Laparoscopic Bariatric (Obesity) Surgery

Obesity is managed by conservative (diet and exercise), medical and surgical approaches.

The decision of which treatment is best for you depends on factors such as your BMI, waist circumference and also the presence of other medical problems. Usually combinations of the various approaches are used, directed by guidelines such as the NICE guidelines for NHS patients, although the clinicians overall judgment presides. All studies that directly compare surgical with conservative treatments conclude that surgery is superior in providing long term, sustained weight loss.

The focus of this website is the surgical treatment for obesity.

Is Surgery Suitable?

The National Institute for Health and Clinical Excellence (NICE) have produced guidelines on obesity. It stated that those who have a BMI over 40 or a BMI over 35 accompanied by an existing condition which would benefit from weight loss, are suitable for surgery. Ideally you would have tried to lose weight by diet and exercise and can demonstrate to your surgeon that you will be able to persevere with such measures after the surgery. Obesity management is a lifelong process and not a quick fix. It involves preparation for the surgical procedure and also continual cooperation after the surgery to accompany the weight loss process.

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What is Bariatric (Obesity) Surgery

How Surgery Works

The medical term for weight loss surgery is Bariatric or Obesity Surgery. There are various types of operation available for weight loss. Operations generally fall into two categories:

Malabsorptive surgery
Restrictive surgery

Malabsorptive surgery is a process where the anatomy is surgically altered such that food bypasses the areas where it is absorbed the most.

Restrictive surgery is where the stomach is either divided or has a band wrapped around it to make its spaces effectively smaller thus giving a feeling of fullness with less food.

There are short term risks related to all weight loss surgery, but these are far outweighed by the lifetime risks of remaining severely overweight.

Advantages Of Laparoscopic Surgery

Operations are either open – where the abdomen is opened with a large cut or laparoscopic (key-hole surgery). A few procedures can be performed endoscopically, without the need for surgical cuts.
Over 95% of weight loss surgery is performed laparoscopically. The surgeon will use 4-5 small cuts (1 – 2 cms in size) to enter the abdomen through cannulae (narrow tube like instruments). The laparoscope, which is connected to a video camera, is inserted through the small cannula. The entire operation is performed through the small holes, after the abdomen has been filled with gas. The gas is removed after the operation is completed. The small cuts a usually sealed using dissolving stitches and glue.
All laparoscopic weight loss procedures involve:

A full general anaesthetic
4-5 small keyhole surgery cuts in the abdomen
A permanent change to the stomach
A reduced food portion size and reduced hunger between meals
A 1-2 day hospital stay
A commitment to post-operative follow up, involving lifestyle changes & nutritional support

The advantages of the laparoscopic approach is that it usually provides:

Reduced post-operative pain
Shorter hospital stay.
A faster return to work
Lower mortality (death) rate compared to other surgical treatment options.

Laparoscopic Gastric Bypass

What is a Laparoscopic Gastric Bypass?

Gastric Bypass (RNY) is the most common weight loss procedure performed worldwide. It is a well-established procedure that can produce excellent long term results.
Gastric Bypass combines the restriction found with Gastric Band or Sleeve Gastrectomy surgery, with a small element of malabsorption. A small pouch is formed at the top of the stomach. This pouch is then joined to the bowel lower down. Patients find that their portion size is significantly reduced and rarely feel hungry after Gastric Bypass surgery. As well as eating less, you will only absorb part of the calories that you have eaten.

Some patients feel unwell when they eat sweet foods after Gastric Bypass. This feeling is known as 'dumping'. Some people find dumping to be an advantage of Gastric Bypass, particularly if they have difficulty controlling their sweet or chocolate intake.

Am I suitable for a Laparoscopic Gastric Bypass?

Gastric Bypass is particularly suitable for patients with metabolic problems such as Type 2 Diabetes. Food that is eaten misses out, or bypasses the first part of the small bowel after Gastric Bypass. The new connection has a dramatic effect on blood sugar levels after Gastric Bypass surgery. Patients with adult-onset, or Type 2 Diabetes can revert to normal blood sugars within a few days of their surgery. Over 80% of diabetic patients can leave the hospital without the need for insulin after Gastric Bypass surgery. This effect is less likely the longer you have had diabetes and the more insulin you are on.

Although Gastric Bypass is now routinely performed laparoscopically, it is still major surgery. It involves a permanent change in your gut anatomy. There is a quoted 1 in 200 chance of dying and a life-long risk of nutritional problems following Gastric Bypass.

The following animation demonstrates the procedure - The blue liquid represents food, while the yellow liquid represents the body's natural digestive juices. The food only starts to be digested once the two flows of liquid meet.

