Bariatric surgery can be performed in a variety of ways to change the size of the stomach, length of the small intestine, or both. The goal of bariatric surgery is to limit how much food is eaten or absorbed. Medical professionals at the Johns Hopkins Center for Bariatric Surgery will advise you about which procedure is best for you.
The Johns Hopkins Center for Bariatric Surgery offers the following surgical options for weight loss:
- Roux-en-Y Gastric Bypass (open and laparoscopic)
- Adjustable Gastric Banding System
- Sleeve Gastrectomy
- Revisions of other weight loss surgeries
Procedures may be performed either as open or laparoscopic (minimally-invasive) surgeries.
The laparoscopic approach uses special endoscopic instruments requiring 5 or 6 small incisions measuring about ¼ to ½ inch in size. Laparoscopic procedures have been used in bariatric surgery for several years and utilize the same techniques as open surgery. However, laparoscopic patients may experience less post-operative pain, fewer wound complications and may return to regular daily activities more quickly.
The open surgery will require an incision from just below the breast bone (sternum) to the belly button (umbilicus). The length of the incision depends on your anatomy.
Roux-en-Y Gastric Bypass
The Roux-en-Y gastric bypass is a combination of two surgeries for obesity: gastric stapling and intestinal bypass. It works by reducing caloric intake two ways. First, it restricts the amount of food a person can eat by reducing the holding capacity of the stomach. Second, it interferes with the complete absorption of nutrients by shortening the length of small intestine through which the food travels.
During the procedure, the surgeon applies a line of staples across the entire diameter of the stomach close to where it joins the esophagus. This reduces the stomach’s capacity by creating a pouch that is approximately the size of an egg. The small pouch and the rest of the stomach are divided from each other in order to minimize the chance of staple line breakdown.
Next, an opening, or stoma, is made in the pouch and a piece of the small intestine is connected. The new connection between the pouch and the small intestine is called a Roux-en-Y limb. The standard length of the Roux limb is about 60 cm. Some patients may benefit with a longer limb of approximately 150 cm (discuss this with the surgeon), which can result in more malabsorption.
After stapling the stomach and creation of the Roux-en-Y limb, food that travels down the esophagus will bypass nearly all of the stomach and the first two feet of the small intestine. In effect, most of the stomach and the beginning portion of the small intestine will have been shut off from the rest of the digestive system. The gall bladder, if still present, may be removed at the time of surgery to prevent complications related to gallstones which tend to form during rapid weight loss.
The Roux-en-Y gastric bypass procedure discourages the intake of high-calorie sweets by producing nausea, diarrhea and other unpleasant symptoms when these foods are eaten. This is known as "dumping syndrome."
Adjustable Gastric Banding System
The adjustable gastric band is a band made of a hollow, silicone ring, which is filled with saline and placed around the upper portion of the stomach and stitched into place. This creates a new, small stomach pouch, with the larger part of the stomach below the band. The food storage area of the stomach is greatly reduced. This procedure is done laparoscopically.
The adjustable gastric band also controls the stoma (stomach outlet) between the two parts of the stomach. The size of the stoma controls the flow rate of the food from the upper to lower part of the stomach and lets you feel full sooner and also a sensation of feeling full longer.
To change the size of the opening between the two parts of the stomach (stoma), the inner surface of the band can be adjusted by adding or removing saline. The band is connected by a tube to a reservoir placed beneath the skin during the surgery. Later, the surgeon can control the amount of saline in the band by piercing the reservoir through the skin with a fine needle. This is a simple, same-day procedure performed in the doctor's office.
The minimally-invasive sleeve gastrectomy is much like the biliopancreatic diversion with duodenal switch procedure. Patients are left with a smaller stomach that still is connected in the normal anatomical way. The stomach that remains is larger than a gastric bypass pouch, but much smaller than the normal human adult stomach. This causes restriction and a possible decrease in appetite due to gut hormones released by the removed fundus. The pylorus is preserved, so most patients should not experience "dumping syndrome." The procedure has no malabsorption and in theory, less nutritional deficiencies, as there is no bypassed intestine.
Currently, there is no long-term (beyond 5 years) data on the results of this procedure. As with all restrictive procedures, including adjustable gastric band and vertical gastric banding, excess weight loss will most likely be significantly less than for a combined restrictive and malabsorption procedure, such as gastric bypass and biliopancreatic diversion with duodenal switch.
The laparoscopic sleeve gastrectomy may be used as a stage procedure to induce weight loss for patients who are at a higher risk for complications if the entire gastric bypass or duodenal switch operation is done at the same time. The patient would then need a second operation in three to six months, after significant weight loss causes their risk of complications to decrease.
The sleeve gastrectomy may be an alternative for those who do not want an adjustable band or have less weight to lose and do not want the malabsorption component of a gastric bypass or duodenal switch.