In view of the present age distribution of the population with its increasing life-expectancy, it is not possible to designate an upper age limit, although mortality and the risk of complications are known to increase with age (14). Thus, the biological age of the patient in question should play a decisive role.

Surgery in children and adolescents younger than 18 years is indicated only in exceptional cases (personal responsibility, puberty completed, expert recommendation). In these cases, intensive cooperation between bariatric surgeons, pediatricians experienced in the treatment of obesity and pediatric psychotherapists is extremely important (obesity guideline in pediatrics 2004, 22).

1. Antecolic-antegastric: Simplest option technically, longest distance is favored.
2. Retrocolic-retrogastric: Technically demanding, shortest distance
3. Retrocolic-antegastric: Technically more challenging than 1, without substantial gain in "length"

Author:

Prof. Rudolf Weiner, MD

SANA Klinikum Offenbach

Department of Metabolic and Obesity Surgery

In all gastric procedures, the trocar for the camera is placed in the upper left quadrant. The distance to the xiphoid is at least 15 cm, but no more than 20 cm.

In obesity, the umbilicus may not be used as landmark because it may be markedly displaced distad, particularly in men. The pneumoperitoneum will further increase the distance between the xiphoid and umbilicus. Many surgeons prefer to initiate the pneumoperitoneum at the same location in the left upper quadrant.

Tip: Since in men the umbilicus is not a proper landmark, in many cases the trocars are placed too far away from the region of the hiatus. This problem may be solved by placing additional trocars in the epigastrium.

If the abdominal wall is extremely thick (gynecoid fat distribution) the following options are available:

• Double-click puncture with the Veress needle (extra-long)
• Use of threaded trocars under camera vision
• Use of optical trocars under camera vision

In initial surgery, we prefer the double-click technique, and in more than 4000 initial procedures we have not encountered any complication requiring termination or conversion to open surgery. In revision surgery (following prior epigastric procedures, status post peritonitis and in preoperatively confirmed extreme hepatomegaly) infraumbilical open laparoscopy (Hasson technique) is performed.

Each laparoscopic procedure should start by inspecting the abdominal cavity.

One pertinent mistake would be to overlook ovarian malignancy.

Tip: 360° inspection of the abdominal cavity will rule out severe intra-abdominal adhesions and lower the risk of overlooking ovarian tumors.

This inspection and checking the accessibility of the oral (later alimentary) loop can help prevent the mistake of performing gastric resection in the presence of massive adhesions of the small intestine ("frozen abdomen"), where the option would be sleeve gastrectomy.

The other trocars are placed step-by-step. The trocar for the camera followed by a 10-mm trocar for the liver retractor inferior to the right costal arch. The retractor then is clamped in a retaining bracket. This retractor will also be used to lift the greater omentum. This is followed by a 13-mm trocar in the left lateral abdominal wall inferior to the costal arch. Both epigastric working trocars (13 mm) are introduced in such a way that they will result in the best working angle possible for manipulations in the hiatal region.

Tip: To avoid any interference, the distance between the working trocars should be as long as possible.

• Major omentum
• Whenever the intestinal loop is placed anterior to the colon or the major momentum is rather fatty, it is recommended to transect the free part of the major momentum, thereby decreasing tension on the anastomosis.Mistake: Hypoperfusion with necrosis of the omentumPrevention: Sagittal transection of the omentum sparing the blood supplySolution: Repeat resection of the hypoperfused omentum (rare: 1 in >1,000).
• Billroth-II
• Because of the potential bile reflux single anastomosis Billroth-II gastric bypass is reserved for special indications.
• Ring augmentation
• Ring augmentation of the gastric pouch to prevent dilation of the alimentary loop is an option mostly employed in revision surgery.Mistake: Ring-induced stenosisPrevention: Calibration with the probe, circumference 6.5 cmSolution: Repeat resection if the pouch is too large and a corner of the alimentary loop of the small intestine is present.

Author:

Prof. Rudolf Weiner, MD

SANA Klinikum Offenbach

Department of Metabolic and Obesity Surgery

The angle of His should be exposed first. Herniation of the gastric fundus into a hiatal hernia should always be reduced because otherwise the gastric pouch might become too large. As a matter of principle, the left crus of the diaphragm is exposed and incised.