Risks of Gastric Bypass surgery include bleeding, infection, leakage of bowel content, hernias or twisted bowel. In some patients the new stomach join up can narrow and will need to be stretched. Patients need to take life-long supplements of vitamins, iron and calcium and require regular blood tests to check that they are not running in to problems.

Although weight loss is most dramatic in the first six months after Gastric Bypass surgery, this tails off and there is a tendency for some patients to regain weight after the first three years. The majority of people experience long term success with surgery, although about one in ten fail to maintain their weight loss over the long term.

An alternative form of Gastric Bypass, known as a ‘One Anastomosis Gastric Bypass’ (OAGB) or ‘Mini Gastric Bypass’ is also available. If you wish to consider this option, please discuss this with your surgeon.

Laparoscopic Sleeve Gastrectomy

What is Laparoscopic Sleeve Gastrectomy?

Laparoscopic Sleeve Gastrectomy is a purely restrictive procedure. It involves the permanent removal of about two thirds of the stomach. The outer 'sleeve' of stomach is removed and the edges sealed using staples. The remaining stomach forms a long, narrow tube through which the food can pass. Portion size is reduced, resulting in significant early weight loss. Most patients expect to lose just over half of their excess weight after Laparoscopic Sleeve Gastrectomy.

Laparoscopic Sleeve Gastrectomy was originally designed as a first procedure, to be followed by more radical surgery (duodenal switch). More recently we have found that a lot of patients who have this operation do not require any further surgery.

Am I suitable for Laparoscopic Sleeve Gastrectomy?

Laparoscopic Sleeve Gastrectomy is often recommended in very large patients (BMI over 60) in whom a Laparoscopic Gastric Bypass may be considered too high a risk. There is an estimated 1 in 500 chance of dying following Laparoscopic Sleeve Gastrectomy.

Risks of Sleeve Gastrectomy surgery include bleeding, infection, leakage of stomach content, or strictures. Patients are more prone to acid reflux and a sleeve is not recommended for patients with pre-existing reflux. Patients need to take life-long supplements of multivitamins and iron.

While Laparoscopic Sleeve Gastrectomy can produce good early weight loss, there is a one in four chance of inadequate or late weight regain. Further surgery such as gastric bypass can be planned at a later date in order to gain further sustained weight loss.

Laparoscopic Gastric Band Insertion

What is Laparoscopic Gastric Band Surgery?

Laparoscopic Gastric Banding involves the placement of a constricting silicone band around the top of the stomach, creating a small pouch and a narrow passage into the remainder of the stomach, therefore restricting food intake. The Gastric Band is adjusted to a level where it will slow the passage of solid food. It will have little if no effect on the passage of soft or liquid foods such as sweets or cakes. The Gastric Band is intended to be in place permanently, but can be removed at a later date.

The Gastric Band is carefully placed around the top portion of stomach and secured in position with stitches. An access port is attached to the band and placed under the skin, to allow for adjustments of the band in the future. Most patients are able to return home either the same day, or the next morning.

Band adjustments take place in an outpatient setting and only take a few minutes. Adjustments are tailored to suit individual needs but usually take place from 6 weeks onwards following surgery and then periodically to limit dietary intake and achieve optimal weight loss. If you develop unexpected problems with a gastric band, we may perform an X-ray swallow test to confirm that the band is in the correct position.

Laparoscopic Gastric Band surgery is the safest type of weight loss surgery currently available. There are still risks common to any operation such as bleeding, infection or blood clots. There is around a 1 in 2000 chance of dying from Gastric Band surgery. Risks associated with a gastric band include band slippage, pouch dilatation or band erosion. Approximately 10% of patients may require the band to be repositioned or removed with further surgery.

Am I Suitable For Laparoscopic Gastric Band Surgery?

Results from Laparoscopic Gastric Band surgery are quite variable. The gastric band is best suited to younger, motivated, active patients. It can be suitable in patients with lower BMI (30-35) where their health is affected by significant medical problems that would benefit from weight loss.

While most people do very well, there is no guarantee and some people fail to lose any weight at all. Up to one in four people do not lose as much weight as they would had hoped following Gastric Band surgery. Do not expect the band to physically stop you eating. Food will still get through if you are determined. It is important to learn to work with the Gastric Band, as a partner, to enable optimal weight loss. If the Gastric Band is too tight, you will eventually either stretch the pouch above the band, or increase the amount of soft foods that you eat. Both problems are likely to lead to Gastric Band failure.

A proportion of patients have further surgery to either replace the band or convert to another procedure, such as gastric bypass. The risks of redo surgery are far higher than the first time round and are best avoided. It therefore makes sense that if you feel that you wouldn’t do well with a gastric band, then it may be better to opt for one of the alternatives.

