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General Surgery
Morbid Obesity and Its Surgical Treatment
Built from Maingot's Abdominal Operations
What’s inside
9 sections · 184 slides
Overview
- What this topic covers
Obesity as a disease
How obesity is measured, how common it is, and what it does to health
- Body mass index and what it measures
- Scale of the obesity problem
- Spread of obesity to Asia and Africa
- Body mass index categories of obesity
- Severe obesity and the age of the guidelines
- Obesity as a disease rather than a habit
- Cost of obesity and the insurance response
- Comorbid disease as the main threat
- Medical diseases associated with obesity
- Neurologic, metabolic and neoplastic disease in obesity
- How obesity shortens life
- Severe obesity in the United States by age and sex
- Reading the age and sex table
- Cancer risk and why patients seek surgery
- Causes of obesity under investigation
- Fat distribution and the gut's role in glucose control
Medical therapy, selection and preparation
Why diets fail, who qualifies for surgery, and how patients are prepared
- Role of diet, exercise and lifestyle change
- Patients who have never dieted
- Surgery as one part of treatment
- What makes bariatric surgery work long term
- Criteria for offering bariatric surgery
- How insurance shapes the choice of operation
- Access to bariatric surgery
- Two areas of preoperative preparation
- Support networks and the family
Choosing between the operations
Restriction, malabsorption, and which patient suits which procedure
- Bariatric operations grouped by mechanism
- Risk and weight loss across the four operations
- Selecting patients for the adjustable band
- Weight limits and the dieter's mentality
- Selecting patients for gastric bypass
- Why gastric bypass is the commonest operation
- Diabetes and reflux as reasons to choose bypass
- Contraindications and the laparoscopic advantage
- Selecting patients for sleeve gastrectomy
- Cover, candidates and the origin of the sleeve
- Concerns about the sleeve
- Selecting patients for duodenal switch
- Who is offered a duodenal switch
Adjustable gastric banding
An inflatable ring around the top of the stomach, tightened in clinic
- What the adjustable gastric band is
- Preparation and getting into the abdomen
- Port positions for adjustable gastric banding
- Dissection at the angle of His and pars flaccida
- Grasper passed behind the stomach
- Band pulled into place behind the stomach
- Buckling the band into its ring
- Fundal imbrication sutures over the band
- Securing the reservoir to the fascia
- Priming the band, then discharge and diet
- Adjusting the band
- Excess weight loss after banding and gastric bypass
- Reading the curves and what predicts success
- Weight loss and diabetes after banding
- Complications of gastric banding
- Prolapse and slippage
- Band prolapse from suspicion to treatment
- Prolapsed gastric band on plain film and contrast study
- Treating band prolapse and erosion
- Oesophageal dilation
- Port, tubing and overfilling problems
- Poor weight loss and nutrition after banding
Sleeve gastrectomy
Turning the stomach into a narrow tube by removing its greater curvature
- What sleeve gastrectomy is
- Port placement for sleeve gastrectomy
- Dividing the greater curvature vessels
- Choosing the bougie size
- Stapling the stomach alongside the bougie
- Avoiding a leak at the top of the sleeve
- The completed gastric sleeve
- Hospital stay and diet after sleeve gastrectomy
- Follow-up and vitamins after the sleeve
- Weight loss and the unanswered question
- The lesson of vertical banded gastroplasty
- Death rate, complications and leaks after the sleeve
- Narrowing and nutrition after the sleeve
Roux-en-Y gastric bypass
A small pouch joined to a limb of jejunum: the most performed operation
- Steps of laparoscopic Roux-en-Y gastric bypass
- Positioning for gastric bypass
- Arms, antibiotics and skin preparation
- Preventing clots in the veins
- Vena cava filters and the state of the evidence
- Entering the abdomen in the severely obese
- Port positions for Roux-en-Y gastric bypass
- Adjusting the ports during the operation
- Retracting the liver and finding the ligament of Treitz
- Stapling the proximal jejunum
- Dividing the mesentery of the Roux limb
- Penrose drain sewn to the end of the Roux limb
- The two limbs and how long the Roux limb should be
- Stapling the enteroenterostomy
- Closing the stapler defect of the enteroenterostomy
- Closing the mesenteric defect below the join
- Retrocolic versus antecolic Roux limb
- Passing the Roux limb through the mesentery
- When the Roux limb will not pass
- First stapler firing across the lesser curvature
- Stapling upward to complete the gastric pouch
- Suture line approximating Roux limb to gastric pouch
- Stapler placement for the gastrojejunostomy
- Closing and testing the anastomosis
- Linear versus circular stapler
- Triple stitch securing the Roux limb and mesentery
- Finishing the operation
- When an open operation is needed
- Incision, exposure and how the open operation differs
- Drains, oversewing and gastrostomy
- Fluids and early walking after gastric bypass
- Feeding, pain and wound care
- Oxygen and sleep apnoea after surgery
- Discharge and follow-up visits
- What the later follow-up visits cover
- Weight loss after gastric bypass
- Rise in gastric bypass operations performed each year
- Why the numbers rose and what it did to the results
- Effect of gastric bypass on obesity-related disease
- Reading the comorbidity results
- Diabetes after gastric bypass
- Gallstones after rapid weight loss
- Removing the gallbladder at the same operation
- Recommendations on the gallbladder and on reflux
- Death rate after gastric bypass
- Bariatric surgery outcomes in a national quality database
- Morbidity and complications during the operation
- Recognising an anastomotic leak
- How a leak presents and how it is treated
- Vomiting in the first week
- Distended distal stomach on computed tomography
- Internal hernia after gastric bypass
- Swirling mesentery on computed tomography
- Diagnosing and reducing an internal hernia
- Narrowing of the gastrojejunostomy
- Marginal ulcer and its causes
- Diagnosing and treating marginal ulcer
- When acid washes back onto the anastomosis
- Why nutrients are missed after bypass
- Other deficiencies to watch
- Supplements after gastric bypass
Biliopancreatic diversion and duodenal switch
The malabsorptive operations: most weight loss, most complications
- Origins of the malabsorptive operations
- Who these operations suit
- Port placement for laparoscopic duodenal switch
- How biliopancreatic diversion is built
- Completed biliopancreatic diversion
- The lesson of the common channel
- How the duodenal switch differs
- Sleeve gastrectomy component of the duodenal switch
- Completed duodenal switch
- Early care and diarrhoea after the switch
- Nutrition and supplements after the switch
- Follow-up after duodenal switch
- Weight loss after duodenal switch
- Complications after duodenal switch
- Vitamin deficiency and protein malnutrition
Revisional surgery and special situations
Reoperation, pregnancy, age and weight limits, and endoscopic approaches
- Principles of revisional surgery
- Two reasons for revision
- Lessons from abandoned operations
- Revising vertical banded gastroplasty and the band
- Revising gastric bypass
- Why narrowing the anastomosis does not work
- The verdict on revisional surgery
- Pregnancy after bariatric surgery
- Bariatric surgery in adolescents
- Bariatric surgery in older patients
- Upper weight limits and the logistics of extreme weight
- Endoscopic approaches to weight loss
- Key points: the disease
- Key points: choosing the operation
- Key points: staying safe after surgery
- Key points: what decides long-term success
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- Maingot's Abdominal Operations, 12th Edition