Tip: Consistent exposure of the gastroesophageal transition on the left (spleen) helps reduce the danger of creating too large a gastric pouch in the presence of a large hiatal hernia with parts of the stomach displaced into the mediastinum

Author:

Prof. Rudolf Weiner, MD

SANA Klinikum Offenbach

Department of Metabolic and Obesity Surgery

The rib cage (thorax) comprises these bones: Sternum, ribs (costae) and thoracic spine. The three components of the sternum include: Manubrium, corpus and xiphoid process. Typically, humans have 12 paired ribs which in turn are classified as true (costae verae 1-7, directly attached to the sternum) and spurious ribs (costae spuriae 8-12, no direct attachment to the sternum). Spurious ribs are either attached to the cartilaginous costal arch (arcus costalis, ribs 8-10) or floating freely within the abdominal wall (costae fluctuantes, ribs 11 and 12).

Each rib comprises both an osseous and cartilaginous part. The posterior articulation between the spine and each rib (costovertebral articulation) comprises its head (caput costae) and tubercle (tuberculum costae, projecting from the body of the rib (corpus costae)). Head and body of the rib are separated by its neck (collum costae). The corresponding anterior joint with the sternum is the sternocostal articulation.

As such, the rib cage has a superior and inferior aperture:

The superior thoracic aperture is formed by the first thoracic spinal body, first left and right rib and the manubrium of the sternum. Both the trachea and esophagus pass through this aperture which also comprises the top of the lungs and sometimes inferior segments of the thyroid. The aperture is traversed by large blood vessels (common carotid artery, brachiocephalic trunk, internal thoracic arteries and veins, subclavian artery, brachiocephalic veins), the thoracic duct, bronchomediastinal lymphatic vessels as well as the vagus nerve, phrenic nerves and parts of the sympathetic trunk.

The inferior thoracic aperture comprises the spinal body of Th12, ribs 10-12, the costal arches and the xiphoid process. The diaphragm with its plate-like arch closes off the aperture, and has openings for vessels, nerves and the esophagus.

Author:

Prof. Gebhard Reis, MD

Medical School (Department of Medicine)

Institute of Anatomy and Clinical Morphology/Head

Witten/Herdecke University

In its upstream sections the colon demonstrates the typical mural anatomy of the mucosa (simple columnar epithelium with lamina propria mucosae and thin muscularis mucosae as well as only crypts, lymph follicles), submucosa, muscularis and serosa/adventitia. As serosa, the peritoneum covers about half of the anterior aspect of the upper rectum and only ¼ of the lateral and medial rectum, while the posterior aspect is free of any peritoneum. This creates a deep pouch (rectouterine or rectovesical excavation = Douglas pouch) at the deepest part of the abdominal cavity.

The distal parts of the colon demonstrate a characteristic transition of the mucosa to the skin of the outer body surface. At the anal pectinate line the interior epithelium of the mucosa transitions into a stratified squamous epithelium; the mucosa comprises the anal columns noted above and the cavernous body of the anus, while pockets between the columns contain anal glands (glandulae anales). Further distad at the level of the internal anal sphincter there is the bright transition zone which, even more distad, turns into the skin zone with its marked pigmentation and keratinized stratified squamous epithelium. Apart from hairs, this also includes sebaceous and sudoriferous glands.

Author:

Prof. Gebhard Reis, MD

Medical School (Department of Medicine)

Institute of Anatomy and Clinical Morphology/Head

Witten/Herdecke University

Comorbidities are vital in the indication for this procedure in patients with a BMI of 35 – 40 kg/m². The following list only includes evidence-based trials. According to the NIH criteria comorbidities include: Sleep apnea and other ventilation disorders (10, 18); diabetes mellitus type II (26, 30, 31, 34, 36, 44); obesity-related cardiomyopathy and hypertension (4, 9, 15, 35, 40, 44); hyperlipidemia (29); cerebral pseudo tumor (28, 43); orthopedic knee injuries (18); spinal disorders (33); stress urinary incontinence (7, 18),;polycystic ovary syndrome (45); infertility (17, 27, 50); and further less known effects on other disorders, e.g., asthma and fibromyalgia up to carpal tunnel syndrome, whose bariatric surgery-induced effects are documented. Science has demonstrated that massive weight reduction will result in the prevention, relative improvement and even remission of obesity-related somatic diseases (13, 25, 38).

