LAP-BAND PROCEDURE BRIGHAM AND WOMEN’S HOSPITAL BOSTON, MASSACHUSETTS Broadcast July 27, 2005 NARRATOR 00:00:15:00 Laparoscopic Adjustable Gastric Banding is a new minimally invasive surgical treatment for weight loss that requires no stomach stapling or intestinal rerouting. This innovative procedure offers a new option for patients with morbid obesity that allows for a quicker recovery with less pain and risk of wound complications than traditional weight loss surgery. Laparoscopic Adjustable Banding is one of the many new options available at the Brigham and Women's Hospital Program for Weight Management, which offers a comprehensive range of personalized nutritional, medical and surgical weight loss and weight maintenance approaches. Today’s program is part of Brigham and Women's ongoing educational efforts to bring the latest information in healthcare to physicians and patients. During the program, you may send your questions to the OR surgeons at any time. Just click the MDirectAccess button on your screen. And now, your host. MALCOLM ROBINSON, M.D. 00:01:16:00 Hello, I’m Dr. Malcolm Robinson and I’m the director of the Program for Weight Management here at Brigham and Women's Hospital. Welcome to our live surgical webcast, Laparoscopic Adjustable Gastric Banding for weight loss. As many of you know, the number of Americans with unhealthy weights is rapidly increasing. Currently, over 60% of adults in the United States meet the medical criteria for being overweight or obese. Weight-loss surgery has proven to be very effective in helping those in the highest weight categories lose weight. So effective is weight loss surgery, that greater than 100,000 individuals have this type of procedure each year across the country. Today, we would like to focus on a relatively new type of weight-loss operation, known as Laparoscopic Adjustable Gastric Banding, or the LAP-BAND procedure. What’s new about the LAP-BAND procedure is that it requires no cutting of the stomach, no cutting of the intestines, nor any rerouting of the intestines. Because of this, the time to perform this procedure is significantly less than traditional weight-loss operations. Now there are other type, other weight-loss operations that we offer here through the Program for Weight Management at the Brigham. You may have heard of the gastric bypass operation. This is, indeed, effective. There are also non-surgical treatments for those who are not interested in surgery or who are in lower weight categories, such as medication that’s been approved by the FDA for weight loss, nutrition and diet counseling and behavior techniques.

00:02:47:00 Today, however, we want to focus on the LAP-BAND procedure because this procedure is rapidly gaining popularity amongst patients, primary care physicians and weight-loss surgeons alike. Performing this innovative operation is my colleague, Dr. Ashley Vernon. She will be assisted by my colleague Dr. David Lautz, Director of Bariatric Surgery here at the Brigham. Both Dr. Vernon and Dr. Lautz have extensive experience with placing of the LAP-BAND and they will be performing today’s procedure with the rest of the OR team. We hope you find this webcast informative and we look forward to and encourage you to send questions via email at any time. You can do this by clicking on the MDirectAccess button at the bottom of your screen. Dr. Vernon, Dr. Lautz and I will do our best to answer your questions throughout the procedure. 00:03:42:00 Now, Dr. Vernon and Dr. Lautz are just getting started with the procedure. Let’s check in with them now. I’ll ask Dr. Vernon to introduce her OR team and to tell us a little bit about the patient on whom she’s performing today’s operation. Dr. Vernon? ASHLEY VERNON, M.D. 00:03:57:00 Yes, thank you, Dr. Robinson. Welcome. We’d like to join you here in the operating room at the Brigham and Women's Hospital and I’d like to introduce you to the team here. Across from me is Dr. David Lautz, who’s one of my partners and the director of the Bariatric Surgery Program here. He will be assisting me during this procedure. Above the drape we have Dr. Jeff Strickland, who’s the anesthesiologist. He specializes in anesthesia for GI and bariatric procedures. And then over here to my right are Kelly and Paul, part of the operating room nursing staff. 00:04:32:00 This patient is a 34-year-old woman who came to my office interested in weight-loss surgery. She was interested in the LAP-BAND procedure. She went to our information session and we had two visits in the office to discuss her decision. Her body mass index is 45 and she is 5 feet, 6 inches, weighs 285 pounds. And she had no comorbid factors except for some depression, which is treated with an anti-depressant. We obtained an upper GI study pre-operatively which showed no hiatal hernia and she was prepared for surgery in the usual manner. We are going to get underway. We’ve got some of our ports in and we need to do a couple more things. Back to you, Dr. Robinson. MALCOLM ROBINSON, M.D. 00:05:25:00 So, just to get people oriented with the procedure who may be less familiar with it, we did want to show a few slides. What exactly is a Laparoscopic Adjustable Gastric Band? Well, it’s a device placed by a surgeon doing an operation to help a patient lose weight. The device, which is a small band, looks like a belt, is made of silicone and is wrapped around the upper part of the stomach. By wrapping this device around the upper part of the stomach, it squeezes or constricts the stomach in such a way that it limits the amount of food that a patient can eat. It is placed using laparoscopic instruments and minimally invasive surgery. For those of you who may not be familiar

