Surgical Associates.
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What
is the LAP-BAND® System?
 The
LAP-BAND® Adjustable Gastric Banding System is an adjustable silicone banding device
that is fastened around the upper end of the stomach
to create a smaller stomach reservoir (pouch).
We use the only United States Food & Drug
Administration (FDA) approved band on the market
today – the LAP-BAND® Adjustable Gastric Band made by the Inamed
Corporation. In this procedure, the surgeon makes
several small incisions through which the laparoscopic
instruments are inserted to place and fasten the
LAP-BAND® Adjustable Gastric Band around the upper portion of the stomach.
There is a small port attached to the band that
is secured to the underlying abdominal muscle
that is easily accessible for adjustments. Adjustments
take only a few minutes and are performed in the
office without sedation. Most people need only
one or two adjustments after surgery, but depending
upon their eating habits and the amount of weight
lost they may require more. This procedure functionally
restricts the size of the stomach to about 2-oz
and is considered a strictly gastric restrictive
procedure, although some suggest when it’s
appropriately adjusted, it does decrease one’s
appetite, as well. The difference between this
and other restrictive bariatric procedures is
that the restrictive effect can be adjusted. This
is currently the only bariatric procedure that
can be adjusted without surgery in the post-operative
period. Weight loss occurs by restricted intake
– the smaller stomach pouch creates the
sensation of fullness earlier (satiety), thereby
decreasing the desire for food and limiting the
volume of food one is capable of consuming at
one time. There is no division or bypass of the
stomach in this procedure. Of note, with this
limit intake, if you eat too much at one meal,
you may feel discomfort and may even vomit until
you learn the capacity of your “new”
stomach. It generally carries the least complications
of the current bariatric procedures. Weight loss
is more gradual than other bariatric procedures
and eating high calorie liquid or soft foods can
circumvent the procedure. There is no malabsorption
of nutrients, no “leaks”, and no “dumping”
(see below).
The usual hospital stay is less
than 23 hours (outpatient or same day surgery).
Weight loss with the LAP-BAND® Adjustable Gastric Banding System is reported at 35-68%
of excess body weight. Health problems associated
with excess weight are also usually benefited.
Lastly, the LAP-BAND® Adjustable Gastric Band is easily reversible/removed
and can be laparoscopically converted to a Roux-en-Y
gastric bypass if needed or desired.
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Advantages of the
LAP-BAND® System
- No
cutting of the stomach
- Quick
operative time
- Outpatient
surgery
- The
only adjustable bariatric procedure available
today
- Proven
to be the safest bariatric procedure available
today
- Reversible
- Weight
loss equivalent to gastric bypass after 2 –
3 years in compliant patients
- Less
chance of protein or vitamin deficiency, and
hair loss
- Can be converted laparoscopically
to a gastric bypass
- Weight
loss of 35% - 65% excess body weight at 2 –
3 years
Disadvantages/Risks of the LAP-BAND® System
- Slower, more gradual weight
loss than the gastric bypass
- 1- 2% risk of slip requiring
laparoscopic revision
- Less than 1% risk of infection
which would require removal of the port and/or
band
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What
is the Laparoscopic Roux-en-Y Gastric Bypass?
 This
procedure is the most commonly performed bariatric
surgery in the nation today. The laparoscopic
Roux-en-Y gastric bypass procedure involves making
several small incisions through which the surgeon
inserts laparoscopic instruments to perform the
surgery. The procedure is designed to make a small
reservoir (pouch) for food at the upper end of
your stomach with a capacity of about 2 oz. This
pouch is connected to the upper small intestine
by a new small anastomosis (outlet) of about ½
inch (1.2 cm) in diameter. The ingested food thereby
bypasses the majority of your stomach, which remains
alive and undisturbed, but functional otherwise.
In other words, the majority of your stomach does
not have food passing through. It often is associated
with a permanent decrease in appetite. The nature
and purpose of this operation is to functionally
limit the amount of food or liquid intake at any
given time. There is a small component of malabsorption,
at least initially. This procedure is often associated
with fairly rapid weight loss initially, which
stabilizes over time to a weight that is healthy
for you.
Advantages of the
Laparoscopic Roux-en-Y Gastric Bypass
- Weight
loss averages 60 –70% excess body weight
within one year after surgery
- Proven
long term effectiveness – studies show
that after 10 – 14 years, patients still
maintain 50 – 60 % excess body weight
loss
- Studies
show that 90% of obesity-related medical problems
such as hypertension, sleep apnea, heartburn
(gastroesophageal reflux disease/GERD), adult-onset
diabetes, cardiac function, and depression to
name a few, improve or are completely resolved
- If
performed laparoscopically, the gastric bypass
IS REVERSIBLE laparoscopically
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Disadvantages/Risks
of the Roux-en-Y Gastric Bypass
- See
tab on this website for consent form for Roux-en-Y
Gastric Bypass for more details
- Potential
for protein, vitamin, and mineral deficiency
in non-compliant patients
- Commitment
to the program for optimal results
- “Dumping”
- a symptom complex that can involve sweating,
flushing, diarrhea, nausea, or vomiting, pain
that occurs after eating foods high in fat or
sugar content
- Stretching
of the stomach pouch or outlet over time secondary
to overeating
- Decreased
imaging capabilities of the bypassed stomach,
duodenum, and segments of the small bowel
- Strictures
(narrowing) of the outlet requiring Endoscopic
dilatation
- “Leak”
(1%) which if untreated, can lead to severe
peritonitis. If addressed appropriately and
early, a leak is usually well controlled with
good outcomes
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Patient Consent Forms
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