An upper age limit cannot be established given the age structure of the population with increasing life expectancy, although mortality and the risks of complications are known to increase with age (14). Therefore, the biological age of the affected patients should play a decisive role.

Operations in children and adolescents under 18 years are only indicated in exceptional cases (self-responsibility, puberty completed, expert recommendation). Intensive collaboration between a bariatric surgeon and a pediatrician specialized in obesity treatment, as well as child and adolescent psychotherapists or psychiatrists, is extremely important in these cases (Guideline Obesity in Pediatrics 2004; 22).

1. Antecolic-antegastric: technically the simplest, longest distance is favored
2. Retrocolic-retrogastric: technically complicated, shortest distance
3. Retrocolic-antegastric: technically more difficult than 1st without significant gain in "distance"

Author:

Prof. Dr. med. Rudolf Weiner

SANA Klinikum Offenbach

Clinic for Obesity Surgery and Metabolic Surgery

The position of the camera trocar is in the left upper abdomen for all gastric procedures. The distance to the xiphoid should be at least 15 cm, but not more than 20 cm.

The navel does not provide reliable orientation in obesity, as it can be displaced very far caudally, especially in men. The creation of the capnoperitoneum further increases the distance between the xiphoid and the navel. The capnoperitoneum is predominantly created at the same location in the left upper abdomen.

Tip: Due to the lack of orientation by the navel in male patients, trocars are often placed too far from the hiatal region. To solve this problem, additional trocars in the epigastrium are recommended.

For extremely thick abdominal walls (gynecoid type of fat distribution), the following techniques are available:

• Double-click puncture with the Veress needle (extra-long)
• Use of screw trocars under camera view
• Use of visual trocars under camera view

We prefer the double-click method for primary procedures and have not encountered any complications leading to conversion or termination of the operation in more than 4000 primary procedures. For secondary procedures (after previous upper abdominal surgeries, past peritonitis, or preoperatively diagnosed extreme hepatomegaly), open laparoscopy (Hasson technique) is performed infraumbilically.

Inspection of the abdominal cavity should always be at the beginning of every laparoscopic operation.

An example of an error is an overlooked ovarian tumor.

Tip: A 360-degree inspection of the abdominal cavity can exclude severe adhesions in the abdomen and reduce the risk of an overlooked ovarian tumor.

By inspecting and checking the accessibility of the oral (later alimentary) loop, the error of performing a gastric resection in a completely adhered small intestine can be prevented, and alternatively, a sleeve gastrectomy in a "frozen" abdominal cavity can be chosen.

The placement of the additional trocars is done step by step. After the optical trocar, a 10mm trocar for the liver retractor is placed below the right costal margin. This is then fixed with a holding arm. The retractor is also used to lift the greater omentum. Subsequently, a 13 mm trocar is placed below the left costal margin on the lateral abdominal wall. The two epigastric working trocars (13 mm) are introduced to provide an optimal working angle for manipulation in the hiatal area.

Tip: The distance between the working trocars should be as wide as possible to avoid interference.

• Greater omentum

Transection of the free part of the greater omentum is recommended in antecolic loop guidance and in a very fatty omentum to relieve tension from the anastomosis.

Error: Circulatory disorders with omental necrosis

Prevention: Sagittal omentum transection considering blood supply

Solution: Omentum resection in case of circulatory disorders (rare: 1 in >1000).

• Billroth-II

The execution of a single-anastomosis gastric bypass in Billroth-II form is an exceptional indication due to potential bile reflux.

• Ring reinforcement

The ring reinforcement of the gastric pouch to prevent dilation of the alimentary limb is an option that is increasingly being adopted for redo procedures.

Error: Stenosis due to ring

Prevention: Calibration with probe, circumference 6.5 cm

Solution: Resection in case of an oversized pouch and in the presence of a small intestine segment of the alimentary limb.

Author:

Prof. Dr. med. Rudolf Weiner

SANA Klinikum Offenbach

Clinic for Obesity Surgery and Metabolic Surgery

First, the presentation of the His angle should be performed. Herniations of the gastric fundus into a hiatal hernia are always repositioned to avoid leaving a too large gastric pouch. The left crus of the diaphragm is generally exposed and incised.

