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Port Placement In Lap Bariatric Surgery​

Bariatric Surgery Procedures

1. Laparoscopic Sleeve Gastrectomy

The Laparoscopic Sleeve Gastrectomy – often called the sleeve – is performed by removing approximately 80 percent of the stomach. The remaining stomach is a tubular pouch that resembles a banana.

The Procedure

This procedure works by several mechanisms. First, the new stomach pouch holds a considerably smaller volume than the normal stomach and helps to significantly reduce the amount of food (and thus calories) that can be consumed. The greater impact, however, seems to be the effect the surgery has on gut hormones that impact a number of factors including hunger, satiety, and blood sugar control.

Short term studies show that the sleeve is as effective as the roux-en-Y gastric bypass in terms of weight loss and improvement or remission of diabetes. There is also evidence that suggest the sleeve, similar to the gastric bypass, is effective in improving type 2 diabetes independent of the weight loss. The complication rates of the sleeve fall between those of the adjustable gastric band and the roux-en-y gastric bypass.

LAPAROSCOPIC SLEEVE GASTRECTOMY
Advantages
  • Restricts the amount of food the stomach can hold
  • Induces rapid and significant weight loss that comparative studies find similar to that of the Roux-en-Y gastric bypass. Weight loss of >50% for 3-5+ year data, and weight loss comparable to that of the bypass with maintenance of >50%
  • Requires no foreign objects (AGB), and no bypass or re-routing of the food stream (RYGB)
  • Involves a relatively short hospital stay of approximately 2 days
  • Causes favorable changes in gut hormones that suppress hunger, reduce appetite and improve satiety.

2. The Roux-en-Y Gastric Bypass

The Roux-en-Y Gastric Bypass – often called gastric bypass – is considered the ‘gold standard’ of weight loss surgery.

LAPAROSCOPIC ROUX-EN-Y GASTRIC BYPASS​
The Procedure

There are two components to the procedure. First, a small stomach pouch, approximately one ounce or 30 milliliters in volume, is created by dividing the top of the stomach from the rest of the stomach. Next, the first portion of the small intestine is divided, and the bottom end of the divided small intestine is brought up and connected to the newly created small stomach pouch. The procedure is completed by connecting the top portion of the divided small intestine to the small intestine further down so that the stomach acids and digestive enzymes from the bypassed stomach and first portion of small intestine will eventually mix with the food.

The gastric bypass works by several mechanisms. First, similar to most bariatric procedures, the newly created stomach pouch is considerably smaller and facilitates significantly smaller meals, which translates into less calories consumed. Additionally, because there is less digestion of food by the smaller stomach pouch, and there is a segment of small intestine that would normally absorb calories as well as nutrients that no longer has food going through it, there is probably to some degree less absorption of calories and nutrients.

Most importantly, the rerouting of the food stream produces changes in gut hormones that promote satiety, suppress hunger, and reverse one of the primary mechanisms by which obesity induces type 2 diabetes.

Advantages
  • Produces significant long-term weight loss (60 to 80 percent excess weight loss)
  • Restricts the amount of food that can be consumed
  • May lead to conditions that increase energy expenditure
  • Produces favorable changes in gut hormones that reduce appetite and enhance satiety
  • Typical maintenance of >50% excess weight loss

3. laparoscopic mini gastric bypass

It is very similar to the traditional RNY bypass but only has one connection (single anastomosis) to the small intestine. Compared to gastric sleeve surgery and RNY, the MGB procedure is less invasive and requires less time for surgery and recovery. The complete procedure takes about 90 minutes or less and patient can be released from the hospital in 72 hours.
The Procedure

The mini-gastric bypass procedure is performed laparoscopically (keyhole surgery) under general anaesthesia. Five small incisions (between 5 and 12mm in length) are made for the insertion of the keyhole surgery instruments. Using these instruments, the top of the stomach is stapled to form a thin tube (30ml to 50ml in size). The thin tube becomes the new, smaller stomach and is completely separate to the rest of the stomach. This stomach is then sewn to a loop of the small intestine, bypassing the first part of the intestine called the duodenum and approximately 150–200cm of the bowel. The rest of the stomach and upper part of the small intestine remains in the body but is no longer used for food digestion. In skilled hands, the surgery takes approximately 60 minutes to perform.

LAPAROSCOPIC Mini GASTRIC BYPASS​
Advantages
  • Weight loss
  • Fast recovery time
  • High percentage of success (up to 80%)
  • Shorter operating times
  • Technically easier
  • Fewer complication rate than the traditional RNY bypass
  • Less chance for dumping syndrome
  • Reduction in co-morbidities such as hypertension, diabetes, high cholesterol, etc.
  • Less re-routing of the intestines

4. laparoscopic adjustable gastric band

The Adjustable Gastric Band – often called the band – involves an inflatable band that is placed around the upper portion of the stomach, creating a small stomach pouch above the band, and the rest of the stomach below the band.

LAPAROSCOPIC ADJUSTABLE GASTRIC BAND​​
The Procedure

The common explanation of how this device works is that with the smaller stomach pouch, eating just a small amount of food will satisfy hunger and promote the feeling of fullness. The feeling of fullness depends upon the size of the opening between the pouch and the remainder of the stomach created by the gastric band. The size of the stomach opening can be adjusted by filling the band with sterile saline, which is injected through a port placed under the skin. Reducing the size of the opening is done gradually over time with repeated adjustments or “fills.” The notion that the band is a restrictive procedure (works by restricting how much food can be consumed per meal and by restricting the emptying of the food through the band) has been challenged by studies that show the food passes rather quickly through the band, and that absence of hunger or feeling of being satisfied was not related to food remaining in the pouch above the band.  

What is known is that there is no malabsorption; the food is digested and absorbed as it would be normally.

The clinical impact of the band seems to be that it reduces hunger, which helps the patients to decrease the amount of calories that are consumed.

Advantages
  • Reduces the amount of food the stomach can hold
  • Induces excess weight loss of approximately 40 – 50 percent
  • Involves no cutting of the stomach or rerouting of the intestines
  • Requires a shorter hospital stay, usually less than 24 hours, with some centers discharging the patient the same day as surgery
  • Is reversible and adjustable
  • Has the lowest rate of early postoperative complications and mortality among the approved bariatric procedures
  • Has the lowest risk for vitamin/mineral deficiencies

5. Endoscopic Intragastric Balloon

It is an endoscopic procedure, during which a balloon is inserted in the stomach, occupying about half of it. The balloon remains in the stomach for a maximum of six months and it is meant to increase the feeling of satiety and limit food intake. Since it does not require surgery, the procedure is conducted in an out-patient setting.

Endoscopic Intragastric Balloon ​
The Procedure

The gastric ballon is a soft, biocompatible silicone device that is filled with sterile saline solution that is placed during a non-surgical procedure that takes between 20 and 30 minutes. The physician will insert the unfilled gastric balloon through the mouth and oesophagus into the stomach, using an endoscopic camera. Following the procedure, which can be conducted under local or general anesthesia according to the characteristics of the patient, the physician uses a fluid supply tube to fill the gastric ballon.

Advantages
  • Reduces the amount of food the stomach can hold
  • Patients feel satisfied during the treatment and the weight loss is often more significant than with other non-surgical programs
  • The device helps avoid the risks associated with a surgical procedure and patients may be more comfortable with a non-surgical and non-pharmacological approach.