with this type of surgery, let me demonstrate a few of the standard devices. Generally what is done with a laparoscopic procedure is that the surgeon makes a small incision. Often this incision is less than an inch in length. Through this incision, a sleeve-like device, which we refer to as a port is inserted. This allows the surgeon to place a variety of different types of instruments through the port into the abdomen, in this particular circumstance, to perform a surgical procedure. The instruments may be scissors that can cut things, it may be a suturing device, it may be a grasper as I have here and there may be staplers that are placed through this device, although we will not be using any staplers today. And you will see Dr. Vernon and Dr. Lautz introducing devices like this in this manner that allows them to perform the procedure, opening and grasping tissues in the body. This is referred to as minimally invasive surgery because the incisions are, again, only about an inch in length and much smaller than what might be traditionally used with a weight-loss operation where the incision might be about eight inches long. 00:07:14:00 So, one of the most important features of the laparoscopic band procedure is that it’s adjustable. Tightening or loosening it controls the amount of food that can be eaten and causes weight loss. I’ll spend a little bit of time later on talking about exactly how that tightening/loosening process occurs. The LAP-BAND is a type of laparoscopic adjustable silicone gastric band, or an LASGB. The LAP-BAND was approved for use in the United States in 2001. It’s generally been used in the Massachusetts area since about 2003. There are other types of laparoscopic adjustable gastric bands that are being tested and will be available soon but because the LAP-BAND is the only one that’s approved for use currently, people often refer to this procedure just as the LAP-BAND procedure. 00:08:01:00 Let me show you a little bit about the important features of the LAP-BAND. There are at least three important components. One, there is an outer ring of plastic or silicone that is flexible enough that allows surgeons to introduce it into the body and wrap it around the stomach but it’s rigid enough that it can cause constriction or squeezing of the stomach to limit the amount of food intake. Lining the inside of this white silicone band is a fluid-filled sac. One can inflate this sac with fluid and when one does so, it tightens the band and therefore limits the amount of food that can be eaten. In addition, people can take out the fluid in the fluid-filled sac, loosening the band and therefore allowing more food to be consumed. The third important function, or part of the LAP-BAND that you can see in the left-hand panel is the access port. This port is connected to the LAP-BAND via connection tubing and this allows the surgeon in his or her office to introduce a syringe and needle apparatus through the skin into the access port, allowing fluid to be added or withdrawn as needed to control the amount of food that a patient is eating and hopefully optimize the weight loss along the time after the surgery. 00:09:18:00 So, who should consider a Laparoscopic Adjustable Gastric Band? Well, a patient must be significantly overweight as determined by his or her body mass index and I will explain a little bit more about the body mass index in a little while. The patient should not have severe diseases such as severe heart, lung or liver disease because such diseases may make the surgery too risky. The patient should not have severe uncontrolled psychological problems. If the patient is stable, on medication or is working with a

therapist, psychiatrist or psychologist and is stable, then this would not prohibit him or her from participating in this type of operation. Back now to the body mass index. The body mass index is what we use to determine who is an appropriate candidate for this operation. It can be determined by taking one’s weight in pounds and multiplying by the number 703 and dividing it in one’s height in inches squared. Now I know that this is a relatively complex formula. In reality, those of us who use this formula all the time have charts, and there are charts available, that will help you to determine, you know, what your body mass index is. The bottom line is, however, that a patient with a body mass index of 35 to 40 with conditions that are caused by being overweight, these may be diabetes, high blood pressure, sleep apnea, such patients can be considered for the LAPBAND procedure. A patient who has a body mass index of at least 40, even with or without conditions that are caused by being overweight, can also be considered for the LAP-BAND procedure. 00:10:53:00 Now for those of you who may be interested in calculating your BMI precisely, I have an example here. A patient who’s 5 foot, 5 inches tall and weighs 300 pounds, what one would do is multiply 300 by 703 and then you would divide by height in inches squared. In this instance you would convert 5 feet, 5 inches to 65. It would be 65 times 65. And then it works out to a body mass index of 49.9. For those of you who want a kind of ballpark estimate of who would qualify, I’ve included a couple of other examples for specific heights. The average sized woman in the United States is about 5 foot, 4 inches and in such a person who is 5 foot, 4 inches, a body mass index of 35 would correspond to a weight of 203 pounds and a body mass index of 40 would correspond to a weight of 233 pounds. The average man in the United States is about 5 foot, 10 inches tall and in such a person, a body mass index of 35 would correspond to 243 pounds, a body mass index of 40 would correspond to 278 pounds. So, again, if one has a body mass index of 35-40, which is roughly about 80 pounds overweight, if that person also has conditions that are caused by being overweight, such as diabetes, high blood pressure, then he or she can be considered for this type of procedure. In a patient who is greater than 100 or 110 pounds overweight and has a body mass index of at least 40, even if he or she does not have conditions that are caused by being overweight, they may be an appropriate candidate for the operation. 00:12:33:00 So, let’s go back to the operating room and just get Dr. Vernon to explain where she is at this point and hopefully orient us where she is in the procedure. Dr. Vernon. ASHLEY VERNON, M.D. 00:12:46:00 Okay. So we have all of our ports in. You can see we have four of the laparoscopic ports placed in the abdomen. This one is going to be used as our camera port and you can see the laparoscope in that port. We may have to move the camera at some point into this port, but not right now. And then we’ll be using our instruments in these ports. This is our liver retractor which is used to hold the liver and you’ll be able to see that in a minute here. I don’t know if you have your laparoscopic view up on the screen, okay. Great, here we go. This is—you can see up here at the top is the liver retractor.

There it’s retracting the left lateral segment of the liver anteriorally and this makes it so that we can see the gastro-esophageal junction, the GE junction, right here. So here’s the diaphragm that separates the abdomen from the chest and then right here is the esophagus coming down. And this is the stomach right here. And over here to the right, Dr. Lautz is pushing on the omentum, which we’re going to have to push over to the side to be able to start the procedure. And over here is the liver. We’ll come back to this side in a minute. We’re going to start the procedure over here by the angle of Hiss, which is the uppermost portion of the left side of the stomach. I’m going to get my other instrument in. DAVID LAUTZ, M.D. 00:14:14:00 So she’s going to start by dissecting the peritoneum overlying the upper part of the stomach and dissecting out the stomach away from the left crus of the diaphragm, which comes down. It’s a part of the diaphragm that comes down around the esophagus on the left side. ASHLEY VERNON, M.D. 00:14:35:00 So you can actually see this thin veil of peritoneum. It’s like saran wrap that covers the inside of the abdomen. You can pick it up with this hook electrocautery. It opens it up and this should show us the left crus of the diaphragm. There’s a big blood vessel up there on the diaphragm, let’s try to avoid that. Here we go. And that’s probably enough for us right now. We can try to come in, I’m going to try to avoid that vessel. Just need to make a little window to be able to bring the band through. Right, now we’re going to turn our attention to the other side of the stomach. MALCOLM ROBINSON, M.D. 00:15:25:00 Dr. Vernon, we often get questions about the importance of losing weight before surgery. Maybe you could comment about the liver and why you think that might be important. ASHLEY VERNON, M.D. 00:15:32:00 Well, actually, you can see in this patient, actually, you can see her liver is retracted well anteriorally and so we have no problem seeing what we need to see. If she had gained weight or hadn’t lost weight before her surgery, it would be difficult to see the GE junction. DAVID LAUTZ, M.D. 00:15:52:00 You can see the liver is more or less the ceiling that we’re working under here. ASHLEY VERNON, M.D.