Intra-Gastric Balloon Insertion

What is a Gastric Balloon?

The Gastric Balloon is an inflatable balloon that is positioned within the stomach. The gastric balloon does not require surgery or a general anaesthetic to be placed. Gastric Balloons are not designed to be permanent and usually have to be removed after six to twelve months.

A Gastric Balloon can be placed during a gastroscopy using a mild sedative. The balloon is placed in the stomach and then inflated using up to 500ml of saline fluid. The balloon fills the stomach, reducing the space for food. When used with the appropriate dietary support, people can lose an average of 20kg (three stone). With continued support the weight loss can be maintained after balloon removal.

Am I suitable for Gastric Balloon?

The Gastric Balloon can be useful in people with a lower BMI, particularly where rapid weight loss is required for a particular event. An example may be where weight loss is recommended prior to an orthopaedic operation. It is licensed for use in people BMI 28 and above. The Gastric Balloon can also be used as an initial weight loss aid to prepare patients for a permanent procedure such as Sleeve Gastrectomy or Gastric Bypass.

The Gastric Balloon is the safest weight loss procedure available, but permanent weight loss cannot be guaranteed. Severe motion sickness is common in the first few days after Gastric Balloon insertion. This feeling should settle after a period of rest, but can lead to requests for the Gastric Balloon to be removed prematurely.

If the Gastric Balloon deflates or bursts while in the stomach there is a very rare risk of bowel blockage, which may require emergency surgery. The Gastric Balloon fluid is often coloured with a blue dye so that a leak can be identified before it causes a problem.

Tips for successful weight loss

Eat three regular meals a day
Drink fluids between, not with meals
Stick to textured foods. If you don’t need a knife and fork to eat it, you shouldn’t be having it
Avoid overeating. If you feel uncomfortable after a meal, you have probably eaten too much too quickly
Sit at a table to eat, without distractions such as television
Eat for 20 minutes then stop. You don’t need what you haven’t eaten
Enjoy leaving food on your plate
Attend for regular follow-up, including nurse and dietetic appointments
Join a patient support group
Plan 20 minutes of aerobic exercise 5 times per week. Exercise to a level where you are out of breath, but can still talk in sentences
Contact your local bariatric team should you develop any problems or concerns
Contact your local bariatric team should your weight loss halt at any time. Do not feel a failure, it is important that we know so that we can help
The above points are helpful for long-term success with all types of weight loss surgery. If you are not able to make this commitment, then weight loss surgery may not be right for you.

Expected Weight Loss

It is important to be realistic about the amount of weight you expect to lose following surgery. Patients lose an average of half (50%) of their excess weight after bariatric surgery. If for example you currently weigh 20 stone and your ideal weight is 10 stone, then you may achieve a five stone weight loss. This is an average, some people will lose a lot more than this but some people will lose less. The average initial weight loss after gastric bypass or sleeve gastrectomy is up to 70% of your excess weight (Up to seven stone in the example above). This weight loss is expected over the first nine months after surgery. If you learn to work with a gastric band, there is no reason why you cannot lose as much weight with band surgery as you would with a gastric bypass, but the weight loss will be slow and gradual over two to three years. There is, however, no guarantee that you will lose this amount of weight, particularly with a gastric band. The advantage over dieting alone is that there is a greater chance that the weight will stay off. Unless you are able to maintain a healthy lifestyle, there is a risk of weight regain, particularly after 3-4 years. The degree of weight loss may not seem huge but is enough to produce significant long-term health benefits.

Keys to success following weight loss surgery include:

Following the appropriate changes to your eating habits that have been advised
Relearning the feeling of satisfaction after eating and knowing when to stop
Instead of seeing how much you can eat, try to see how little you can eat to remove hunger
As well as controlling diet it is important to increase activity levels. Regular daily activity is best
Joining a local patient support group and keeping up with the follow-ups that are scheduled with your local bariatric team will all build toward long-term success
If you have difficulties after weight loss surgery, it is important not to give up and do not feel a failure. Often a brief adjustment to a gastric band or lifestyle can bring you back on track.

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Making A Decision

Deciding which procedure is right for you

Deciding which procedure is right for you can be very difficult. It is important to research all procedures carefully. Information should be gleaned from as many sources as possible. It is recommended that you take advantage of online patient forums and local patient support groups, to meet with people who have been through the decision making process.

While the surgeon and team will advise you on what is appropriate for you, it is important that the final decision is your own. Any operation is hard work and certainly not a quick fix. Unless you take responsibility for the whole process, surgery is unlikely to be right for you.