Tip: By consistently exposing the gastroesophageal junction on the left (spleen side), the risk of leaving a large hiatal hernia with gastric portions in the mediastinum with a large pouch can be counteracted.

Author:

Prof. Dr. med. Rudolf Weiner

SANA Klinikum Offenbach

Clinic for Obesity Surgery and Metabolic Surgery

The thorax (chest) consists of the bony elements sternum (breastbone), costae (ribs), and the thoracic spine. The sternum can be divided into its three components: manubrium, body, and xiphoid process. Typically, humans have 12 pairs of ribs, which are further distinguished into true ribs (ribs 1 – 7 with respective attachment to the sternum) and false ribs (ribs 8 -12 without direct connection to the sternum. The latter ribs are connected to the cartilaginous costal arch (arcus costalis, ribs 8 – 10) or are free in the abdominal wall (floating ribs, ribs 11 and 12).

Each rib has a bony and a cartilaginous part. Dorsally, it is articulately connected to the spine with its head of the rib (caput costae) and a tubercle of the rib (tuberculum costae) projecting from the body of the rib (corpus costae) (costovertebral joint). Between the head and body is the neck of the rib (collum costae). The respective sternocostal joint forms the ventral articular connection with the sternum.

The thorax as a whole has an upper and a lower opening:

The superior thoracic aperture is formed by the 1st thoracic vertebral body, the right and left 1st ribs, and the manubrium sterni. It includes, in addition to the passing trachea and esophagus, the apex of the lungs and occasionally caudal sections of the thyroid gland. It 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, and finally the vagus nerve, phrenic nerves, and parts of the sympathetic trunk.

The inferior thoracic aperture is formed by the 12th thoracic vertebra, ribs 10 – 12, the costal arch, and the xiphoid process. The diaphragm forms a flat, domed closure of the aperture with passageways for the large vessels and nerves as well as the esophagus.

Author:

Prof. Dr. med. Gebhard Reis

Faculty of Health (Department of Human Medicine)

Institute of Anatomy and Clinical Morphology/Director

University of Witten/Herdecke

The rectum in its upper parts has a typical wall structure consisting of mucosa (simple columnar epithelium with lamina propria and thin muscularis mucosae, as well as crypts only, lymph follicles), submucosa, muscularis, and serosa/adventitia. The peritoneum covers about half of the ventral side of the upper rectum as serosa, only ¼ laterally on the rectum, and the dorsal side is free of peritoneum. This creates a deep pouch in front of the rectum (rectouterine or rectovesical pouch = Douglas space) as the deepest point of the abdominal cavity.

Its distal sections show a characteristic transition of the mucosa into the skin of the external body surface: At the linear pecten analis, the inner epithelium of the mucosa changes into a stratified squamous epithelium, the mucosa features the mentioned anal columns and the corpus cavernosum, and glands (anal glands) are found in the recesses between the columns. Further distally at the level of the internal anal sphincter muscle, there is the light-appearing transitional zone (zona transitionalis ani), which further distally transitions into the heavily pigmented skin zone with stratified keratinized squamous epithelium. Here, in addition to hair, sebaceous and sweat glands are also found.

Author:

Prof. Dr. med. Gebhard Reis

Faculty of Health (Department of Human Medicine)

Institute of Anatomy and Clinical Morphology/Institute Director

University of Witten/Herdecke

Comorbidities are crucial in selecting patients with a BMI between 35 and 40 kg/m² for indication. Only evidence-based studies were included in the following list. Comorbid conditions according to NIH criteria include sleep apnea and other ventilation disorders (10,18), type II diabetes mellitus (26, 30, 31, 34, 36,44), obesity-related cardiomyopathy and hypertension (4, 9, 15, 35, 40, 44), hyperlipidemia (29), pseudotumor cerebri (28,43), orthopedic damage to the knees (18), spinal problems (33), stress incontinence (7, 18), polycystic ovary syndrome (45), infertility (17, 27, 50), and other less known effects on other diseases such as asthma, fibromyalgia, and carpal tunnel syndrome, whose effects are documented by bariatric surgery. It is scientifically proven that massive weight reduction leads to prevention, relative improvement, or even remission of obesity-associated somatic diseases (13, 25, 38).