00:15:58:00 Right, that’s right. DAVID LAUTZ, M.D. 00:15:59:00 And the thicker that ceiling is, the less room we have to work. So Ashley’s taking down the pars flaccida, which is this thin layer. This is the caudate lobe of the liver behind the pars flaccida. She’s taking that down again with electrocautery. ASHLEY VERNON, M.D. 00:16:17:00 I’m just trying to open it so I don’t tear it. Okay. MALCOLM ROBINSON, M.D. 00:16:32:00 Dr. Lautz, I know you like the pars flaccida technique as well. Can you tell us about why you prefer using this as well as Dr. Vernon? DAVID LAUTZ, M.D. 00:16:38:00 There was a previous technique called the perigastric technique that involved placing the band a little bit lower and directly around the stomach. It was associated with a higher slipping rate of the band. The pars flaccida technique more or less anchors the band along the lesser curve of the stomach, essentially what you’re looking at on the left side of the stomach, and is associated with a lower slip rate. So pretty much everyone who is putting the band in nowadays is using the pars flaccida technique because of its lower complication rate. 00:17:06:00 So Dr. Vernon is incising the peritoneum just in front of the right crus of the diaphragm. She just passed her grasper directly behind the stomach. We’re now going to look back over where we did our initial dissection and she’s going to be looking for the end of her grasper which is right there. ASHLEY VERNON, M.D. 00:17:27:00 We’re going to introduce the band into the abdomen now. So I’m going to give you, actually, if we could have a shot up here onto the table of the band. Can you see this? This is the band. It’s been prepped. Saline’s been placed inside the balloon and the air’s been flushed out. DAVID LAUTZ, M.D. 00:17:50:00 So this is the silicone outer area with the balloon on the inside. MALCOLM ROBINSON, M.D. 00:17:55:00 Dr. Vernon, Dr. Lautz, which band size have you chosen here?

DAVID LAUTZ, M.D. 00:17:59:00 This is a 10 cm band, which is more or less what we use pretty much in all women. There’s a 9 ¾ cm band that we’ll use on occasion, really fairly rarely and then there’s now an 11 cm band called the VG band and that band is useful in men who tend to have thicker stomachs and they have more fat around the upper part of their stomach. Now Dr. Vernon is introducing the band into the abdomen through one of our trocars. ASHLEY VERNON, M.D. 00:18:34:00 Okay. So we’ve got to get a little more insufflation, more gas back in the abdomen before we can feed this around. And Dr. Lautz is helping me so well. Here we go. And here we’ve gotten it around. DAVID LAUTZ, M.D. 00:18:59:00 So Ashley’s already pulled the band around the upper stomach. She’s now going to start advancing the tubing around the stomach until the band more or less engages onto the angle of Hiss where we did our original dissection. So you can see the band starting to engage. ASHLEY VERNON, M.D. 00:19:18:00 This is where I have to make sure I don’t pull it all the way through. DAVID LAUTZ, M.D. 00:19:22:00 So as it starts to engage it will more or less start to open up. MALCOLM ROBINSON, M.D. 00:19:27:00 Now, Dr. Lautz, maybe you can just point out that perigastric fat that may need to be defatted if it’s too tight. I’m not sure whether Dr. Vernon feels she needs to do that today. ASHLEY VERNON, M.D. 00:19:37:00 No. DAVID LAUTZ, M.D. 00:19:37:00 The fat pads look reasonable. If the fat pads are— ASHLEY VERNON, M.D.

00:19:43:00 If the band is tight— DAVID LAUTZ, M.D. 00:19:44:00 If the band is tight around the stomach, then we can defat, we can take off the fat pads away from the upper part of the stomach. You’ll see one of the fat pads sitting here. Fat pads tend to be more of an issue, again, with men who have thicker fat pads. So she just passed the end of the band tubing through the slot in the other end of the band and now she’s going to advance it through the band itself until it locks into position. ASHLEY VERNON, M.D. 00:20:13:00 Yeah, there’s hardly any fat around the stomach. It’s an interesting thing. Patients have fat pads in different places so even though her body mass index is 45, she’s relatively small up here. DAVID LAUTZ, M.D. 00:20:26:00 So you can see the band is about to lock into position. ASHLEY VERNON, M.D. 00:20:31:00 This is where you have to be really strong. Here we go. All right. And then we’re going to place some sutures. DAVID LAUTZ, M.D. 00:20:39:00 You can see there’s an appropriate amount of distance. You don’t want the band too tight around the upper stomach. ASHLEY VERNON, M.D. 00:21:02:00 So one of the important things is that we place one of these sutures, the top—Right now, what we’re going to do is place a stitch from the stomach below the band to the stomach above the band. And it’s important to place the stitch all the way over here on the side because that’s the site in which most of the slippages occur. So we need to make sure that we get all the way around to the side. DAVID LAUTZ, M.D. 00:21:27:00 The stomach is essentially wrapped around the front wall of the band to keep it into place and keep it from slipping. ASHLEY VERNON, M.D. 00:21:44:00 I’ve got to take a cap off. Hold on one sec.

