Step 2: Preoperative Considerations
- ♦
This procedure is currently mostly reserved for those patients who are super obese or who may be high risk for a gastric bypass procedure. The sleeve gastrectomy can be used as a staging procedure for a future gastric bypass or duodenal switch. It works as a restrictive-only procedure.
- ♦
The patient’s height and weight should be measured accurately in the office by the surgeon to determine the patient’s body mass index (BMI). The patient’s BMI should fall within the NIH guidelines for weight loss surgery. The BMI should be greater than 40 kg/m 2 or >35 kg/m 2 with an obesity-associated comorbidity.
- ♦
All patients should be asked to stop smoking prior to any weight loss procedure. Smoking will impede healing and increase risk of perioperative pulmonary complications. Furthermore, smoking is currently the number one cause of preventable death. There is no indication to correct the second cause, obesity, if the first one will already result in early mortality.
- ♦
Patients should undergo psychologic evaluation to rule out a binge eating disorder. The psychologist or psychiatrist can also help assess the patient’s readiness for surgery and determine if the patient has realistic expectations from the surgery. The patient should have a nutritional evaluation and a thorough medical evaluation prior to surgery.
- ♦
Review the potential complications with the patient in detail including risk of anastomotic leak and death. Every patient’s perioperative risk will vary depending on his or her comorbidities.
- ♦
The patient should be well educated about the dietary and lifestyle changes that will be required for successful, sustained weight loss. The patient should know and prepare for the modified diet he or she will follow after the surgery.
- ♦
It is helpful to advise the patient to lose weight prior to surgery to help facilitate the operative procedure. One option is to require patients to lose 10 lbs between their first clinic visit and the surgery date. Placing patients on a liquid diet for 2 weeks prior to the surgery is also advisable. This helps to shrink the visceral fat and particularly the fatty deposits within the liver.
- ♦
Have an operating room team that is familiar with bariatric surgery. The nurses should be familiar with the steps of the procedure. The anesthesiologist should be aware of the aggressive fluid resuscitation the patient will require intraoperatively and be skilled at difficult intubations.
- ♦
Patients receive a bowel prep the day prior to the procedure.
- ♦
On the day of the procedure patients receive prophylactic antibiotics. Patients receive deep venous thrombosis prophylaxis with sequential compression devices and subcutaneous or fractionated heparin.
Step 3: Operative Steps
1.
Room Setup ( Figure 22-1 )
- ♦
The patient is positioned supine on the bed. The feet are secured to a footboard, and both arms are left out. Care should be taken to be sure the arms are well padded to avoid a brachial plexus injury. The feet should be positioned flat on the footboard and secured so that they cannot supinate or pronate. A Foley catheter should be placed prior to positioning. The surgeon stands to the right side of the patient. The assistant stands to the left of the patient and will also operate the camera.
