Bariatric Surgeries

Types Of Surgeries

Sleeve Gastrectomy - Banded and Conventional

What Is It?

The vertical sleeve gastrectomy, or sleeve gastrectomy, is a type of restrictive weight loss surgery. It causes weight loss by restricting the amount of food that a person can consume before feeling full.

How is it performed?

Conventional Sleeve Gastrectomy is a surgical procedure that can be performed by minimally invasive surgery(Laparoscopically or robotically). The procedure reduces the size of the stomach to about 10% of its original volume and results in a limited capacity of food intake. In sleeve gastrectomy, the left side of the stomach is surgically removed by cutting and stapling. This results in a new stomach which is roughly the size and shape of a banana.

Who can undergo this procedure?

The surgery is typically performed on patients who are too heavy to have other types of weight loss surgeries with the expectation that a second surgery will be performed once weight has been lost, or on individuals who do not suffer from severe co morbidities and are young.

Advantages

  • It does not require disconnecting or reconnecting the intestines
  • It is technically a simpler operation than gastric bypass
  • It may be used as the first stage of a 2-stage operation.
  • The operation eliminates the portion of stomach (fundus) that produces the hormone ghrelin which stimulates hunger.
  • Vitamin and mineral supplementation maybe needed for a shorter duration as compared to gastric bypass.

Disadvantages

  • Possibility of weight gain after a few years due to stretching of stomach muscles.
  • Possible late dilatation of stomach pouch
  • Leaks from the staple line of the newly formed stomach (1 in 1000 people)

What is a Banded Sleeve Gastrectomy?

A silastic (GaBP) ring of 7.5 cm diameter is wrapped around the upper part of the sleeve. Adding a silastic band to sleeve gastrectomy increases the success rate by preventing gastric tube dilatation. This allows in maintenance of weight loss in the long term.

Sleeve Gastrectomy Video

Roux-en-Y Gastric Bypass – Banded and Conventional

What Is It?

This procedure has a restrictive as well as a malabsorptive effect. Physically, it restricts food intake; portions sizes after the RNYGB are much reduced with an early feeling of fullness. Over-eating may then cause abdominal discomfort and vomiting. While the majority of the reduction in a patient’s calorie intake is attributable to the restriction, initially there is also an element of malabsorption of fat.

RNYGB also reduces a patient’s appetite. The mechanism by which this occurs is not fully understood, but is related to a change in the normal gut hormonal patterns. Bypassing the first part of a patient’s small intestine affects the production of hormones that control appetite. After RNYGB most patients feel far less hungry, often forgetting to eat. Bypass surgery also affects the hormones that control blood sugar and consequently many diabetic patients become non-diabetic soon after surgery.

How is it performed?

Conventional Roux-en-Y Gastric Bypass (RYGB) is a surgical procedure that can be performed by a minimally invasive surgical method. The volume of the stomach pouch after RYGB is between 30 and 50 ml. The alimentary limb in RYGB is 150-200 cm long, the biliopancreatic limb consists of the 50 cm of small intestine.

Who can undergo this procedure?

  • This operation is ideally suited for patients with Diabetes Mellitus, Hypertension and other obesity – related diseases
  • Operation for sweet eaters
  • Operation for patients with heartburn (GERD/ acidity)

Advantages

  • It is a very successful operation for patients who failed restrictive procedures like balloon, banding and sleeve gastrectomies , causing 50-70 % excess weight loss.
  • It has been found to have a 90-100% remission rate for Diabetes Mellitus for upto 5-15 years after surgery.
  • It is a reversible procedure unlike the sleeve gastrectomy.

Disadvantages

  • Frequent passage of stools.
  • Life-time vitamin and mineral supplements needed after surgery.
  • Conventional upper gastroscopy of duodenum and remnant stomach is not possible.

What is a Banded Roux-en-Y Gastric Bypass?

In this procedure, a GaBP Ring Autolock™ is added above the joint between the stomach and intestine. Like the Banded Sleeve Gastrectomy, this helps in maintenance of weight loss in the long term.

Gastric Bypass Video

Mini Gastric Bypass / Single Anastomosis Gastric Bypass

MGB is very successful (50-70% excess weight loss) as a primary weight loss procedure, especially in type II DM. It can be used on patients who have failed previous restrictive procedures, sweet eaters, and patients with heartburn. It has a lower complication rate than RNYGB, and is also completely reversible. In addition, it can also be converted to a RNYGB or a VSG at a later stage if required.

What is it?

The mini gastric bypass is also a restrictive and malabsorptive procedure that reduces food intake and reduces the absorption of nutrients from the food. Absorption of nutrients is limited because part of the intestines is bypassed and not used.

How is it performed?

A stomach sleeve is created and separated from the rest of the stomach which is retained in the body(like the RNYGB). The volume of the stomach sleeve after MGB is between 70-90 ml. The small intestine is anastomosed in continuity without disconnecting it (unlike in RNYGB) to the newly created stomach sleeve.