DAVID LAUTZ, M.D. 00:22:00:00 So as Ashley was saying, you want to have these sutures far enough laterally to help prevent a slipping of the band. On the other hand, as we come around the front side with our wrap, you want to have a certain amount of distance between the collar of the band and the wrap so that you can prevent an erosion. MALCOLM ROBINSON, M.D. 00:22:17:00 We’re starting to get a few questions now. One of the questions from an individual is that he had his gall bladder removed several years ago and he would like to know whether that would prevent him from having this type of procedure. DAVID LAUTZ, M.D. 00:22:30:00 So, that usually will mean there will be some adhesions in the area of the surgery, some scarring. But that’s something we can usually deal with fairly easily. The gall bladder, as you know, is on the right side of the abdomen; we’re working over in the midline or towards the left side of the upper abdomen, so usually it doesn’t preclude us from putting a band in. MALCOLM ROBINSON, M.D. 00:22:56:00 And then we have another question about the size of the incision. The question is: Was the 8-inch incision referring to the open procedure or the laparoscopic? The 8-inch incision refers to the open procedure. But the other part of the question is: How big’s the largest incision for this procedure? Dr. Lautz, how large? DAVID LAUTZ, M.D. 00:23:15:00 So the largest incision we make for this procedure is a 15 mm incision, so it’s 1.5 cm. MALCOLM ROBINSON, M.D. 00:23:23:00 So that’s a little bit under an inch. DAVID LAUTZ, M.D. 00:23:24:00 Right and that’s something that—we have to make that one a little bit bigger than the others to fit the band through. All the other incisions are smaller than that. As you can see, we’re using—there’s four small incisions, one for each of the ports and then we have another small incision for the liver retractor. 00:23:47:00 So Dr. Vernon put her first stitch into the lower part of the stomach and just below the band.

ASHLEY VERNON, M.D. 00:23:56:00 I had a little bit of problems with that at the beginning, but I’m okay now. So this is clearly stomach above the band. DAVID LAUTZ, M.D. 00:24:03:00 So this is going to be the first stitch in our wrap. ASHLEY VERNON, M.D. 00:24:12:00 And that’s going to be okay. MALCOLM ROBINSON, M.D. 00:24:13:00 We have another question, Dr. Lautz, from an individual who says that she’s scheduled for surgery in September and wants to know whether she’ll be able to feel the port once it’s in place after surgery. DAVID LAUTZ, M.D. 00:24:23:00 So usually you can feel the port. It will feel like a small lump under the incision, there’s a small incision in the right upper abdomen. Usually you cannot see the port, at least initially, prior to the weight loss. And it’s usually not, again, not noticeable unless you’re feeling for it. MALCOLM ROBINSON, M.D. 00:24:44:00 And another technical question for either Dr. Lautz or Dr. Vernon. If those fat pads shrink during the time one is losing weight, does this increase the possibility of the band slipping? DAVID LAUTZ, M.D. 00:24:56:00 No, usually the chance of the band slipping go down over time as the band heals into place. We worry most about the band slipping within the first few weeks and that’s why we do everything we can to minimize vomiting during the first few weeks until the band is more or less healed into place. It’s also one of the reasons why we don’t do adjustments early on. We don’t want to more or less challenge the system, so we generally don’t start adjusting the band until the patient’s around six weeks out. ASHLEY VERNON, M.D.

00:25:33:00 So I’m just trying to get this stitch in and it’s taking me a little more time than usual. This is the final stitch here, the final throw of the tie of this stitch and then we’ll put two more stitches across the front here. MALCOLM ROBINSON, M.D. 00:25:51:00 And we just received a question saying that, “I notice there’s no bleeding. Does this allow for more quick recovery?” DAVID LAUTZ, M.D. 00:25:59:00 Yes, the laparoscopic band has relatively minimal amounts of bleeding in general and also a really minimal amount of scarring so recovery, post-operative pain, those sorts of issues are just something we don’t have as much of a problem with as the open procedures. ASHLEY VERNON, M.D. 00:26:27:00 And then we’re going to get the next stitch in. MALCOLM ROBINSON, M.D. 00:26:31:00 Now Dr. Lautz, Dr. Vernon mentioned about getting an upper GI and a question that we just received is: “Is this routine and what if this individual’s surgeon didn’t request it?” DAVID LAUTZ, M.D. 00:26:42:00 It’s certainly a specific pre-operative workup variable. There are surgeons out there who feel that if the patient has a hiatal hernia that can interfere with your ability to adjust the band into an appropriate range, it may decrease the functioning of the band, so we’ve chosen to do pre-operative upper GI series to rule out a hiatal hernia. So there are other ways to do that. Some surgeons choose to do that with a balloon in the operating room to make sure there’s no evidence of a hiatal hernia. It also is nice for us to have ruled out any other significant problems with the lower esophagus or upper stomach. MALCOLM ROBINSON, M.D. 00:27:26:00 We just received another question about hiatal hernia. “What do you do in the case of a hiatal hernia?” is the question. DAVID LAUTZ, M.D. 00:27:32:00 Usually we would fix it. We try to a posterior hiatal hernia repair, which generally I think most authors would agree that it’s a better repair.

ASHLEY VERNON, M.D. 00:27:47:00 You have to minimize the dissection posteriorally to prevent slippage so it’s nice if you can do the hiatal hernia repair and then find another path. DAVID LAUTZ, M.D. 00:27:58:00 Right, so you can tell when we pass our instrument behind the stomach that we minimize the dissection behind the stomach. Again, the more dissection you do there, the greater the chance that there can be a slip. So, if you had a hiatal hernia, we would, at least at this center, choose to repair it at the same time. MALCOLM ROBINSON, M.D. 00:28:20:00 We just received a couple questions about stitches. One is, “Do the stitches stay on the stomach, holding the band in place forever? What happens if the stitches dissolve?” And then another related question: “Is the stitch going into the stomach or the stomach muscle?” and the patient who’s had a LAP-BAND surgery is just wanting to know. DAVID LAUTZ, M.D. 00:28:38:00 These sutures are going into the wall of the stomach but not through and through the stomach. If you were inside the stomach looking in, you would not see them come into the stomach themselves. The sutures are made up of material that is permanent, will not dissolve over time. ASHLEY VERNON, M.D. 00:28:55:00 Right and you can tell, specifically, I’m making sure that I take my bites in the stomach below the band and above the band. Sometimes if a patient has large fat pads, the large fat pad is right up here. It’s the GE fat pad and it can interfere with your ability to see the stomach. In this case, we can clearly tell this is stomach and we just have to make sure that we have stomach because we don’t want to place the band on the esophagus. I’m going to get one more stitch in there. Did we answer all those questions, Dr. Robinson? MALCOLM ROBINSON, M.D. 00:29:42:00 We have several questions. One of the questions is: “How far below the lower esophageal sphincter is the device placed?” ASHLEY VERNON, M.D.

