Robotic Surgery Holds Great Promise for Bariatric Surgery Patients.

As many of you know, qver the last several weeks I have been observing robotic surgery, logging time practicing on the newest robot and doing a lot of planning for my first robotic gastric bypass operation scheduled on September 14th , just a little over two weeks from now.

Today I spent the entire day training in the robotic laboratory at Good Samaritan Hospital in Cincinnati, Ohio. It was an intense day with many hours in the console of the robot performing several operations, learning to “dock” the robot to the ports and instruments and learning much more about this elegant and sophisticated machine.

The training will continue nearly each day in preparation for the first operations but everything is progressing very smoothly.
I must say, I believe the da Vinci Robot is very likely to bring considerable value to my gastric bypass patients. I am even hopeful that many will be able to go home the day after surgery since I believe I will be able to decrease the incision “footprint” by about 50% and there should be even less discomfort involved with this operation.

Congratulations to Intuitive Surgical, Inc. for many improvements in the newest model of the da Vinci robot!

Posted by Stephan Myers, MD, FACS, bariatric surgeon, Columbus Ohio

Six Stages of Eating After a Gastric Bypass

You are likely to pass through 6 separate stages of eating after your gastric bypass operation.

Recently I saw a patient who had a laparoscopic Roux en-Y gastric bypass by me a few months ago who was quite frustrated that she could not eat and drink what she wanted to consume. She wanted to eat a regular diet but was not yet able to eat as much solid food as she had expected. She seemed to be someone who could not allow the process to proceed in the usual fashion.

The fact is you cannot rush the healing process and trying to speed things up will only make a person frustrated and could be harmful. After performing several hundred of these operations there is a natural progression I have observed after a gastric bypass operation and it usually goes like this:



1). FIRST WEEK

It seems almost impossible to get as much liquid down. The only way to stay hydrated is to sip very small amounts every 15 minutes or so all day long.

2). WEEKS 2 THOUGH 5

Slowly liquids become somewhat easier to go down. This is when a patient starts learning how much they can swallow at one time. If you drink faster than the pouch can empty fluids will back up in the esophagus and cause a pressure sensation in the chest. Slowing down even more will relieve this unpleasant sensation.

3). WEEKS 6 THROUGH 9

The patient often feels they are having more difficulty eating and drinking than they had over the previous few weeks. This is because the connection between the gastric pouch and the intestine is healing and the scar is becoming thicker resulting in a narrower outlet to the pouch. Just as you have observed when you have cut yourself the scar is relatively smooth for the first few weeks but it becomes thicker and more angry looking at about 6 to 9 weeks. As the scar is remolded the scar will slowly become softer over the next several weeks and months. The scar at the connection between the gastric pouch and intestine goes through this same process and the thickened scar is the reason that it takes more time for the food and drink to pass out of the pouch into the small intestine. We frequently call this the “window of misery” and you will find a posting by that name elsewhere in this blog.

4). WEEKS 10 THROUGH 12

The scar that I mentioned above softens and the opening between the gastric pouch and the small intestine starts to slowly open up more and food and drink passes through more easily.

5). BETWEEN 3 and 6 MONTHS Although things continue to improve, usually meat and bread is still difficult unless the meat is ground and the bread is toasted to make the fragments and particles smaller.

6). BETWEEN 6 MONTHS and 1 YEAR Things continue to Improve and sometime during this period patients begin to have less and less difficulty swallowing meats and bread. By this time the diet has returned to normal although many people tell me there food choices have changed considerably and they eat much healthier.

Hopefully this week by week description will help you as you go through the various stages and you will be more patient with yourself since you know better days are coming.

By Stephan Myers, MD, FACS, bariatric surgeon in Columbus, Ohio

Gastric Sleeve Operation

Recently we have noticed that more and more patients are choosing to have a laparoscopic gastric sleeve operation. I have now performed over 80 of these operations and patients seem to be generally very pleased with the results. Their weight loss is quite good having lost an average of 87 lbs in the first year which is 78% of their excess weight. The range of weight loss is between 41% and 102% of their excess weight.

The weight loss appears to occurring in a very similar fashion to the weight loss from a gastric bypass. nearly all of the weight is lost in the first year.

There is no rearranging of the small intestine and therefore vitamins and calcium are not medically necessary although still a good idea.

A gastric sleeve operation is likely to improve or resolve many obesity related medical problems such as sleep apnea, urinary stress incontinence and high cholesterol but it is not as good as a gastric bypass to resolve type II diabetes or severe gastroesophageal reflux.

The complication rates are low and the two most frequent problems have become even more infrequent in our practice over the last year. Fairly early in our series we had two people who had leaks along the staple line and two patients had narrowing of the sleeve which was treated with revision to a gastric bypass. Neither of these problems have occurred since we have gained more experience with the procedure but they are still a possibility.

All operations have been able to be performed laparoscopically with no conversion to open operation.

All commercial insurance companies in our area cover a gastric sleeve except Anthem/Blue Cross and Blue Shield companies.
I feel a gastric sleeve operation is an excellent option for patients who do not have severe type II diabetes or severe gastroesophageal reflux disease.

