A laparoscopic vertical banded gastroplasty, or LVBG, is performed with the help of a bariatric laparoscope. A laparoscope is a small (10 mm in diameter) tube that holds a fiberoptic cable that allows the surgeon to view the inside of the abdominal cavity on a high-resolution video screen and record the operation on a video recorder. In a laparoscopic VBG, the surgeon makes three small incisions on the left side of the abdomen for inserting the laparoscope, and a fourth incision about 2.5 in (14 cm) long on the right side. The formation of the stomach pouch and insertion of the plastic band are done through these small incisions. Because it is more difficult for the surgeon to maneuver the instruments through the small openings, an LVBG takes longer than an open VBG, about two to four hours.
A laparoscopic VBG requires that the surgeon spend more training and practice than with an open VBG. As of 2003, about 90% of VBGs performed in the United States are done as open procedures. In the event of complications developing during a laparoscopic VBG, the surgeon usually completes the operation using the open procedure.
DETERMINATION OF OBESITY. The diagnosis of a patient for bariatric surgery begins with measuring the degree of the patient's obesity. This measurement is crucial because the NIH and almost all health insurers have established specific limits for approval of bariatric procedures.
The obesity guidelines that are cited most often were drawn up by Milliman and Robertson, a nationally recognized company that establishes medical need for a wide variety of procedures for health insurers. The Milliman and Robertson criteria for a patient to qualify for weight loss surgery are as follows:
be least 100 lb (45 kg) over ideal weight, as defined by life insurance tables; have a BMI of 40 or higher; or have a BMI over 35 with a coexisting serious medical condition (for example: severe diabetes or coronary artery disease)
demonstrate failure to lose or regain of weight despite having tried a multidisciplinary weight control program
have another cause of obesity, such as an endocrine disorder
have attained full adult growth
The patient must be treated not only by a doctor with special training in obesity surgery, but in a comprehensive program that includes preoperative psychological screening and medical examination; nutritional counseling; exercise counseling; and participation in support groups
There are several ways to measure obesity. Some are based on the relationship between a person's height and weight. The older measurements of this correlation are the so-called "height-weight" tables that listed desirable weights for a given height. The limitation of height-weight tables is that they do not distinguish between weight of human fatty tissue and weight of lean muscle tissue—many professional athletes and body builders are overweight by the standards of these tables. A more accurate measurement of obesity is body mass index, or BMI. The BMI is an indirect measurement of the amount of body fat. The BMI is calculated in English measurements by multiplying a person's weight in pounds by 703.1, then dividing that number by the person's height in inches squared. A BMI between 19 and 24 is considered normal; 25–29 is overweight; 30–34 is moderately obese; 35–39 is severely obese; and 40 or higher is defined as morbidly obese.
More direct methods of measuring body fat include measuring the thickness of the skinfold at the back of the upper arm, and bioelectrical impedance analysis (BIA). Bioelectrical impedance measures the total amount of water in the body, using a special instrument that calculates the different degrees of resistance to a mild electrical current in different types of body tissue. Fatty tissue has a higher resistance to the current than body tissues containing larger amounts of water. A higher percentage of body water indicates a greater amount of lean tissue.
PSYCHOLOGICAL EVALUATION. Psychiatric and psychological screening before a VBG is done to evaluate the patient's emotional stability and to ensure the expectations of the results of weight loss are not unrealistic. Because of social prejudice against obesity, some obese people who have felt isolated from others or suffered job discrimination come to think of weight loss surgery as a magical or quick solution to all the problems in their lives. In addition, the surgeon will want to make sure that the patient understands the long-term lifestyle adjustments that are necessary after surgery, and that the patient is committed to making those changes. A third reason for a psychological assessment before a VBG is to determine whether the patient's eating habits are compulsive; these would be characterized by the persistent and irresistible impulse to eat with unknown or unconscious purpose. Compulsive eating is not a reason for not having weight loss surgery, but it does mean that the psychological factors contributing to the patient's obesity will also require treatment.
OTHER TESTS AND EXAMINATIONS. Patients must have a complete physical examination and blood tests before being considered for a VBG. Some bariatric surgeons will not accept patients with histories of major psychiatric illness; alcohol or drug abuse; previous abdominal surgery; or collagen vascular diseases, which include systemic lupus erythematosus (SLE) and rheumatoid arthritis. Many will not accept patients younger than 16 or older than 55, although some surgeons report successful VBGs in patients over 70. In any event, the patient will need to provide documentation of physical condition, particularly comorbid diseases or disorders, to their insurance company.
Rebecca Frey Ph.D., The Gale Group Inc., Gale, Detroit,