Before we look at the three most common procedures, it is important to understand how weight loss surgery promotes weight loss and the modern tools used to perform weight loss surgery. In addition, consideration should be given to how your life as well as your body will change as a result of weight loss surgery.

How does weight loss surgery promote weight loss?

Gastric bypass, gastric banding and sleeve gastrectomy are considered restrictive methods (decreasing food intake). The term "restrictive" sounds negative but there is very little interference with normal absorption of food - weight loss surgery works by reducing food intake, and by reducing the feeling of hunger. The result is a very early sense of fullness, followed by a very profound sense of satisfaction. Even though the portion size may be small, there is no hunger, and no feeling of having been deprived: when truly satisfied, you feel indifferent to even the choicest of foods.  Patients continue to enjoy eating - but they enjoy eating a lot less.

Both Gastric Bypass and Gastric Banding options should be discussed with your surgeon. Every patient is different and in some circumstances a newer procedure called Sleeve Gastrectomy may be ideal. So learn about all three and be prepared to discuss them with your surgeon. Keep in mind that weight loss surgery is recognized by the American College of Surgeons and the American Heart Association, and it is endorsed by the National Institutes of Health and many other prominent medical institutions.

How is weight loss surgery performed?

Laparoscopic surgery or minimally invasive surgery first became available around 1990, when small, light-weight, high-resolution video cameras were developed, allowing surgeons to "see" into the abdomen using a pencil-thin optical telescope, and to project the picture from the video camera on a TV monitor at the head of the operating table. The benefits of the laparoscopic approach come from the very small incisions which are necessary, which cause much less pain, and very little scarring. Patients are able to get up and walk within hours after surgery, can breath easier, and move without discomfort. Bowel activity usually is not affected, as it is with an open incision.

The risks of surgery performed laparoscopically are comparable to those the standard operation – when done by an experienced and skilled laparoscopic surgeon. Some bariatric surgeons have been unable to master the techniques of advanced laparoscopic surgery, and therefore do not offer this method – or may even try to claim that it is less effective – which is certainly not true. The results have been equal to, or better than, those obtained with the open operation, but with major reduction of discomfort, hospital time, and disability, and excellent cosmetic results as an additional benefit.

The latest technique is called single incision laparoscopic surgery or SILS. Typically the band surgery requires five small incisions as noted above. In the SILS procedure, only a single incision around the belly button is needed resulting in minimal discomfort and a barely visible scar compared to traditional laparoscopic gastric band surgery requiring four to five incisions. The incision is then closed with surgical glue, leaving no other scars from instruments or sutures in the abdomen. The procedure requires longer-than-normal laparoscopic instruments to move the band into place around the patient’s stomach and usually takes 2 ½ hours to perform.

Life after weight loss surgery

Bariatric surgery is not a quick fix. It's an ongoing journey toward weight loss through lifestyle changes. After surgery, the difference in your body makes it physically easier to adjust your eating and lifestyle habits. Fortunately, you will not have to go through the process alone. A team of professionals will be there to support your efforts. Positive changes in your body, your weight, and your health will occur, but you will need to be patient through the recovery process.

Gastric Bypass Roux en-Y

The objective of Gastric Bypass, Roux en-Y surgery is to make a very small pouch (thumb-sized) out of the upper stomach, to restrict the amount of food which can be eaten.  That pouch is separated from the rest of the stomach, which is bypassed, by creating a new pathway into the intestines.  This pathway is called a “Roux en-Y” (named after the French surgeon, Dr. Roux, who first described this reconstruction in the 1800's).  The bowel is cut, and reconstructed in a Y configuration, so that two parts of the GI tract can feed into one.

Although the reconstructed "Y" configuration creates some malabsorptive traits, there is very little interference with normal absorption of food. The Gastric Bypass provides an excellent tool for gaining long-term control of weight, without the hunger or craving usually associated with small portions, or with dieting. Weight loss of 80 - 100% of excess body weight is achievable for most patients, and long-term maintenance of weight loss is very successful, but does require adherence to a simple and straightforward behavioral regimen.

Of patients who have undergone laparoscopic gastric bypass surgery; weight loss averages over 80% of excess body weight, one year after surgery, and is usually maintained over 80% for over 5 years. Over 95% of all health problems (co-morbidities) associated with their obesity have been resolved following surgery. Patients enjoy a normal-style diet, and are satisfied to eat smaller portions.