The metabolic impact of the bypass procedure on diabetes mellitus goes far beyond just the weight loss and is not attained by any other therapeutic measure (24, 36). Gastric bypass is also a highly effective treatment of GERD possibly present in obesity (18, 39). Studies on mental comorbidities in patients with obesity stage III (21, 46) seem to indicate a prevalence of mental disorders which is markedly higher than in those with normal body weight; this is particularly true in women where affective disorders; anxiety disorders; eating disorders; and personality disorders are predominant (21, 38).

Most of the studies demonstrated significant improvement, particularly in anxiety and depression disorders. In general, (behavioral) eating disorders (binge eating) and the problematic attitude towards eating, body weight and figure will improve (44). Postoperatively, mental and psychosocial parameters such as self-esteem; human interaction; partnership; sexuality; sick leave; and work disability undergo market improvement (44).

In patients with a BMI of 40 – 50 kg/m² the alimentary loop should be 120 cm to 150 cm long.

For a BMI > 50 kg/m² a long-limb bypass with a loop of 200 cm should be considered.

Author:

Prof. Rudolf Weiner, MD

SANA Klinikum Offenbach

Department of Metabolic and Obesity Surgery

Dear patient,

According to the widely known calculation, you have a body mass index of more than 35 kg/m². Morbid obesity significantly shortens the average life expectancy and may result in accompanying diseases, e.g., diabetes; high blood pressure; sleep apnea; gallstones; heart disorders; muscle and joint injury; as well as psychosocial problems.

Basic therapy comprising a special diet and possibly psychological support has not been successful with you. You are fulfilling the medical criteria for surgical treatment.

During the informed consent discussion, I was personally informed in detail about the gastric bypass procedure and its surgical aspects.

The procedure is performed under anesthesia. Informed consent for the anesthesia will be obtained by the anesthesiologist,

In this procedure parts of the stomach are transected, while parts of the small intestine are bypassed (see figure).

In general, even if the access is minimally invasive (laparoscopy), this is major surgery with the possibility of numerous complications.

According to the international meta-analysis by Buchwald (2004) the mortality risk is 0.5%. Thus, it is higher than the 0.1% in the gastric balloon procedure.

Particularly in gastric bypass surgery there is the risk of injury to the stomach, esophagus and other organs (spleen…). In case of injury to the spleen it may become necessary to remove the organ, which may result in future susceptibility to infection. In case of complications and whenever continued video-endoscopic surgery entails too much risk, it may become necessary to convert from laparoscopic to open surgery. The responsibility whether a laparotomy is required rests with the surgeon.

Prior surgery within the abdominal cavity increases the surgical risk and degree of difficulty. , previous operations in the left upper quadrant (stomach, hiatal hernia…) complicate the procedure.

There are various types of gastric bypass for weight reduction. Often, the determination which type is best suited for the patient can only be established during the actual surgery. The loop of the small to be sutured to the stomach may course in front of or behind the large intestine. This depends on the length and mobility of the small intestine. Since this cannot be determined for certain before the operation, the surgeon will have to decide on the loop placement to the best of his/her knowledge and skill. In high-risk and extremely obese patients, as well as in those with previous operations, it may become necessary to perform a mini-bypass with just one anastomosis, i.e., a single new connection between the stomach and small intestine. In this case, there will be no second anastomosis between loops of the small intestine. Thus, the length of the small intestine for nutrient absorption will be longer. The intestinal juices will then flow over the connection between the stomach and the small intestine.

I have been informed of the necessity for this procedure, its risks and possible early/late complications. , I was informed of the following risks and possible complications:

General complications: Infection (including hepatitis); thrombosis and embolism; necessity of blood transfusions; impaired wound healing. The transfusion of blood and blood components carries its own risk of infection.

Complications during surgery such as organ injury, bleeding, nerve injury.

Intestinal surgery runs the general risk of suture failure. Insertion of a gastric tube may be complicated by injury to the throat and esophagus.