00:29:54:00 Okay, look up here, maybe we can show them. The lower esophageal sphincter is right about, somewhere right up here and then this is stomach right here and you can see this vessel here is usually the top of the stomach. DAVID LAUTZ, M.D. 00:30:08:00 So you can see it’s fairly close. The pouch that’s created is a relatively small pouch. Again, you don’t want the pouch very large because the weight loss results won’t be as good. MALCOLM ROBINSON, M.D. 00:30:25:00 And a patient says that she’s had her gall bladder removed laparascopically before and wants to know whether you can use the same incisions or port sites to do the LAP-BAND surgery. DAVID LAUTZ, M.D. 00:30:36:00 We can use some of the same port sites as long we’re already in the abdomen and then we know that there’s no scarring at those sites to worry about. ASHLEY VERNON, M.D. 00:30:44:00 Generally I place my own ports so that I can make sure that I have my ports in the right place. It’s not worth struggling with ports in the wrong place just to prevent making another quarter-inch scar. DAVID LAUTZ, M.D. 00:31:00:00 If the ports are in a location where we can use them, fine. If not, then generally we would use our own sites. MALCOLM ROBINSON, M.D. 00:31:07:00 Now we have a question asking if you could talk a little bit more about the equipment and instruments that you’re using to perform this surgery. ASHLEY VERNON, M.D. 00:31:15:00 Yeah. This grasper that I’ve got in my hand that I’m rotating right now is a Hunter grasper. It’s a—atraumatic bowel grasper. It can be used to—you know, you can see I can grab the stomach easily with it without tearing the stomach, as opposed to a grasper with teeth. And then in my right hand is a needle driver, not unlike the needle driver one would use for open surgery except that it’s long. It has a similar handle, though. Anything else, Dave?

DAVID LAUTZ, M.D. 00:31:46:00 That’s pretty much all we’ve used so far. MALCOLM ROBINSON, M.D. 00:31:48:00 We have a couple questions about age. One of the questions which we just received: “Is the LAP-BAND a better option for older patients, say, for example, patients who are in their 50’s or 60’s, relative to non-laparoscopic weight loss surgery?” Presumably the person means such as an open gastric bypass or maybe even a laparoscopic gastric bypass. DAVID LAUTZ, M.D. 00:32:10:00 Well, I think many surgeons feel that the LAP-BAND is a nice option for anyone who has a little bit higher risk. We do worry more about patients in their 50’s and 60’s as far as comorbid conditions associated with obesity that can increase their risk of going through an operation. And certainly a LAP-BAND is a lot easier to go through for most patients than an open procedure, particularly an open bypass. So it is something we consider more strongly in that patient population. MALCOLM ROBINSON, M.D. 00:32:43:00 We just received a question saying that if one already had trouble with esophageal reflux or heartburn, will it be aggravated by having a LAP-BAND? ASHLEY VERNON, M.D. 00:32:52:00 I can answer that. I think most patients when they lose weight, their reflux improves dramatically and so generally, even patients with reflux disease, I believe that the band is adequate treatment. DAVID LAUTZ, M.D. 00:33:06:00 So you can see there’s nice, easy right-to-left movement of the band here. It’s not tight, the wrap is not tight, it’s not tight on the underlying stomach. This is the collar of the band we had talked about. This collar, one of the worries we have or one of the complications that’s known is that that can erode into the stomach wrap next to it so we want to have a certain amount of distance here and you can see Dr. Vernon has left an appropriate amount of distance between the collar of the band and the wrap. MALCOLM ROBINSON, M.D. 00:33:33:00 So while we still have you there live, Dr. Vernon and Dr. Lautz, there’s a question about becoming nauseous and vomiting immediately after surgery and do you worry about that in terms of the band?

DAVID LAUTZ, M.D. 00:33:45:00 The main thing we worry about with that is vomiting. ASHLEY VERNON, M.D. 00:33:49:00 And retching. DAVID LAUTZ, M.D. 00:33:49:00 And retching and the band slipping as the stomach forcibly contracts under the band. So we maximize the medication that we use to prevent nausea after the surgery. And as I said, we start the patient on a liquid diet and slowly advance it from there also to help prevent any vomiting. ASHLEY VERNON, M.D. 00:34:13:00 Okay, I’ve pulled this band out through one of the ports and taken that port out. And we’re going to take this liver retractor out now and maybe come to a operating room shot. I think you’re here. You can see over here, down here, I’ve got my finger in the hole, I’ve got the band coming up. And I just—just so you can see, here’s the band and we need to go back in for a laparoscopic view one more time to get the liver retractor out. So now come back in to the laparoscopic view. Okay and we’re going to get this liver retractor out. MALCOLM ROBINSON, M.D. 00:34:48:00 And while you’re doing that, Dr. Vernon, we got a question about—a person says that she’s heard that there’s a higher incidence of gallstones with rapid weight loss and do you routinely remove the gall bladder during LAP-BAND surgery? ASHLEY VERNON, M.D. 00:35:00:00 Yeah, I don’t usually take the—I don’t look for gallstones pre-operatively unless patients have complaints of—that are typical of gallstones. But if—Let me just get this thing out. Oh, we’ve got a little bleeding. We’ve got a little bit of bleeding from that initial port but it doesn’t look like it’s a problem. About the gallstones, so with a Rouxen-Y gastric bypass— DAVID LAUTZ, M.D. 00:35:33:00 So there’s increasing data now that suggests that the problems with gall bladder issues that you see after a gastric bypass you generally do not see with weight loss in a band patient. The weight loss is slow enough and gentle enough over time that gall bladder issues don’t tend to be as much of a problem. So we do not recommend taking the gall bladder out at the same time as a LAP-BAND unless the patient has gall

