Prior to Surgery
Once it is decided that LAP-BAND is the appropriate procedure for you, the following steps will become part of the pre-operative work up :

1. Consultation with our Surgeons
   to discuss your medical and weight history, and the procedure in detail, including general and specific risks and to complete the process of informed consent.
2. History and Physical
   by your family doctor. This allows us to identify any potential medical conditions that could affect the safety of the operation or the post-operative course.
3. Pre-Operative Ultra Low Calorie Diet using OPTIFAST
   this prescribed nutritionally complete dietary regimen is used pre-operatively for at least 2 weeks to reduce fat stores in the liver and make the surgical procedure easier and safer. It also gives you a head start prior to your operation.
4. Assessment by a dietician/nutritionist (if indicated)
   this gives us a detailed report on your dietary history including prior attempts at weight loss. It also identifies any potential dietary factors that may affect the anticipated success of the surgical procedure.
5. Assessment by a psychologist (if indicated)
   this gives us a report on any potential psycho-social factors that may affect your ability to comply with the modified eating pattern that is integral to the success of the gastric banding procedure.

The reduced surgical trauma and pain of the LAP band surgery results in shorter hospitals stays and less risk for the patient. However, follow-up treatment is an essential part of the operation. Most patients are only kept overnight in the hospital, with a post-op exam a week later. During this exam, the band size will be checked and possibly adjusted through the injection port created during the surgery. The band size will be adjusted throughout treatment, when necessary, to help control over or under-eating.

Light physical activities can be resumed within five days in most cases, avoiding heavy exercise and lifting. Patients can usually return to work within three weeks. Banding requires careful management of patient diet, both before and after surgery. If possible, patients should reduce calorie intake by 25%, but avoid any fad or binge diets. Increased physical activity is encouraged to increase the healing time. Patients may be placed on a low energy liquid diet for two to four weeks prior to the surgery to ease surgical risks by reducing the size of the liver. Others may be allowed a semi-normal diet, with a clear liquid diet on the day before surgery. No food or drink is allowed the day of surgery. Patients must also follow a completely liquid diet for two weeks following the surgery. A pureed diet is prescribed for the following two weeks; only then may patients gradually begin a normal diet consisting of low energy foods spread out over several small meals and snacks. Only by following these strict guidelines will the patient continually lose weight. As this is a radical diet change for most LAP band patients, patients are urged to seek a dietician's input, as well as participate in group and/or individual therapy. Patients who follow clinical advice will typically lose a third of the weight within twelve to eighteen months.

Surgical Procedure
LAP-BAND surgery is performed under general anaesthesia at The Taj Medical Group's Internationally approved Hospital. Fellowship trained anaesthetists with extensive experience will be performing the anesthetic and directing the immediate post-surgical care.

LAP-BAND surgery is usually performed laparoscopically. A series of small puncture openings are made in the abdominal wall to accommodate instruments. A video camera is attached to a special telescope to provide visualization in the abdominal cavity. The abdominal cavity is filled with absorbable gas to create the space necessary to complete the procedure.

A tunnel is created around the upper stomach and the LAP-BAND device is manipulated into the proper location. Sutures are placed in the stomach to hold the LAP-BAND in place and prevent it from sliding into a less optimal position. Tubing from the Lap-Band is then attached to a port, which is placed under the skin, but on top of the muscle, of the abdominal wall. Fluid can be injected through the port to precisely adjust the size of the Lap-Band reservoir and thus modify the size of the opening into the rest of the stomach. There may be situations where it may be necessary to make a larger incision to place the LAP-BAND System. This could happen if there are problems completing the surgical procedure using the laparoscopic technique. These problems could be due to anatomical variation, scarring from previous surgery and unexpected findings at surgery.

The operation usually takes about 60 minutes to complete. After the surgery you will be closely monitored in the Recovery Area until you are able to be discharged, which is usually 3 - 4 hours later.

You will be given extensive instructions regarding activity and diet recommendations. Follow-up in the clinic with your surgeon and the Clinical Nurse Specialist will be arranged.