The metabolic effect of the bypass procedure on the disease diabetes mellitus goes far beyond mere weight loss and is not achieved by any other therapeutic measure (24, 36). A possible reflux disease present in obesity is highly effectively treated by the gastric bypass procedure (18, 39). Studies on the psychological comorbidity of people with obesity grade III (21,46) indicate a significantly higher prevalence of psychological disorders compared to normal-weight individuals, especially in women, with affective disorders, anxiety disorders, eating disorders, and personality disorders being prominent (21, 38).

The vast majority of studies show a significant improvement, particularly in anxiety disorders and depressive disorders. Postoperatively, there is usually a decrease in eating (behavioral) disorders (binge eating) and problematic attitudes towards food, weight, and body shape (44). Psychological or psychosocial parameters such as self-esteem, interpersonal relationships, partnership, sexuality, sick leave, and employability generally experience significant improvement postoperatively (44).

The length of the alimentary limb should be 120 to 150 cm for a BMI of 40-50 kg/m2.

For a BMI > 50, a long-limb bypass with a limb length of 200 cm can be considered.

Author:

Prof. Dr. med. Rudolf Weiner

SANA Klinikum Offenbach

Clinic for Obesity Surgery and Metabolic Surgery

Dear Patient,

Your body mass index is over 35 kg/m2 according to the calculation method you are familiar with. Morbid obesity significantly reduces average life expectancy and can lead to secondary diseases such as diabetes, high blood pressure, sleep apnea, gallstones, heart disease, muscle and joint damage, and psychosocial problems.

The basic treatment, which consists of a specific diet and possibly supportive psychological measures, was not successful for you. The medical criteria for surgical treatment are met.

In the medical consultation, I was personally informed in detail about the gastric bypass surgery and its surgical procedure.

The operation is performed under anesthesia. The anesthesiologist will provide information about this.

The operation involves the division of stomach parts and exclusion of small intestine parts (see illustration).

In general, it is a major procedure with many potential complications, even if the approach is only minimally invasive (laparoscopy).

The mortality risk according to an international meta-analysis by Buchwald (2004) is 0.5%. It is therefore higher than with gastric banding at 0.1%.

Specifically for gastric bypass surgery, it must be noted that during the operation, injury to the stomach, esophagus, and other organs (spleen, ...) can occur. If the spleen is injured, the organ may also need to be removed, which can later result in susceptibility to infections. A change in procedure (from laparoscopic surgery to open surgery) is possible if complications arise or if continuing the video-endoscopic operation poses too high a risk. The surgeon decides whether an abdominal incision should be made.

Previous surgeries in the abdominal area increase the surgical risk and the level of difficulty. Especially previous surgeries in the left upper abdomen (stomach, diaphragmatic hernia, ...) complicate the procedure.

There are different forms of gastric bypass for weight reduction. Often, it can only be decided during the operation which form will ultimately be chosen. The loop to the stomach can be guided above or below the colon. This depends on the length and mobility of the small intestine. This cannot be determined before the operation, so the surgeon must make the choice to the best of their knowledge and belief. In high-risk patients, extreme fat accumulation, and previous surgeries, the mini-bypass with only one anastomosis may be chosen, where only one new connection between the stomach and intestine is formed. The second anastomosis between intestine and intestine is omitted. Accordingly, the digestive loop is longer. These digestive juices then run over the stomach-intestine connection.

I was informed about the necessity of the procedure, its risks, possible early and late complications. In particular, I was informed about the following risks and potential complications:

General complications: Infection (including hepatitis), thrombosis and embolism, necessity of blood transfusions, wound healing disorders. Blood transfusions and transfusions of blood components have their own infection risk.

Complications during the procedure, such as organ injuries, bleeding, nerve injuries.

Operations on the intestine inherently carry the risk of suture insufficiency. Injuries to the throat and esophagus can also occur when inserting the gastric tube.