bladder issues and even then we may decide to take out the gall bladder first and come back at a later point for the band. MALCOLM ROBINSON, M.D. 00:36:09:00 Is this a good time, Dr. Vernon, to talk a little bit more about the evaluation and risk and benefits. ASHLEY VERNON, M.D. 00:36:13:00 That sounds terrific. MALCOLM ROBINSON, M.D. 00:36:18:00 So we’ve received a few questions and we did want to kind of go where more specifically about the evaluation process for people who are interested in the LAPBAND. Certainly the surgeon evaluates each person individually, discusses the surgical risks, the surgical options and makes the plan for surgery. That includes talking about the relative benefits of LAP-BAND versus other type of procedures. The surgeon then coordinates this plan with the patient as well as the patient’s primary care physician, getting input from the PCP just to make sure that everybody’s on the same page. A dietician who specializes in caring for weight-loss surgery patients evaluates our patient and evaluates the dietary issues that a patient may have and then develops a plan for surgery afterwards. We feel it’s very important that the dietician that does this evaluation process has a lot of experience in working with the weight-loss surgery population because there are a lot of nuances and special things that one needs to consider with the LAP-BAND procedure as well as other type of weight-loss operations and that’s why we’re very fortunate to have specialist dieticians. We have consulting physicians and we use them liberally as necessary to help optimize the patient for surgery, such as cardiologists, or heart doctors, lung doctors, or pulmonologists, and gastroenterologists. We want to make sure that this surgery is performed as safely as possible and part of that is getting input from our colleagues to make sure that things are going to go smoothly for an individual. In terms of what type of support that we have, we feel that an educated patient helps for the long-term success of this operation. We start off with the information session, detailing all aspects of the surgery and the care afterwards. There’s a preoperative support group which allows patients and family members considering surgery to meet our patients who’ve already had surgery so they get an opportunity to ask what it felt like one week after surgery, one month after surgery, one year after surgery and beyond and really kind of discuss what the recovery is like and get a sense from people who’ve had LAP-BAND or possibly other types of procedures, what might be best for them. We have a pre-op weight loss group for patients to help them lose some weight before surgery. As we briefly touched on earlier, losing weight can help shrink the liver and therefore make it a little bit easier. It may also help some of their risks associated with surgery and, in fact, some of the insurance companies may require participation in a weight loss group before approval for this type of surgery. We also have a dedicated operating room staff and nurses on dedicated patient care units, all of whom have been

trained to care for the particular needs of the weight-loss surgery patient. We feel that this is very important for making a smooth intra-operative course as well as a post-operative course and you’ll note that Dr. Vernon has an excellent team working with her today to help with the smooth running and conductance of the operation. There are—Of course, the surgeon follows closely after surgery, along with our physician’s assistants and the dietician. We have telephone and email consultation. There is a post-op support group. This is led by a dietician, who again specializes in this area. We talk about specific things in the group: how to deal with holiday meals, how to deal with relatives who may or may not be supportive of your attempts to lose weight. And there’s general support from other patients around you. And our patients, on their own, have actually developed an online chat room to discuss weight-loss surgery and to support one another. 00:39:53:00 What are the potential benefits? We do want to discuss the benefits as well as the risks, starting with the benefits. All of the procedures that are currently done here at the Brigham and around the country and accepted in the nation produce substantial weight loss and one of the benefits of it is it’s long-lasting. For people in this weight category, and I stress in this weight category, not people who are, say, 10 pounds overweight, but in this category, it’s more effective than dieting and medication alone. Weight loss for the LAP-BAND averages at two years, about 40 to 50%. This, at two years, may be a little bit less than one might expect with the gastric bypass, but there is some recent literature, as well as some experience in other areas of the world, such as Australia, that suggests that in about three years, the weight loss from the LAP-BAND is equivalent to that which is observed with the gastric bypass. Certainly most of our patients have improved health and improved quality of life after this type of procedure. Particular to the LAP-BAND, we talked about there’s no cutting of the stomach or rerouting of the intestine so the surgery time is shorter, the hospital stay is shorter and the recovery time is faster. The risk of death is often less than that observed with traditional weight-loss operations. 00:41:12:00 Now, I do want to talk about the risks. There’s no such thing as risk-free surgery and like any other major operation, serious complications and death can occur with the LAP-BAND so we want to make sure that people are well aware of that. There can be reoperation and this can be usually laparoscopically. This can be done to adjust the port, for example. Occasionally, people will have intolerance of the band and even when it’s completely evacuated or not filled, there may be instances of having persistent nausea and vomiting. Occasionally, there’s band slippage, but with the pars flaccida technique that Dr. Lautz and Dr. Vernon have performed today and Dr. Lautz was describing, this has been a little bit less of a problem. There can be some port problems, band erosion. Early in the experience with the LAP-BAND, there was some concern about a dilated esophagus but with more experience it appears that this is mostly related to the band either being too tight or if the band is placed a little higher than one might like and it is on the esophagus as opposed to on the stomach. There can be damage to adjacent organs, as Dr. Lautz pointed out. The procedure is done within a relatively small area around the area of the spleen, the liver and occasionally, and very rarely in experienced hands as Dr. Lautz and Dr. Vernon, there can be damage. The death rate worldwide is about one out of

2,000 within 30 days and this is certainly significantly less than what is experienced with gastric bypass procedure. 00:42:43:00 What are some of the disadvantages of the LAP-BAND compared to, say, the gastric bypass or other traditional types of weight-loss surgery? There’s no doubt that weight loss is slower. When we examine our patients in the office after a gastric bypass, after about a month, the weight loss may be about 15 to 20 pounds, whereas with the band it’s significantly lower than that. But we tell our patients up front that one should anticipate that the weight loss is going to be slow and gradual, about one to two pounds per week and ultimately people feel that over time the weight loss catches up to the gastric bypass. So the total amount of excess weight, although substantial to LAP-BAND may be less with the LAP-BAND, particularly in the beginning. In addition, patients may require more frequent follow-up to insure effective weight loss primarily related to making sure that the band is adjusted properly and that that’s going to require some inoffice visits. 00:43:43:00 We’ve received a couple questions about the port adjustment and we actually want to show some video about that. Can we go to the video showing a band adjustment, please? VIDEO DAVID LAUTZ, M.D. 00:43:59:00 Hi Joann. JOANN 00:44:00:00 Hi, how are you? DAVID LAUTZ, M.D. 00:44:01:00 How are you? JOANN 00:44:01:00 I’m fine, thank you. DAVID LAUTZ, M.D. 00:44:02:00 How’s it going? JOANN 00:44:03:00 Good.

