Much of the layout and organization of the operating room is standard from room to room. Specific needs for the bariatric patient include the operating bed which must be outfitted to safely hold and secure a bariatric patient. According to the Association of Operating Room Nurses (AORN) bariatric surgery guidelines, OR bariatric beds should have the capacity to hold 1,000 lb with 600 lb tilt capacity [12]. The OR tables should have side extenders, footboards, sufficient arm holders, and foam padding available for the arms, heels, and feet to prevent falls and pressure injuries. Because obese patients are not likely to be able to transfer themselves after recently having had general anesthesia, lifts or other appropriate moving devices, like an air mattress, should be utilized to facilitate easy transfer.

Since most procedures are now performed laparoscopically, special abdominal instrument sets may be needed including longer suction catheters, laparoscopic graspers, needle holders, drivers, and laparoscopes [11]. An adequately sized OR room should be used since additional space may be needed not only for patient transfer to a larger bed but also for the use of intraoperative endoscopy when performing bariatric procedures. Circulating nurses and scrub technicians should be prepared at a moments’ notice should any laparoscopic case require conversion to an open procedure and have all necessary open instruments ready to use.

Immediately after surgery, the patient is brought to the recovery room, one that is capable of providing critical care is necessary. In addition, an available intensive care unit and a step-down area for patients are necessary should the patient require such postoperative care.

The need for specialized equipment starts in the preoperative holding area. Extra large hospital gowns, a high capacity patient scale, appropriately sized stretchers, gurneys, and wheelchairs are all needed. Appropriately sized sequential compression devices and blood pressure cuffs are required. To safely facilitate patient transfer to and from the stretcher to bed, patient rolling devices or air-assisted transfer devices such as the Hovermatt (Hovertech International, Bethlehem, PA) may be used.

Once out of the recovery room, patients are transferred to a regular nursing floor bed or step-down unit, if not to an intensive care unit. For obesity surgery programs, consider establishing a dedicated location, floor, or unit in the hospital to house all of the inpatient bariatric patients. This creates an environment dedicated to the care of the bariatric patient and provides a framework for specialized ancillary care having undergone special training in the nursing care of the bariatric patient. In addition, having a dedicated unit or area for these patients makes the logistics much simpler and more efficient, such as having all necessary equipment present at the particular unit.

If a dedicated floor or unit is in its construction infancy, then a blueprint for success should be carefully thought out. The actual physical requirements are more complex. Larger door widths up to 60 in. wide may be needed to accommodate larger equipment such as patient beds (Fig. 4). This includes the door to the bathroom. It is recommended that there be 5 ft of space between the foot of the bed and the walls and 5 ft between either sides of the bed and walls [13]. Space is needed for room for rolling equipment such as EKG carts, portable X-ray machines, and code carts. Bathrooms and room design will need to be constructed so that bathroom doors are at least 20 in. wide. Bathrooms should have floor mounted commodes and properly installed grab bars to prevent patient falls. Floor mounted toilets can support up to 1,000 lb (453 kg), while most standard wall mounted commodes have a 250-lb weight limit (Fig. 5).

Most regular hospital beds can handle patients up to 440 lb; however, these beds are probably too narrow at 35 in., making it difficult for bariatric patients to reach the adjustment buttons or operate the side rails. Bariatric beds should be at least 44 in. wide and support up to 1,000 lb. The mattresses should be the low air loss type so patients will not tend to sink in their beds. The low air loss mattresses make it easier for patients to get out of bed and thus assist with preventing skin breakdown leading to sacral decubitus ulcers. It is optimal if the beds can be automatically adjusted into a chair position so patients can walk out of their beds from the seated position [11].

Many bariatric patients undergo routine postoperative upper GI contrast studies to assess their stomach pouches and proximal anastomosis [14]. Such fluoroscopy studies require a radiology table that can adequately support the heavy patient. In addition, patients may need CT scans or MRI, and similar to the fluoroscopy unit, a CT scan capable of accommodating the size of a bariatric patient may be unavailable. Backup plans for knowing which outside facilities or sites that may have the capabilities for oversized CT scanners are important.

Specialized resources for weight loss surgery require a significant investment. The average low-end per patient cost is $50,000; remodeling rooms and restocking inventory can cost up to $200,000 in 1 year. Many centers lease rather than purchase equipment, and advantages here include lower initial cost outlay and less need for storage space with the option of having more up-to-date equipment [11].

