It is another Bariatric Friday, and Kemal Erkan, Chairman of American Surgery Center, is joined by Dr. Isaias Irgau, President of Christiana Institute of Advanced Surgery (CHRIAS). For the last 20 years, Dr. Irgau has specialized in bariatric surgery. Today’s discussion is focused on the patient's experience on the day of bariatric surgery. The preparation for bariatric surgery commences a long time before the date of the procedure. Erkan emphasizes this matter; the process can begin anywhere from three to nine months before the day of the surgery.

Erkan asks Dr. Irgau to explain the process of preparing for bariatric surgery. Because the patients have been prepping for months prior to the date of the procedure, “it is a day they have been waiting for for months,” Dr. Irgau states. Patients often feel excitement and apprehension leading up to this moment; however, Dr. Irgau explains that these are two very common emotions for patients to experience before undergoing bariatric surgery. The rigorous preparation consists of a two week meal replacement diet leading up to the day aimed to decrease the size of the patient’s liver. A dense, enlarged liver can affect the safety of the procedure, so this diet allows physical movement of the liver to be much easier for the doctors performing the surgery.

On the day of the procedure, the patient arrives at the surgery center, completes registration, and the patient is taken to the preoperative area. The patient is greeted by nurses who specialize in preoperative processes. Following the preoperative examination, the patient is given an intravenous line inserted by an experienced nurse, which will provide medications to the individual. These medications aim to minimize complications and enhance recovery. By decreasing discomfort after the surgery, the recovery process goes much more smoothly. Blood thinning medications are also administered on site by the nurses to the patient. “Blood clots can form after any surgery,” Dr. Irgau explains, “ and the best way to take care of blood clots is to prevent them”. When the individual consumes the blood thinning medication, it decreases the likelihood that they will develop blood clots postoperatively.

Following the assessment and preparation in the preoperative area, the patient is interviewed by the anesthesiologist, the specialist who will help them go to sleep during surgery in order to prevent the patient from feeling anything during surgery. This interview determines what type and quantity of medication will ensure that the patient does not feel any pain during the operation. This time is also utilized to address any questions or concerns the individual may have.

Once all of these steps are all completed, it is time for the patient to enter the operating room. The patient is placed on the operating table and given a sedative by the anesthesiologist. The patient drifts off to sleep and a breathing tube is inserted to ensure steady breathing while asleep. Compression boots are placed and utilized during surgery, as it is important to increase circulation to the heart to minimize the risk of blood clots. The surgery itself takes sixty to ninety minutes, fairly short in comparison to other operations. The procedure is undertaken laparoscopically; this means it is done through small, keyhole incisions that are placed in the abdomen. The instruments used to conduct the operation are slender pieces as well as using a telescope to monitor the patient’s stomach.

Erkan asks “which medications can patients definitely not take before the surgery?” Dr. Irgau responds by explaining how important it is to look into the patient’s health history and known allergies; the nurses are well educated on knowing exactly what medications the patient should or should not be taking prior to the operation. Dr. Irgau was also asked by Erkan what happens right after surgery to ensure a fast recovery. Dr. Irgau breaks down the psychological findings of the patient’s behavior. He explains that when a patient awakes from the procedure and is laying horizontally while being provided everything to them??, they assume the role of someone who is sick; however, if the patient is up and moving sooner rather than later, they are less likely to feel symptoms of nausea or other ailments. This, overall, sets the brain to go into recovery mode rather than sick mode. American Surgery Center patients do very well with the recovery process; “out of the last three hundred sixty patients only two had to stay overnight,” Erkan proclaims.

Dr. Irgau strongly believes in increasing the education on what the patient’s date of surgery looks like. It is all about enhancing the process of the patient’s recovery. Another helpful addition to the surgery is giving the patient a top block. A top block is a technique done by the surgeon which, at the time of the surgery, numbs the patient's nerves that supply the abdominal wall. This allows the patient to wake up feeling no pain in that site. This lack of pain increases the individual’s confidence that the rest of their post operational experience will continue to be painless even after the numbing medication wears off. The brain’s perception of health translates to the patient’s actual health.

Dr. Irgau states that after surgery “traditionally most of the pain that patients would feel… is the incisions”. Because the technique he uses are the small keyhole incisions, pain does not play a big role in the patient’s post operational experience. The one pain that can occur, however, is gas pain. Until the body reabsorbs the carbon dioxide used to raise the abdomen during the procedure, there can be some discomfort. Dr. Irgau mentions, “the good thing is that this discomfort actually is very transient, and it usually goes away as the patient starts walking after surgery”.

The first two hours after surgery are a period of intense monitoring. The patient’s vitals need to be at a good level, and the patient needs to be monitored to ensure that there are no effects from the anesthesia. Nurses will be observing the patient at their bedside for these hours. In total, after the surgery, the patients are expected to remain in the center for six to eight hours. Erkan mentions, “at American Surgery Center, we are able to have one nurse dedicated to one bariatric patient. What is the ratio in the hospital setting?”. Dr. Irgau responds by telling him that hospitals are much different. One nurse monitors a number of patients, which is fine, but does not give the same personal experience. “That is one of the advantages of having a surgery center,” Dr. Irgau recounts. Erkan speaks from personal experience that he notices patients are much happier when having a dedicated nurse; “we have almost one hundred percent patient satisfaction… when we provide the same service in the hospital with the same surgeons it is not one hundred percent”.

After discharging the patient, a nurse will follow up with the patient the day after the procedure. Two weeks following the procedure a nurse will perform a postop encounter visit via video chat or in person visit. The surgeons are on call twenty-four hours a day, seven days a week. Erkan states, “this is important, and our patients are important. We are happy to see the results”.