DAVID LAUTZ, M.D. 00:44:06:00 How’s the band feeling? JOANN 00:44:08:00 Okay. DAVID LAUTZ, M.D. 00:44:09:00 Any problems? JOANN 00:44:11:00 No. Just the same things as before. It feels a little bit tighter in the eveningtime when I try to eat. DAVID LAUTZ, M.D. 00:44:19:00 Starting with the evening meals? JOANN 00:44:21:00 Evening. DAVID LAUTZ, M.D. 00:44:22:00 How is your hunger doing? Do you still feel less hungry than you did before the— JOANN 00:44:25:00 No, I mean, I can feel my appetite creeps up sometimes, but other than that— DAVID LAUTZ, M.D. 00:44:35:00 Comparing your appetite now to what it was before the band, is it different? JOANN 00:44:40:00 Totally different. DAVID LAUTZ, M.D. 00:44:43:00 Your drive to eat is different?

JOANN 00:44:44:00 Totally different. I mean, even when eating less food and I don’t feel hungry the way I did before. Or with eating the small portions, I just don’t feel hungry. DAVID LAUTZ, M.D. 00:45:03:00 So you’ve got 1 ¾ cc in there and your weight is down about 70 pounds now since last fall. So you want to go ahead and do a fill or you feel like you— JOANN 00:45:16:00 I can do a fill. DAVID LAUTZ, M.D. 00:45:18:00 Okay, so here’s her port. Can you make a muscle? I give her a little local. Okay, so the port’s right there. We’re now in the port. That’s it. END VIDEO MALCOLM ROBINSON, M.D. 00:46:02:00 So you can see that the adjustment is fairly straightforward in the majority of patients as Dr. Lautz demonstrated with his patient. That particular patient has done very well losing about 70 pounds in a relatively short period of time. Just want to go over some of the general principles that we use in terms of adjusting the port. The goal is to achieve a sensation of feeling full for a long period of time after eating. We aim for weight loss to be gradual and we purposely want the weight loss to be gradual, anticipate that a patient will lose approximately one to two pounds per week. The tightening should not lead to any heartburn, vomiting, pain with eating appropriate foods and the goal is to lose the estimated amount of desired weight over a period of 18 months to 3 years. 00:46:52:00 So, when might one consider in tightening the band as Dr. Lautz just did on that particular patient? If a patient is having poor weight loss, defined as losing less than, on average, one to two pounds per week. If the patient’s becoming hungry too quickly after meals or is hungry between meals, then this might be a time to consider tightening the band. If the patient is able to eat large volumes of food without difficulty that may suggest that it’s time to tighten the band. One thing that we did not see on the video is that after tightening of the band, it is routine to have the patient swallow some water, just to make sure that the adjustment didn’t lead to complete obstruction of the passage of food and/or fluid through the band and that’s routinely done after any type of adjustment. 00:47:39:00 What we’re aiming for is that kind of sweet zone or green zone in terms of how to tell when the band tightness is just right. The speed of weight loss is at the desired

rate, which, again, is about one to two pounds per week, on average. We want the patients to eat the appropriate range of foods, types of foods, we’ll talk a little bit about that, as well as the amounts of food. We don’t want there to be significant hunger between meals. And if the patient is struggling, then this may not be the perfect adjustment size for the band. And we don’t want there to be excessive vomiting, of course. We don’t want there to be any pain with eating or any heartburn. 00:48:21:00 What might be time when one should consider loosening the band? If there is excessive vomiting, heartburn, or food and liquid seem to be backing up, that might suggest that the band is a little bit tight. If there’s difficulty swallowing or particularly if there’s pain with eating the expected amounts and types of food, then that might be a time to loosen the band. Now, occasionally patients find that if they eat too quickly or if they take a large amount of food, chew it once or twice and swallow it, then they may have an experience of things feeling as if they get stuck. This is part of the behavior modification and it doesn’t necessarily mean that the band is too tight, but if they’re eating the appropriate amounts of food, the appropriate volumes of food, then this may suggest that an adjustment downwards might be appropriate. 00:49:09:00 There’s something called maladaptive eating. Occasionally, if the band is too tight and the patients can’t eat solid food, then they instinctively switch to eating high-calorie soft foods or drinking high-calorie liquids. They’re hungry, they can’t get down the appropriate solid foods and so they start eating the softer stuff and even though they are eating, they may actually start gaining weight, not because the band is too loose but because the band is too tight and that might be an opportunity to loosen the band. 00:49:41:00 So at this point, let’s go back to the operating room and see where Dr. Lautz and Dr. Vernon are in terms of getting the port situated. Dr. Vernon? ASHLEY VERNON, M.D. 00:49:50:00 Great, we have actually gotten—this is the tubing that was coming through that you saw before and we’ve actually hooked it to this subcutaneous port, this access port, which is the port that can be accessed in the office to inject the saline. The two of them are connected right here. This is going—we’re going to—we’re about to place these sutures into the abdominal wall and we’re going to parachute this down. You’ll see that right now. I’m going to hold this up. I don’t know how well this is projecting, but this access port is going down here. Can you see this? Not really. I’ve already closed up the abdominal wall fascia here to prevent a hernia at this site. The tubing’s going down and we want to make sure that there’s a gentle angle. DAVID LAUTZ, M.D. 00:50:57:00 So there you can see the port in the subcutaneous tissues. ASHLEY VERNON, M.D.