Advantages

  • Very successful (50-70% of excess weight loss) as a primary weight loss procedure especially in type II DM
  • Operation for patients who failed restrictive procedures like balloon, banding and sleeve gastrectomies
  • Completely reversible surgery if done as a first procedure and also convertible to RNYGB or LSG at a later stage if required

Disadvantages

  • Conventional upper gastroscopy of duodenum and remnant stomach is not possible
  • Life long supplementation of fat soluble vitamins is usually required
  • Increased risk of marginal ulceration and biliary gastritis

LAPAROSCOPIC SLEEVE GASTRECTOMY/DUODENAL JEJUNAL BYPASS


This is a new procedure, specifically designed for patients with Diabetes Mellitus with or without obesity.

This combines the restrictive effect of a vertical sleeve gastrectomy, and also the malabsorptive effect of upper small intestinal bypass, thus leading to weight reduction.


In addition, it induces a variety of intestinal hormonal changes, all of which lead to lowering of blood sugar levels and improved insulin secretion, thus RESOLVING TYPE II DIABETES MELLITUS EVEN IN PATIENTS WHO ARE NOT OBESE.

The advantage of this procedure is that the chances of frequent stools and esophageal reflux are less. Also, a single anastomosis is made, which can be examined via endoscopy.

It is a partially reversible procedure, which works to its advantage in selecting this surgery especially for resolution of type II diabetes mellitus.

Revision Bariatric Surgery

What is it?

Revision Bariatric Surgery is performed to alter or repair one of the many types of weight loss surgery for the treatment of morbid obesity. The two currently popular procedures, Roux-en-Y gastric bypass and Mini Gastric Bypass, while successful, also require occasional revision. In fact the revision rate for the Gastric Banding Surgery is more than 10% during the first two years for either device-related problems or unsatisfactory weight loss. Likewise, the revision rate for gastric bypass is roughly 5-10% after 5 years for either troublesome complications, (e.g., ulcer, etc.) or for unsatisfactory weight loss.

The sleeve gastrectomy, though technically an irreversible procedure, can be revised to a roux-en-y gastric bypass, mini gastric bypass, or a duodenal-jejunal bypass, depending on the indication, anatomy and various patient-related factors.

Who requires a revision surgery?

If you have any of the following conditions, you are a candidate for revision bariatric surgery:

  • Excessive weight loss
  • Inability to eat adequate amounts of food
  • Complications of previous surgery
  • Excessive nausea and vomiting
  • Markedly increased frequency of loose stools, disrupting daily activities
  • Dumping syndrome
  • Marginal ulceration
  • Malignancy

Revision of Complications of Bariatric Surgery

What are the complications associated with bariatric surgery?

Risks are usually categorized as immediate risks which include bleeding, Deep Vein Thrombosis, injury to neighboring organs (like oesophagus and spleen), shoulder pain and delayed risks, such as Pneumonia, Abdominal Infections and Pulmonary Embolism. These risks are common to all abdominal laparoscopic surgeries.

The risks associated specifically with bariatric surgery are chest pain, abdominal hernia, constipation or diarrhea, stoma obstruction, stretching of the stomach and reoperation for various reasons.

Can these be controlled?

Majority of complications are minor, and may prolong in-hospital stay by a day or two. These are usually treated with medications.
Some complications, however, may have to be corrected surgically. These include staple line leaks, injury to surrounding organs, stomal obstruction, and gall stone formation. Hence, bariatric surgeries are best performed in a quaternary care centre, with 24 hour access to all possible medical facilities.

Robotic Bariatric Surgery

What is robotic surgery?

Robotic surgery (or robot-assisted surgery) involves the use of robotic systems to aid in surgical procedures. Some of its major benefits over traditional (open) and laparoscopic surgeries include:

  • Greater surgical precision
  • Increased range of motion
  • Improved dexterity
  • Better visualisation

For the patient, this translates to:

  • Shorter hospital stay
  • Less pain
  • Lower risk of infection
  • Less blood loss
  • Faster recovery
  • Quicker return to daily activities

Can bariatric surgery be performed robotically?

More and more world- class centers all over the world are performing all types of bariatric surgeries by the robot-assisted technique.
This technique, unlike laparoscopic surgery, can be used in high-risk obese patients with difficult anatomy without compromising the surgical performance and outcomes. Robotic bariatrics is highly advantageous to give better results in the super obese patient (whose BMI > 50 kg/m2) as the robotic arms negate the abdominal torque effect. These arms actually lift the heavier than normal abdominal wall of the patient against gravity allowing more space for the surgeon to use his instruments inside the abdominal cavity, thus allowing faster surgery, less post operative pain, faster tissue healing and an ‘ early recovery’.

In addition, specifically for revision bariatric surgeries, and also for reversal procedures, robot – assisted technique is particularly advantageous. This is due to better vision of the altered anatomy, and greater precision in handling previously operated upon scarred tissues. This minimizes trauma to tissues, thus leading a safer surgery.