When the Lap-Band is first placed around the stomach there can be some swelling of the stomach wall which makes the channel across the Lap-Band narrower at the beginning. Therefore we will recommend that you start out drinking only water and fluids. In many cases we will recommend that you continue the Optifast for the first two weeks after your surgery. Your diet will be advanced so that you will start on pureed and soft foods after about 10 to 14 days. After about 3 to 4 weeks we will advise you to start on regular solid food. It is at this point that you will begin to feel the sense of fullness, or satiety, that will restrict how much you can consume at any given meal. You will likely not have the desired feeling of fullness when you are on liquids or even soft foods. It is important to keep this in mind after the surgery, because you may not lose weight for the first few weeks. This is normal and not a cause for concern. It is important to follow the guidelines we will give you. If you try to eat solid food too early, you may cause yourself to vomit which is very uncomfortable. Prolonged vomiting may affect the ability of the Lap-Band to become properly anchored which could increase the risk of "slippage" (see complications). Adjustments to the Lap-Band (called fills, or de-fills) are normally performed in the clinic. The reservoir is placed below the skin and abdominal wall fat at the time or surgery, and is not visible. The reservoir can usually be identified through simple touch and accessed with a specially designed needle.

The first adjustment does not take place until at least 5 weeks after the surgery. By then the swelling of the stomach will have subsided and you will be eating solid foods. It is at this point that we will assess whether an adjustment is necessary or not. The factors that influence the need for an adjustment are:

• Are you feeling full after a smaller amount of solid food?
• What kind of foods are you able to eat?
• What is the rate of weight loss?

Based on the answers to these questions, we may or may not recommend an adjustment to the Lap-Band. The number of adjustments that may be necessary is variable from patient to patient. About 10% of patients never need an adjustment to their band and achieve desired weight loss without a fill. Other patients may need one to many fills to find the "sweet spot" or "green zone" (see chart above). The need for an adjustment is dependant on the response to the above questions at each visit. Standardized protocols (depending on the size of Lap-Band) are used to determine the amount of adjustment necessary.

Occasionally, we may be unable to access the Lap-Band reservoir in the office. In this situation, it may be necessary to make arrangements for an adjustment under X-Ray control at the hospital. This has been shown to be an uncommon situation.

The LAP-BAND System encourages weight loss by restricting the amount of food an individual can consume and by inducing a feeling of early satiety (feeling full). Published literature reports data for up to four years post LAP-BAND System surgery with sustained weight loss. To date, there are no publications noting average weight regain.

New studies are published every month demonstrating the safety and effectiveness of LAP-BAND surgery.

Note : Surgeons report that at 5 years, many LAP-BAND and Gastric Bypass patients achieve comparable weight loss (55% for LAP-BAND and 59% for Gastric Bypass).<sup>10

3</sup> Rubenstein R. Obes Surg 2002; 12: 380-384

⁴ Ren et al. Laparoscopic Adjustable Gastric Banding: Surgical Technique. J of Laparoend & Adv Surg Techniques 2003; 13 (4): 257-263.

⁵ Belachew et al. Long-Term Results of Laparoscopic Adjustable Gastric Banding for the Treatment of Morbid Obesity. Obes Surg 2002; 12: 564-568.

⁶ O'Brien et al. Weight loss and early and late complications - the international experience. Am J Surg 2002; 184: 42S-45S.

⁷ Favretti et al. Laparoscopic LAP-BAND: A 7-year Experience Involving 830 Patients (Abstract). Obes Surg 2001; 11: 160.

⁸ Dargent J. Laparoscopic Adjustable Gastric Banding: Lessons from the First 500 Patients in a Single Institution. Obes Surg 1999; 9: 446-452

⁹ Fielding G. LAP-BAND - Experience with 620 Cases over Forty-five Months (Abstract). Obes Surg 2000; 10: 143.

Morbid obesity is associated with serious medical problems. Studies indicate that even a mild reduction (10%) in weight produces an improvement in blood sugar control and a reduction in blood pressure and cholesterol levels. Many studies have been published that establish the improvement in co-morbidities associated with weight loss through use of the LAP-BAND System.

In Ponce et al , 402 patients who were at least one year post Lap-Band Surgery were studied. Resolution of diabetes occurred in 66% at 1 year and 80% at 2 year follow-up. Hypertension resolved in 60% at 1 year and 74% at 2 years after surgery. (Ponce et al, Effect of Lap-Band induced Weight Loss on Type 2 Diabetes Mellitus and Hypertension Obesity Surgery 14, 2004) Alvarez-Cordero et al report the following improvement in co-morbidities related to weight loss after LAP-BAND surgery:

(Alvarez-Cordero R, Ramirez-Wiella G, Aragon-Viruette E et al. Laparoscopic gastric banding: initial two year experience. Obes Surg 1998;8:360).