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Surgery Types
Laparoscopy-A Surgery Option for a New Era
Until recently, surgery was the most traditional of medical using
techniques and instruments developed more than a century ago. But now
patients have a new choice. Laparoscopy--a minimally invasive approach
to surgery of the abdomen, accomplishes traditional surgical goals
with less pain, faster recovery and happier patients.
The surgical expertise of the doctors at the Bariatric Institute of
Wisconsin has enabled hundreds of patients to achieve full recovery
and get back on their feet in a hurry.
Sometimes known as "keyhole" or "pinhole" surgery, laparoscopy
typically involves five to six incisions of five to 10
millimeters—just large enough to admit the passage of a tiny video
camera and precision- crafted surgical instruments. Without the trauma
of a long incision, both pain and healing time are greatly reduced.
Related benefits of laparoscopic surgery include less need for
postoperative pain medication because large incisions are not made,
and fewer pulmonary or gastro-intestinal complications occur. Most
patients can rebuild strength and return to a normal life in days
rather than weeks.
All of the BIW doctors perform surgery laparoscopically, and were one
of the first teams of physicians in Wisconsin to develop a minimally
invasive bariatric program.
Bariatric surgery changes how much you can eat and how
you absorb food.
How We Digest Food
After you swallow food, your digestive tract breaks it down and
absorbs it.
The digestive track includes the esophagus and stomach, as well as the
small and large intestines. Chewed food passes down your esophagus and
then through the stomach. The stomach stores and partially digests
food and slowly sends it to the small intestine where it is further
digested and absorbed. Enzymes and chemicals help break food down and
some fluids are also absorbed.
The small intestine has three sections called the duodenum, the
jejunum and the ileum.
The majority of fluids the body intakes are absorbed in the large
intestine. Waste products are also concentrated here and passed
through the rectum as stool.
During digestion, the liver, gallbladder and pancreas provide
enzymes and chemicals. Overall, the body turns food into energy.
Excess energy, however, is stored in your body as fat. The more fat
your body carries, the more health risks you'll encounter. During
bariatric surgery, the stomach's size is reduced so you can eat only
small meals. Part of the small intestine may also be bypassed; this
makes you absorb less of the food you eat. These changes allow your
body to use excess fat for energy, and as a result you lose weight.
Surgeons at the Bariatric Institute of Wisconsin perform the most
clinically advanced weight-loss surgery. One of the few surgical teams
to perform weight loss surgery laparoscopically, BIW surgeons are
skilled in two highly-developed bariatric surgery choices, the
BioEnterics Lap-Band® Adjustable Gastric Banding System (Link
to Inamed Health) and Roux-en-Y Gastric Bypass.
The laparoscopic surgical technique for either procedure means
small incisions, a faster recovery and less risk from complications.
Roux-en-Y Gastric Bypass Procedure
The Roux-en-Y Gastric Bypass is the benchmark bariatric operation.
Other procedures are compared to the Roux-en-Y as to their quality and
effectiveness. During the Roux-en-Y procedure, a small pouch (it inner
curve of the stomach and the small intestine is then attached to the
pouch. This procedure provides an excellent tool for long-term control
of weight without the feeling of being deprived and hungry. Patients
eat much smaller portions due to the pouch size, but they have the
sense of fullness and satisfaction that makes them indifferent to even
their favorite foods. Food appetites change after surgery; as the body
no longer tolerates food high in sugar or fat. These foods may make a
patient physically uncomfortable. With this built-in control, you
naturally avoid these foods. Other surgical procedures don’t provide
this important benefit of behavior modification. Because a section of
the small intestine is attached to the pouch, less of the food you eat
is absorbed.
Patients who have the Laparoscopic Roux-en-Y still continue to
enjoy eating, just much smaller portions. Nutrition is also maintained
with vitamin and mineral supplements.
When done laparoscopically the Roux-en-Y Gastric Bypass has the
advantage of avoiding a large incision, thus the recovery is much
faster.
Lap-Band® Procedure
The Lap-Band is the newest surgical treatment for morbid obesity in
the US. Like a wristwatch, the band is fastened around the upper
stomach to create a new, tiny stomach pouch. As a result, patients
experience an earlier sensation of fullness and are satisfied with
smaller amounts of food. Since there is no cutting, stapling, or
stomach rerouting involved in the Lap-Band procedure, it is considered
the least traumatic of all weight loss surgeries. Your surgeon makes
several tiny incisions and uses long, slender instruments to implant
the device. By avoiding the large incision of open surgery, patients
generally experience less pain and scarring.