If a catheter must be inserted into the bladder, this may also injure the urethra and bladder. Patient positioning on the operating table may cause pressure injuries of nerves and soft tissue resulting in impaired sensation and, in rare cases, paralysis of the arms and legs. Compared with normal weight patients, those with extreme obesity run a markedly higher risk. Skin and tissue injury due to electric current, heat and/or disinfectants is rather rare as well. Most of these injuries will heal without treatment.

In laparoscopic surgery, the inhalation of gas may result in a sensation of abdominal pressure and shoulder pain. This, as well as possible crackling of the skin, will quickly disappear. If the gas seeps into the pleural space (pneumothorax), this may require insertion of a chest tube.

Irreducible internal hernias; adhesions; intestinal obstruction; abscess (plus formation); constriction of the connection between stomach and small intestine; and ulcers are possible complications in the immediate postoperative phase as well as after months and years.

Sometimes, laparotomy (open abdominal surgery) is complicated by incisional hernia, which in most cases requires surgical repair. In laparoscopic surgery, these incisional hernias are also possible at the trocar insertion sites. Revision surgery is mandatory, whenever the open procedure is complicated by postoperative suture line failure (burst abdomen). The skin around the scars of the procedure may be permanently numb. Because of impaired healing or corresponding disposition, in some patients the skin will react with exuberant scar tissue (keloid); such scars may be painful and aesthetically distracting.

As in any type of surgery, blood clots may be formed in the major veins (thrombosis) and carried along in the bloodstream, finally obstructing a blood vessel (embolism). Preventive measures involve the administration of anticoagulants (e.g., heparin injection), which in turn may increase the bleeding tendency and in very rare cases result in severe coagulation disorder.

Allergies and hypersensitivity (e.g., to medications, disinfectants, latex) may result in reactions with possibly impaired organ functions.

Postoperative complications such as impaired healing, incisional hernias and functional sequelae are also possible. Leakage at the new connection between the stomach and small intestine may result in peritonitis possibly requiring revision surgery. Later reversal of the gastric bypass procedure (reconnection of the stomach) is virtually impossible or at least entails a substantial surgical risk.

Since the remaining stomach can no longer be studied by endoscopy, endoscopic treatment (ERCP) of gallstones in the bile ducts will no longer be possible.

I have been informed of this.

Long-term sequelae may include vitamin and iron deficiency, short bowel syndrome and metabolic calcium disorders resulting in osteoporosis.

Vitamin supplementation should be increased in planned pregnancy to prevent possible malformations. Contraceptive efficacy is no longer ensured in malabsorption procedures. The stomach can no longer be studied by endoscopy.

Endoscopic retrograde study of the pancreatic duct (ERCP) will no longer be possible.

The success of the treatment and the prevention of complications also depend on the patient's cooperation. I have been adequately informed of the necessity to maintain eating habits and attend follow-up appointments. Noncompliance with the given rules (3 meals, small amounts, selected food) may result in problems and less weight loss. Alcohol must be strictly avoided because it will be absorbed rather rapidly. The efficacy of medication including the "anti-baby pill" may be impaired.

Patient cooperation is vital for successful treatment and to prevent side effects.

In case of any problems, please contact your health care center immediately.

I hereby consent to this procedure. I have no more questions.

Author:

Prof. Rudolf Weiner, MD

SANA Klinikum Offenbach

Department of Metabolic and Obesity Surgery

Gastric functions include storing and mixing the ingested food and propelling it in timely fashion into the downstream segments of the intestinal tract. Motor control of the churning and propulsive peristalsis is governed by the sympathetic and parasympathetic nervous systems. The lower esophageal sphincter, and downstream the pylorus, control the motility and prevent reflux. The stomach produces about 1500 to 3000 mL gastric juices per day, with 70 to 80% being secreted by the mucosa of the fundus and corpus. Apart from the gastric acid, the largest portion, the secretions also include mucoproteins and proteases. The most important factor in gastric bypass surgery is the intrinsic factor, a mucoprotein secreted in the fundus and essential for the absorption of vitamin B12.