Gastric Banding also known as The LAP-BAND® System or the REALIZE™ Solution

In Gastric Banding a band is placed around the outside of the upper stomach, to create a a small pouch with a narrow outlet. The special device used to accomplish this is made of implantable silicone rubber, and contains an adjustable balloon, which allows us to adjust the function of the band, without re-operation. This device enjoys considerable advantage over the standard gastroplasty:

• • It can be inserted laparoscopically
• • It does not require any opening in the gastrointestinal tract, so infection risk is reduced.
• • There is no staple line to come apart.
• • It is adjustable.

This device has been approved by the Food and Drug Administration (FDA) for use in the United States. Since 1993 , many hundreds of thousands of these devices have been used world wide, primarily overseas. Studies have proven that the adjustable gastric band is safe and effective, at least over a 12 year period when inserted by a skilled laparoscopic surgeon, and that they produce an average weight loss of more than half the excess body weight, for most patients.   If there is a problem with the band, if you can't lose enough weight or can't adjust to the new eating habits, your surgeon may suggest removal of the band. This decision will come after your surgeon consults with you. Generally after gastric band system removal, your stomach will be restored to its original form, and the digestive tract should function normally. Please keep in mind that when the band is removed your weight will likely increase.

This operation may be particularly suited to persons between 200 and 270 lb weight, who need to find a rapid and more convenient solution, and to return to full activity very quickly:  businesspersons, salespersons, and the self-employed.  Although its effects may not be as profound as the gastric bypass, the risk of the procedure appears to be less, and the recovery time is the shortest.

Laparoscopic Sleeve Gastrectomy (LSG)

It is the restrictive part of the more extensive mixed restrictive and malabsorptive operation, gastric bypass. It generates weight loss by restricting the amount of food that can be eaten without any bypass of the intestines or malabsorption. With this procedure, the surgeon removes approximately 85 percent of the stomach laparoscopically so that the stomach takes the shape of a tube or "sleeve." This part of the procedure is not reversible. Unlike the gastric bypass, the outlet valve and the nerves to the stomach remain intact.

Because the modified stomach continues to function normally there are fewer restrictions on the types of foods which patients can consume after surgery. The quantity of food the patient can consume is greatly reduced. This is seen by many patients as being one of the benefits of the laparoscopic sleeve gastrectomy, as is the fact that the removal of the majority of the stomach also results in the virtual elimination of hormones (ghrenlin) produced within the stomach which stimulates hunger.

This procedure is usually performed on superobese or high risk patients with the intention of performing a full gastric bypass Roux en-Y at a later time. The stomach that remains is shaped like a thin sleeve and measures 35-60 cc or less, depending on the preference of the surgeon performing the procedure. The nerves to the stomach and the outlet valve (pylorus) remain intact with the idea of preserving the functions of the stomach while reducing the volume. Note that there is no intestinal bypass or malabsorption with this procedure, only stomach reduction.

Tummy Tuck (Panniculectomy)

Excess skin is a common problem for bariatric patients that have lost hundreds of pounds of excess weight. The excessive weight loss can result in a large apron of excess skin in the abdominal area known as the "panniculus." A large amount of excess skin and subcutaneous tissue (usually six to twelve pounds) can cause a variety of medical problems such as back pain, shoulder pain, neck pain, skin infections (known medically as "intertrigo") and pain in the panniculus itself. Please note that excessive weight loss does not always lead to excess skin or panniculus. If treatment is necessary, patients are required to wait at least a year or two after weight loss surgery to give the skin time to mold itself around the new body tissue.

The appropriate surgical procedure for this condition is known as "panniculectomy". Panniculectomy, if associated with tucking the muscle and contouring the body is called "abdominalplasty" or "tummy tuck". An abdominoplasty includes surgically removing excess skin and fat from the middle and lower abdomen and tightening the muscles of the abdominal wall. An abdominoplasty takes approximately three hours to perform (twice as long as the Roux-en-Y Gastric Bypass).

We have focused on the more popular options available for weight loss surgery, Gastric Bypass, Gastric Banding, and the Sleeve Gastrectomy. The option that is best for your situation can only be determined after careful consultation with your surgeon. Having weight loss surgery is a life-changing decision but has the potential to resolve or improve many serious health issues. The next section explores the benefits and the risks of Weight loss surgery which is an essential part of making an informed decision on whether weight loss surgery is right for you.

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