The Lap-Band System is adjustable for a customized weight-loss rate
for each patient. Adjustments to the band, which are performed during
simple outpatient visits, are determined by the patient's weight loss,
the amount of food that can be comfortably eaten, the exercise
regiment and other issues surrounding the patient's health. (The rate
of weight loss with the Lap-Band procedure is slower than with the
Roux-en-Y gastric bypass surgery.)
Because no permanent changes are made to the body's physiology, the
Lap-Band can essentially be reversed. If necessary, all of the system
components can be removed from the body with no damage to the
digestive organs. The stomach will generally return to its original
form and capacity once the band is removed.
To date, more than 100,000 patients worldwide have undergone the
Lap-Band System procedure. Biliopancreatic Diversion
with Duodenal Switch
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The biliopancreatic diversion with duodenal
switch is a procedure that combines limiting food intake, restriction
with malabsorption. This procedure requires a partial gastric
resection. The original procedure was described with a 60% antrectomy.
However, the present procedure with duodenal switch requires resection
of the greater curve of the stomach along a small dilator to construct
a gastric tube. This results in approximately an 80% resection of
gastric volume. This is the restrictive portion of the procedure. This
is done to decrease the amount of acid in the stomach and also to
decrease ghrelin which is felt to account for increased hunger. The
gastric pouch constructed with the biliopancreatic diversion duodenal
switch procedure is approximately three times larger than the pouch
constructed with a Roux-en-Y bypass. This does allow a slightly higher
intake of oral food, which is more satisfying to some patients. It
does however account for restriction, again accounting for an
approximately 80% reduction in gastric size. However, maintaining a
gastric sleeve along with a portion of the duodenum should result in a
lesser incidence of B12 deficiency and perhaps better iron absorption.
Similar to Roux-en-Y bypass, the small bowel is divided. However, with
this procedure, the small bowel is divided 300 – 400 cm distal to the
ligament of Treitz to achieve approximately a 200 cm Roux limb and
anywhere from a 100-150 cm absorptive limb. This accounts for a bypass
of 80% of the absorptive small bowel. Comparing this to the Roux-en-Y
bypass, which achieves a 15-20% bypass of the absorptive small bowel,
the result is more malabsorption and better long-term weight loss. The
advantages of the biliopancreatic diversion duodenal switch procedure
are the highest rate of resolution of type II diabetes and
hyperlipidemia. The procedure also achieves slightly better long-term
weight loss than other bariatric procedures. The procedure is felt
most appropriate for patients who have a higher body mass index (> 50)
and/or comorbidities of diabetes and hyperlipidemia. As with the other
bariatric procedures, the overall quality of life is improved greatly
following this procedure. The procedure in the past was only done as
an open laparotomy. In more recent years, the procedure has been
achieved laparoscopically. On occasion, the procedure is done as a
two-step procedure; that is, the vertical sleeve gastrectomy (partial
removal of stomach) is performed first, followed by the bypass or
malabsorptive portion of the procedure 3-9 months later. This is done
to achieve a lower overall surgical risk. Specifically, this is
appropriate if there has been previous abdominal surgery; for example,
an adjustable gastric band or Nissen fundoplication that requires
revisional surgery in the upper abdomen.
In conclusion, this procedure probably has the best overall weight
loss of bariatric surgical procedures today. The malabsorptive part of
the procedure does carry the risk of nutrient and protein malnutrition
and the patients need to be very compliant and followed closely. Our
patients who have undergone this procedure have done extremely well.
For further information, please contact our office for an appointment
with physician. Vertical Sleeve Gastrectomy
Vertical sleeve gastrectomy is another restrictive operation that
can be performed laparoscopically. Since there is no rerouting of
the intestines, there is no malabsorption with the vertical sleeve
gastrectomy. In this procedure, approximately 85% of the stomach is
removed leaving a narrow tube of the stomach that is shaped like a
banana. The amount of food that can be eaten at one time is
decreased after the vertical sleeve gastrectomy. The food that is
eaten passes through the esophagus, then the narrow gastric tube,
and then through the pylorus into the small bowel, which is the
normal route that food takes through the gastrointestinal tract. The
part of the stomach that is removed produces a hormone causing
hunger and often following vertical sleeve gastrectomy hunger is
reduced. Weight loss following vertical sleeve gastrectomy is
similar to laparoscopic gastric bypass and is probably superior to
lap band in most patients. For some patients, the vertical sleeve
gastrectomy can be used as a first-stage procedure, which can later
be converted to a duodenal switch or gastric bypass if additional
weight loss is needed. This operation is ideally suited for those
patients who require a large number of oral medications, for
patients who have had significant bowel surgery in the past, and for
patients who wish to avoid a foreign body such as the lap band. To
learn more about his procedure, please call the Bariatric Institute
to schedule an appointment with one of our surgeons.
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