An Unusual Way to Keep Weight off after Bariatric Surgery

Last week I saw Peggy Lauritzen, one of my patients, in the office and she told me of the unusual way she reminds herself to eat slowly. She carries chopsticks in her purse and uses them for all of her meals!

Think it is crazy? She has kept her weight off and is doing very well several years after her gastric bypass. It may be a little quirky but it works for her.

Once a friend of hers said "I would lose weight too if I used chop sticks." Peggy said, "so what's your point.

How do slow down your eating? Do you have a quirky way to remind yourself to slow down and chew slowly. Leave a comment and I will share it with the other 750 people that follow this blog each month.

Losing Weight Prior to Bariatric Surgery May Help Obtain Your Best Result

Every week I see patients who have been operated on at other programs only to gain back much of their weight or disappointed with the amount of weight they have lost. Often people had their operation when their weight was considerably more than a BMI of 55. (That would be more than 355 lbs for a person that is 5 foot 7 inches tall.)

This is the message:

Gastric bypass and gastric sleeve operations help people lose weight for only about one year.

After the first year the operation is likely to help the patient to maintain their weight at about the same level but it is unlikely that they will lose more weight from the operation.

Whatever a person’s weight is one year after a gastric bypass or gastric sleeve operation is at 1 year after the operation is likely to be about near their best weight.

That is why we choose to make sure each patient is no more than a BMI of 55 prior to surgery. This can be done with dietary changes, medications and/or a physician supervised very low carbohydrate diet.

Shifting the curve I drew for you downwards, (note the purple arrow pointing down), before surgery is the way to obtain the best result after surgery.



The weight loss curve is about the same regardless of how much excess weight someone has. Although there may be the occasional exception, the most a patient is likely to lose after a gastric bypass or gastric sleeve operation is about 170 to 200 lbs. That means if you have 300 to 400 lbs of excess weight you are still likely to have 200 lbs of excess weight after surgery. This is why we encourage our patients to "shift the curve" downward to a BMI of 55 if their weight exceeds this number. Then after surgery they are much more likely to lose nearly all of their excess weight and approach ideal weight and resolve many of their obesity related medical problems.

These are the benefits of reaching a BMI of 55 or less before surgery.

Better results
Weight reaches near Ideal weight at 1 year
Better resolution of obesity related medical problems
Less complications
Less likely to need a tracheostomy
Less likely to need to need ICU stay
Less likely to have skin or muscle breakdown from being in bed after surgery

This is the bottom line:
Safer operation with better results

Posted by Stephan Myers, MD, FACS, Bariatric Surgeon, Columbus , Ohio

Robot and Bariatric Surgery

When using the Da Vinci Robot to perform bariatric surgery I begin the operation at the operating table placing the robotic scope and instruments as I would in a standard laparoscopic operation. I then sit at a consol in the same operating room and thereafter all robotic movements of instruments are controled by me.

The veiw is much better because I can see in 3-D since the scope is a binocular scope. Also most of the instruments are "wristed" alowing me to reach angles that are not possible with standard laparoscopic techniques. If I need an instrument to be changed the first assistant and scrub nurse are continuously at the side of the patient and they will remove one instrument from the robot and attach another at my command. Interestingly, the robot "remembers" exactly where the previous instrument is located within the abdomen and placed the instrument in the same location only a short distance from the previous point to protect the patient from any possible injury.

The placement of stitches is more exact and I am able to see much better with the robot than with other techniques.

I am very pleased Riverside Methodist Hospital presently has 2 of these advanced robots with a third to be installed by mid-September.

Written by Stephan Myers, MD, FACS, bariatric surgeon in Columbus, Ohio.

Da Vinci Robot and Bariatric Surgery

I have been pondering the possible place for the Da Vinci Robot in bariatric surgery for a few years. Although it is an expensive device, (about 2.5 Million dollars per robot), I am now convinced there is very real value for bariatric patients and their surgeons.

First, he patient is likely to benefit by having less incisions decreasing from four ¾ inch incisions and one 1 ¼ inch incision to two ¾ inch incisions and two ½ inch incisions. This alone should decrease pain and shorten recovery time. In addition the robot “remembers” the point each device passes through the abdominal wall and pivots at this point decreasing the trauma to the abdominal wall tissues thus decreasing pain even more.

Second, the surgeon can see better since the view is a 3 dimensional view instead of the 2 dimensional view with standard laparoscopy. The better the surgeon can see the safer the operation. Who wouldn’t like there surgeon to see as well as possible during their operation?

Another issue is the reduced wear and tear on the surgeon. Operation on persons of size is physically demanding and allowing the robot to take the physical load while the surgeon is guiding every move of the robot while sitting comfortably at the console may add years to the length of a surgeons career.

Two weeks ago I spent the day in New England with Dr. Toder who performed 2 gastric bypass operations that day. It was clear to me that using the Da Vinci robot would be of benefit to our patients.

Riverside presently has 2 robots and they will be installing the third and most up to date robot in the operating room I usually use to do bariatric surgery operations by the middle of September 2010.

Over the next 6 weeks I will be training on this new instrument. I am hoping the robot will reduce the number of days a patient stays in the hospital from 2 days to one day.

I will post regular updates as we make this transition to this advanced technique to keep you informed.