The surgeon is central to the bariatric patient’s weight loss experience. The surgeon is the one whom patients want to see and talk to and the one they begin and continue their journey with. Thus it is critical that the surgeon be aware of all of the necessary planning that the bariatric patient undergoes from beginning to end. The surgeon should be in constant communication with the office staff and bariatric nurses to coordinate patient care. With many programs offering an organized patient informational session, it is recommended that a surgeon participates in these sessions in order to educate patients about bariatric surgery. During the actual patient encounter in the preoperative clinic assessment, the surgeon should personally explain to the patient a summary of the prerequisites of surgery, all of the surgical procedural options, and expectations of postoperative care and recovery. The surgeon sees the patients after surgery during their impatient stay and coordinates with consulting physicians and team members regarding their postoperative care upon discharge.

The team approach begins in the office. The office may require 2 receptionists: one to check the patient in and another to confirm that their insurance covers bariatric surger. The insurance specialist is critical in assessing insurance coverage for the surgical procedure. This person should receive his or her own office as taking charge of the insurance needs and requirements is a full-time job [10].

A nurse coordinator is essential, and they may function to partake in patient care in both the clinical outpatient setting and the inpatient setting. First and foremost, they must benefit from education regarding the proper use of bariatric equipment, lifting techniques, and tailored dietary needs for these patients. The ASMBS has developed a certification program for Clinical Bariatric Nurse Specialists. In addition, the ASMBS, the AORN, and the Betsy Lehman Center for Patient Safety and Medical Error Reduction publish bariatric surgical nursing guidelines to address nursing education, practices, and certification goals, in an effort to improve patient care [15].

Registered dietitians provide patients with the information and education of the new diet that patients will be undertaking before and after bariatric surgery. They are essential for the appropriate inpatient care and long-term follow-up. They should work closely with the hospital food services to develop specialized bariatric meals that are high in protein and low in carbohydrates, fats, and sugars and are in appropriate sizes. Bariatric clear liquid diets, for example, are often different from the regular hospital clear liquid diet tray as they will have significantly less sugar. Nutritionists can also help prepare bariatric patients for the postoperative diet changes by educating patients portion control and maintenance of adequate nutrition. Without such education, patients tend to eat more fat and assume an unhealthy, unbalanced diet.

Many patients are at risk for malnutrition and should be evaluated for nutritional and vitamin deficiencies. The lifelong incidence of malnutrition after weight loss surgery can be as high as 44 % and can occur many years after the procedure [16]. This often is due to poor eating habits and poor education of what is required for the long-term process for patients attaining and maintaining a healthy well-balanced diet after bariatric surgery. In one study of 133 admissions of patients who had undergone a bariatric procedure, only 33 % of these patients were taking a multivitamin [17].

The mental and emotional aspects of obesity, weight loss, and weight loss surgery are an important consideration in the care of bariatric patients. Most weight loss programs in the United States require that a patient undergo a mental health evaluation prior to undergoing surgery. In fact, many insurance companies require such psychological evaluation prior to granting precertification for a bariatric procedure. Surgeons want to treat the whole person in order to increase the likelihood of a positive outcome for their patients. While 20–60 % of bariatric patients have a psychiatric disorder noted preoperatively, some psychiatric disorders are diagnosed postoperatively [18]. In addition, while some psychiatric conditions are improved with weight loss, others are made worse or become apparent with weight loss.

The psychological evaluation in the preoperative setting is the first step to ensure that the patient does not have any psychological needs that must be addressed. It is also a means for educating and introducing a patient to the expectations of their journey ahead as they proceed with surgery. Adequate time and attention should be provided for preoperative assessment of and support for psychological disorders. Patients referred for bariatric surgery are more likely than the overall population to have psychopathology such as somatization, social phobia, obsessive compulsive disorder, substance abuse/dependency, binge-eating disorder, post-traumatic stress disorder, generalized anxiety disorder, and depression [19]. In addition, a higher rate of suicide after bariatric surgery has been documented when compared to the general population [20]. While none of these is a contraindication to surgery, these disorders should be controlled prior to undergoing surgical weight loss in an effort to reduce recidivism and produce greater sustained and successful weight loss. While many patients will only require a single preoperative visit with a mental health professional, other patients may benefit substantially from continued short-term or long-term psychotherapy. Of note, the bulk of evidence shows no relationship between preexisting axis I psychiatric diagnosis or axis II personality disorder and total weight loss. It is not certain which psychosocial factors predict success following bariatric surgery, yet many programs exclude patients who are illicit drug and/or alcohol abusers and have active uncontrolled psychosis, severe mental retardation, or lack of knowledge about the surgery [21].