If a urinary catheter is placed, injuries to the urethra and bladder are also possible. Due to the surgical positioning, pressure damage to nerves or soft tissues with sensory disturbances and very rarely paralysis of the arms and legs can occur. However, the risk is significantly higher in extreme obesity than in normal weight individuals. Skin and tissue damage from electric current, heat, and/or disinfectants are also rare. These damages usually resolve on their own.

During laparoscopic surgery, the insufflation of gas can lead to a feeling of pressure and shoulder pain. These subside quickly, as does a crackling of the skin. If the gas enters the pleural space (pneumothorax), it may be necessary to insert a drainage into the chest cavity.

After the operation, internal hernia incarcerations, adhesions, bowel obstructions, abscesses (pus collections), narrowing of the stomach-intestine connection, and ulcers can occur in the immediate postoperative phase as well as later after months and years.

Sometimes, after an operation with an abdominal incision, an incisional hernia occurs, which usually needs to be surgically closed. This can also occur in the area of a trocar in laparoscopic operations. If the abdominal suture breaks open along its entire length after an open operation (burst abdomen), a repeat operation is unavoidable. A numbness of the skin in the area of the surgical scars may remain. In some patients, the skin reacts with excessive scar formation (keloid) due to wound healing disorders or corresponding predisposition, such scars can be painful and aesthetically disturbing.

As with any surgical procedure, blood clots can form in the large veins (thrombosis), which can be dislodged and block a blood vessel (embolism). As a preventive measure, the administration of anticoagulants (e.g., the injection of heparin) is considered, which, however, can lead to a tendency to bleed and very rarely to a serious disorder of blood coagulation.

In the case of allergies and hypersensitivities (e.g., to medications, disinfectants, latex), reactions can occur that can also impair organ functions.

Complications after the procedure, such as wound healing disorders, incisional hernias, and functional sequelae are also possible. If there are leaks (leakages) in the new connection between the stomach remnant and small intestine, peritonitis may occur, necessitating a repeat operation. A later reversal of the operation (reconnection of the stomach) is practically no longer possible or only with a high surgical risk.

The remaining stomach can no longer be endoscopically examined (endoscopy) and an endoscopic treatment of bile duct stones (ERCP) is no longer possible in the conventional way.

I have been thoroughly informed about this.

Long-term consequences can include vitamin and iron deficiencies, short bowel syndrome, and a disturbance in calcium metabolism with the consequences of osteoporosis.

In planned pregnancy, increased vitamin supplementation is required, as otherwise malformations can occur. Contraception is no longer guaranteed with malabsorptive procedures. Preventive gastroscopies can no longer be performed in this way.

An endoscopic retrograde examination of the pancreatic duct (ERCP) is no longer feasible.

The success of the treatment and the avoidance of complications depend on the patient's cooperation. I have been sufficiently informed about the necessity of adhering to eating habits and follow-up examinations. If the prescribed rules (3 meals, small portions, food selection) are not followed, problems may arise and weight loss may be less. Alcohol should be strictly avoided as it is absorbed quickly. The effectiveness of medications, as well as the "pill" for contraception, may be limited.

The patient's cooperation is crucial for the success of the treatment and the avoidance of side effects.

If problems arise, contact the treating clinic immediately.

I hereby declare my consent to this procedure. I have no further questions.

Author:

Prof. Dr. med. Rudolf Weiner

SANA Klinikum Offenbach

Clinic for Obesity Surgery and Metabolic Surgery

The stomach has the task of storing ingested food, mixing it, and timely passing it on to the subsequent sections of the digestive tract. The motor control of pendular and propulsion peristalsis is managed by sympathetic and parasympathetic innervation. The regulation of transport and prevention of reflux are achieved by the lower esophageal sphincter and, aborally, the pylorus. The stomach secretes approximately 1500-3000 ml of secretion per day, with 70-80% produced by the mucosa of the fundus and corpus. In addition to the largest component, gastric acid, mucoproteins and proteases are also secreted. The most significant in terms of gastric bypass surgery is the mucoprotein intrinsic factor, which is produced in the fundus and is essential for the absorption of vitamin B12.