In addition, the stomach also produces numerous hormones which are not fully understood yet. The hormones ghrelin and gastrin, secreted in the fundus, play a particularly important role in satiety control. The control of hunger and satiety is also triggered by stretch receptors and the activation of sympathetic fibers.

1. Layered anatomy

The large area of the anterior abdominal wall from the xiphoid process and both costal arches to the pelvis demonstrates a characteristic layered anatomy: Skin covering the subcutaneous fatty tissue; superficial fascias; muscles and their fascias; and then an extraperitoneal fascia and the parietal peritoneum.

Particularly in the anterior wall inferior to the umbilicus the otherwise single-layered superficial fascia transitions into a double-layered structure (panniculus adiposus abdominis) comprising a superficial fatty layer (Camper fascia) and a deeper membranous layer (Scarpa fascia). The five abdominal muscles comprise:

• Three oblique muscles (1. external oblique, 2. internal oblique and 3. transversus abdominis) Two straight muscles (4.
•  rectus abdominis and the inconsistent 5. pyramidalis muscle).

a) Superficial muscle

It courses directly posterior to the superficial fascia in inferomedial direction to the large aponeurosis; both sides conjoining in the middle to the linea alba (white line). Its inferior margin constitutes the inguinal ligament from the anterior superior iliac spine to the pubic tubercle; medially, the inguinal ligament in turn gives off the lacunar and pectineal ligament (Cooper) respectively.

b) Middle muscle

The fibers course superomedially and conjoin with the fibers from 1. to the linea alba.

c) Deepest muscle

Transverse fibers, also conjoining with the linea alba.

• Both the anterior and posterior aspect of each of the three oblique abdominal muscles is covered by its own thin fascia, and 3. at its posterior aspect the strong transversalis fascia. It invests the abdominal cavity and cephalad becomes the diaphragmatic fascia and posteriorly the thoracolumbar fascia. Caudad it attaches to the iliac crest and becomes the endopelvic fascia.
• Long, straight, paired abdominal muscle divided by 3 – 4 transverse tendinous intersections ("six-pack")
• Triangular rudimentary muscle caudad and anterior to 4. between the pubic bone and linea alba.

2. Fascias and peritoneum

Muscles 4. and 5. are invested by the rectus sheath formed by the 3 oblique abdominal muscles 1.–3. The superior ¾ of 4. are completely invested by the rectus sheath, while the latter only covers the anterior aspect of the inferior ¼ below the arcuate line. The posterior aspect of 4. is only covered by the transversalis fascia and peritoneum. In its superior ¾ the anterior lamina of the rectus sheath is formed by 1. and half of 2., while the posterior lamina is formed by both 2. and 3.

Transversalis fascia and peritoneum are separated by the extraperitoneal space, the extent of which may markedly differ depending on the location. The retroperitoneal abdominal organs are found in the retroperitoneum. At the anterior abdominal wall the slender retroperitoneum often is known as the preperitoneal space (e.g., at the deep inguinal orifice).

The peritoneum (parietal serosa) invests the completely enclosed peritoneal cavity (exception: tube openings in women), and as visceral peritoneum it invests the intraperitoneal organs. Inferior to the umbilicus it forms three folds:

• The single median umbilical fold (obliterated urachus/allantoic stalk)
• The paired medial umbilical fold (former umbilical artery)
• The paired lateral umbilical fold (inferior epigastric vessels)

3. Innervation and blood supply

The anterior abdominal wall is innervated by the anterior branches of spinal nerves Th7 – Th11, Th12 (subcostal nerve) and L1 (iliohypogastric nerve and ilioinguinal nerve).

Its cephalic superficial blood supply comes from the internal thoracic artery (→ musculophrenic artery), while caudad the blood is supplied by the superficial epigastric artery and superficial circumflex iliac artery (both branches of the femoral artery). The deep layers are supplied cephalad by the superior epigastric artery (internal thoracic artery), laterally from the intercostal vessels and caudad from the inferior epigastric artery and deep circumflex iliac artery (both branches of the external iliac artery). Venous drainage is via the corresponding (eponymous) veins.

Author:

Prof. Gebhard Reis, MD

Medical School (Department of Medicine)

Institute of Anatomy and Clinical Morphology/Head

Witten/Herdecke University