If you are looking for quick results then a bypass or sleeve may be better options. If you just need to lose a couple of stone for a limited period such as to be eligible for a surgical procedure, then a balloon may be a useful option. Gastric bypass is particularly useful in patients with medical problems such as diabetes. Previous abdominal surgery or large hernias, may, however, make bypass more difficult. Patients with severe acid reflux may be advised against a sleeve. Many surgeons will advise that a gastric band will not work in someone with a BMI over 50. This is not true. Significant weight loss is possible with a band, it just takes a lot longer. If the main reason you are overweight is that you are hungry all of the time and have large portions as a consequence, then a gastric band can work for you.

Obesity is a lifelong problem. Surgery is not a cure, but a means of controlling and preventing weight-related medical problems. It is therefore important not to expect a single operative procedure to solve all weight problems without continued support. This may include help with behavioural changes from a nurse specialist or clinical psychologist.

Factors that reduce the chances success of weight loss surgery include patients over the age of 50 and patients with limited mobility, type 2 diabetes or hypothyroidism. However, in these groups, even a modest amount of weight loss can still carry significant health benefits.

My personal view is that a young person of childbearing age may be better off considering gastric band surgery, rather than any of the more radical options. It is easy to adjust, to improve nutritional intake if and when required. As medical advances proceed, the future may bring a non-surgical option for sustained weight loss. The patient at least then has the option to have the band removed, with little long-term consequence.

Below is a list of the most common surgical weight loss procedures to help you with your decision:

Pre Operative Preparation

Patients who are having Laparoscopic Bariatric (Weight Loss) Surgery will be asked to make appropriate changes to their diet and activity levels to have the greatest chance of success. It is important that patients get in to a habit of eating three regular meals a day, avoid snacks and avoid drinking while eating. We ask that patients continue regular exercise of at least 20 minutes, five times a week. It is better to choose exercise that you enjoy and that can be fitted in to your daily routine. We also recommend that all patients attend a local support group to meet patients that have had the type of surgery that is being considered.

Patients who are able to make the above changes are more likely to have a successful long-term result from Laparoscopic Weight Loss Surgery.

Patients will be asked to attend for a pre-operative assessment to ensure that the operation will be as safe as possible. This can sometimes identify medical problems that you may not have been previously aware of. If patients have a history of stomach problems, particularly acid reflux, they may be asked to have a gastroscopy examination as part of the pre-operative assessment. This will be booked as a separate appointment.

We ask our patients to have a strict two-week diet prior to surgery. A very low calorie diet is prescribed for this period, with the aim to reduce the size of the liver. This is often called the 'Liver Shrinking Diet'. We expect patients to lose an average of 5kg over this period, which is a sign that the diet has been adhered to. The liver is immediately above the top part of the stomach involved in most Laparoscopic Weight Loss Surgery. There is a risk of damage to the liver if it has not reduced in size. This can lead to complications that may result in the procedure being abandoned. Patients are normally weighed on the day of surgery to ensure they have completed the diet. If your weight has not reduced, the procedure may then have to be cancelled.

The Operation - Day of Surgery

The procedure will be carried out under a general anaesthetic (except for a Gastric Balloon), which means you will be asleep throughout. The operation will take between 1-2 hrs although you may be away from your room longer than this as you will spend some time in the theatre recovery area following your surgery.

Feelings of sickness are not uncommon after surgery. It is important that you inform the nurse looking after you at an early stage as prolonged vomiting can pull on the internal stitches. Anti-sickness medication can be given which will rapidly ease any feeling of sickness. Pain relief is given in the early post-operative period. Some patients experience pain from trapped wind during this time that is not completely controlled with pain relief medication. Common symptoms include pain behind the breast bone or into the left shoulder. It is important that you inform your nurse as symptoms can be relieved with simple remedies such as peppermint water or getting up and moving about. Most patients experience minimal pain after the first day.

Most patients will be on an ‘Enhanced Recovery’ pathway post-operatively. Part of this pathway involves a structured process of getting out of bed, regular breathing exercises and early reintroduction of drinks. This combination aids recovery and reduces the risk of complications. It is important that you follow the advice given.

Patients are normally able to go home within 24 hours of a Laparoscopic Gastric Band procedure. Patients usually go home between one and two days after Laparoscopic Gastric Bypass or Laparoscopic Sleeve Gastrectomy surgery.

The bariatric team will be in regular contact to ensure that you continue to make good progress over the early post-operative period. If you experience any problems at all while at home, it is important that you speak to a member of the bariatric team straight away for support and advice. If you feel unwell in the first few days, it is often better to return directly to the hospital where you had your surgery, as they will be in the best position to manage any problems.

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