Furthermore, a variety of hormonal factors are produced in the stomach, which are not yet fully researched. Of particular importance are the hormones ghrelin and gastrin, both of which play a significant role in the regulation of satiety and are produced in the fundus. The regulation of hunger and satiety is further triggered by stretch receptors and the activation of sympathetic fibers.

1. Structure of the Layers

The large area covering the anterior abdominal wall from the xiphoid process or the costal arches to the pelvic bones has a typical layer structure: Beneath the skin and subcutaneous fat tissue are superficial fasciae, muscles and their fasciae, then an extraperitoneal fascia and the parietal peritoneum.

Especially in the anterior wall below the navel, the otherwise typical single-layered superficial fascia transitions into a two-layered structure (Panniculus adiposus abdominis) consisting of a superficial fat-rich layer (Camper's fascia) and a deeper membranous layer (Scarpa's fascia). The 5 abdominal muscles consist of:

• 3 oblique muscles (1. External oblique muscle, 2. Internal oblique muscle, and 3. Transverse abdominal muscle)
• 2 straight muscles (4. Rectus abdominis muscle and the inconstant 5. Pyramidalis muscle).

a) External Muscle

Located immediately under the superficial fascia, it runs caudomedially to the large aponeurosis, both sides merging centrally to the linea alba. Its lower edge forms the inguinal ligament from the anterior superior iliac spine to the pubic tubercle, which in turn medially gives off the lacunar ligament and the pectineal ligament (Cooper's ligament).

b) Middle Muscle

Fibers run craniomedially, merging with fibers from 1. to the linea alba.

c) Innermost Muscle

Transversely running fibers, also radiating into the linea alba.

• Each of the three oblique abdominal muscles has a thin, own fascia on its front and back surface, 3. on its inner side the strong transversalis fascia. This lines the abdominal cavity and transitions cranially into the diaphragmatic fascia and dorsally into the thoracolumbar fascia. Caudally, it is attached to the iliac crest and transitions into the endopelvic fascia.
• Long straight paired abdominal muscle, interrupted by 3 – 4 transverse tendinous intersections ("Sixpack").
• Triangular rudimentary muscle caudal and ventral to 4. between the pubic bone and linea alba.

2. Fasciae and Peritoneum

Muscles 4. and 5. are enclosed by the rectus sheath, which is formed by the 3 oblique abdominal muscles 1. – 3. 4. is completely enclosed by it in its upper ¾, in the lower ¼ below the arcuate line only covered at the front, while here the back surface of 4. only shows the transversalis fascia and the peritoneum. In the upper ¾, the front layer of the rectus sheath is formed by 1. and half by 2., the back layer half by 2. and 3.

Between the transversalis fascia and the peritoneum lies the extraperitoneal space, which can vary in thickness depending on the location. In the retroperitoneum, the retroperitoneal abdominal organs are located here. At the anterior abdominal wall, it is repeatedly referred to as the preperitoneal space (e.g., at the internal inguinal ring).

The peritoneum (parietal serosa) forms the completely closed peritoneal cavity (exception: opening of the tube in women) and transitions as visceral peritoneum onto the intraperitoneal organs. Below the navel, it forms three folds:

• the unpaired median umbilical fold (obliterated urachus/urinary duct)
• 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 rami of the spinal nerves Th7 to Th11, Th12 (subcostal nerve) and L1 (iliohypogastric nerve, and ilioinguinal nerve).

Its superficial blood supply is cranially from the internal thoracic artery (→ musculophrenic artery), in the lower part from the superficial epigastric artery or the superficial circumflex iliac artery (both from the femoral artery). The deep blood supply comes cranially from the superior epigastric artery (internal thoracic artery), laterally from intercostal vessels, and caudally from the inferior epigastric artery or the deep circumflex iliac artery (both from the external iliac artery). Venous drainage occurs via veins of the same name.

Author:

Prof. Dr. med. Gebhard Reis

Faculty of Health (Department of Human Medicine)

Institute of Anatomy and Clinical Morphology/Institute Director

University of Witten/Herdecke