Obesity is increasing at an alarming rate in the United States, and with morbid obesity comes an increased risk for serious health consequences.

For many patients, bariatric surgery to restrict their caloric intake or absorption is an effective way to reduce this risk. Patients usually face dramatic changes in how they go about their daily lives after this surgery, but a minimally invasive approach can help smooth that transition and even improve their outcomes.

Compared to open surgery, patients who undergo laparoscopic bariatric surgery performed by an experienced surgeon, instead of an open procedure, usually experience:

• Quicker weight loss results
• Shorter hospital stays
• Quicker return to work and other activities
• Less pain and scarring
• Fewer hospital readmissions for complications or additional surgery

Every type of bariatric procedure can now be done laparoscopically, including:

• Gastric bypass (including Roux-en-Y gastric bypass)
• Vertical banded gastroplasty
• Adjustable gastric banding

Laparoscopic bariatric surgeries essentially accomplish what open techniques do. Instead of a long abdominal incision for access, the surgeon makes a few small incisions. These accommodate a small video camera and the surgical instruments. The surgeon then views the procedure on a separate video monitor.

There are two main categories of laparoscopic bariatric surgery:

• Gastric restrictive procedures, which limit the amount of food and calories that can be consumed at one time (laparoscopic vertical banded gastroplasty and adjustable gastric banding are both restrictive procedures)
• Malabsorptive procedures, which limit the absorption of nutrients and calories by forcing food to bypass the duodenum and parts of the small intestine

Roux-en-Y Gastric Bypass

The most common laparoscopic bariatric surgery, Roux-en-Y gastric bypass, combines restriction and malabsorption. It offers certain advantages over banding, such as quicker weight loss.

With this procedure, part of the stomach is basically sealed off with staples. This creates a smaller stomach pouch (15-20 cc), restricting the amount of food the patient can eat at one time.

Next, the small intestine is divided just beyond the duodenum. This distal section of the small intestine is then pulled up and attached to the smaller stomach pouch. As a result, the newly created stomach pouch empties directly into the lower portion of the jejunum, bypassing the upper segments of the small intestine so fewer calories and nutrients are absorbed.

The proximal end of the segment is attached to the Roux limb of the intestine. The intestinal segment may vary in length depending on how much malabsorption is desired.

Patients may be considered candidates for bariatric surgery if either their:

• Body mass index (BMI) equals or is greater than 40 kg/m2 or
• BMI equals or is greater than 35 kg/m2 and they have significant comorbidities, such as type 2 diabetes, cardiopulmonary problems, joint disease, sleep apnea, reflux or other obesity-related conditions.

Patients should also be able to show that diet and exercise have not been effective for long-term weight loss. They must be clearly committed to the postoperative regimen they'll need to adopt. This includes lifelong changes in nutritional habits and ongoing medical visits and testing. It is crucial to make sure patients are fully informed about every aspect of the procedure, so they can make a well-educated decision.

Because bariatric surgery involves such dramatic changes, patients should also be evaluated by a psychiatrist or psychologist before being referred for the procedure.

A laparoscopic approach may be contraindicated if the patient has:

• A large incisional hernia that would need repair simultaneously with the bariatric surgery
• Intraabdominal adhesions that prevent laparoscopic visualization or dissection

As with all operative procedures, be sure to discuss surgical risks with your patients.

Laparoscopic bariatric surgery is technically demanding. Therefore, patients should be referred only to surgeons with substantial experience who perform a high volume of these procedures annually in an inpatient setting. In addition, the surgeon should be experienced with both open and laparoscopic bariatric procedures, in case conversion is required.