00:50:58:00 Here you can see the port in the subcutaneous tissue and then we’re going to start tying these knots down. DAVID LAUTZ, M.D. 00:51:04:00 We’re going to start tying this down. These are sutures that we have onto the abdominal wall that’ll be used to hold the port in place. ASHLEY VERNON, M.D. 00:51:13:00 Dr. Robinson, if you have any questions, we could answer those now. MALCOLM ROBINSON, M.D. 00:51:17:00 Sure. We have a question about: “Does the LAP-BAND stay in permanently or is it removed once a patient has lost their appropriate amount of weight?” ASHLEY VERNON, M.D. 00:51:27:00 You know, we say sometimes that this is a reversible procedure but the reality is that if the band were to be removed, the patient would regain all of their weight. Some patients believe that they’ve changed their ways or their habits have changed such that they can have the band removed and one of the ways you can prove it to the patient is you can remove the saline from the band and see how they do as a trial. Most patients experience so much hunger that they want the saline replaced in the band. So, overall I don’t recommend it to patients, to think of this as a temporary fix for their problem. MALCOLM ROBINSON, M.D. 00:52:07:00 Here we have a question with regards to pregnancy. Is there any issue with having a future pregnancy? Do you do, for example, Dr. Vernon, deflate the band when someone is having a pregnancy or do you not worry about deflating it and do you not worry about a patient getting pregnant? ASHLEY VERNON, M.D. 00:52:24:00 I think that’s a great point. Actually, it’s one of the great things about the band is that you’re able to modulate or regulate the weight loss at any time. So if a patient became pregnant, especially if the patient became pregnant in the early period after surgery, which we don’t recommend, but if the patient were to become pregnant, at least we could take some of the saline out of the band and allow them to either maintain their weight or actually gain weight if they needed to. MALCOLM ROBINSON, M.D.

00:52:52:00 All right. We have a question from, I believe, a physician saying that he or she did not see you close the peritoneum. And then what about the risk of hernias with this type of procedure? ASHLEY VERNON, M.D. 00:53:03:00 Oh, yeah, I think—I tried to say that we—there was a—I don’t know if you can have a shot in here. Probably not. Can you come straight in any? That coating right there, there’s actually a figure-of-eight vicryl suture on the abdominal wall fascia. You can’t really come in. There’s a figure-of-eight right as the tubing is emerging from the abdominal wall. That was closed to prevent herniation. I can’t get my finger in the hole anymore. DAVID LAUTZ, M.D. 00:53:35:00 You can see the port is, the subcutaneous port is sitting right here, the access port. ASHLEY VERNON, M.D. 00:53:42:00 That’s on the abdominal wall. DAVID LAUTZ, M.D. 00:53:44:00 I don’t know if you can make it out on the camera, but there’s, you know, there’s—it’s down on the abdominal wall, well away from the skin and then we will close the skin over it. MALCOLM ROBINSON, M.D. 00:53:54:00 We have a question about the diet progression. I know there’s a little bit of variation but we do use here four stages of diet progression for people after this type of procedure. Stage 1, we start a clear liquid type of diet and that lasts a very short period of time, less than a day. And then there is a Carnation Instant Breakfast-type diet, or HMRtype diet that’s used for a short period of time. And then this progresses to a diced protein or pureed food-type of diet. And then at the end of about four weeks is what I believe you use, Dr. Vernon and Dr. Lautz, and certainly other people do use, start eating with regular food. So that’s kind of our diet progression. Do you use anything different, Dr. Lautz or Dr. Vernon? ASHLEY VERNON, M.D. 00:54:40:00 Nope. That’s exactly right. I think most patients at about four weeks are eating solid foods, or starting to feel hungry. And it’s a good thing we are able to do the band fill at six weeks because that’s right about the time where they start to really lose their patience in being able to manage their hunger.

MALCOLM ROBINSON, M.D. 00:55:03:00 So we have a question from a physician that’s asking, “Do you automatically fill the band six weeks after surgery or is there something that you look for to determine whether you need to fill the band?” DAVID LAUTZ, M.D. 00:55:16:00 Well, if a patient’s feeling the appropriate amount of satiety and lack of hunger between meals and is losing weight in an appropriate range that we look for, then we can not do an adjustment and just see how they do going forward. Most patients need an adjustment at that time but from time to time you see one that doesn’t so— MALCOLM ROBINSON, M.D. 00:55:35:00 We have a question about returning to work. How long do you advise your patients to stay out of work? ASHLEY VERNON, M.D. 00:55:40:00 We usually give them one week off of work. It depends on what they do for work, but the majority of patients can go back to work in one week. I don’t recommend any strenuous weight lifting regimens. DAVID LAUTZ, M.D. 00:55:54:00 You want to avoid heavy straining with the abdomen to avoid a hernia at any of these sites, which can occur but it’s relatively uncommon. ASHLEY VERNON, M.D. 00:56:01:00 I’m also concerned about dislodging the band or causing a slippage so— MALCOLM ROBINSON, M.D. 00:56:06:00 And that answers our next question about abdominal exercises. You generally don’t want people to do that for what period of time would you say, Dr. Vernon? ASHLEY VERNON, M.D. 00:56:12:00 Usually about six weeks, but I really try to—they can do lots of other things. There’s lots of exercises that are permitted within a week: running, walking, even riding a stationary bike or doing an elliptical trainer, all of those are okay. I just don’t want them to have any Valsalva maneuver that might cause them to cause a band slippage.

MALCOLM ROBINSON, M.D. 00:56:37:00 So we have a question about: Does the port ever need to be moved after the patient loses weight or does it kind of stay in the position that you have it now? DAVID LAUTZ, M.D. 00:56:47:00 That’s a common question. There are some people that think that once you lose weight, you can have the band removed. These bands are meant to be permanent. If you even take the saline out of the band, most patients will experience return of their hunger, so it’s meant to be a permanent device. It can be removed if the patient’s not tolerating it or the weight loss isn’t adequate, but that’s relatively uncommon. But in general, for routine practice, it’s meant to be permanent. MALCOLM ROBINSON, M.D. 00:57:11:00 We have a question about subsequent surgery and whether it’s appropriate to deflate or remove all the fluid from the band prior to undergoing a subsequent operation. So if someone has an unrelated operation, do you routinely advise that the band is deflated, Dr. Lautz? ASHLEY VERNON, M.D. 00:57:31:00 If the patient has to undergo a routine endoscopy or they have to undergo a surveillance endoscopy, then I will remove the saline from the band to allow the endoscopist to get down into the stomach. But for other abdominal procedure, I don’t think that they need to remove the saline from the band unless a gastric tube is needed. It just depends on what the procedure is. DAVID LAUTZ, M.D. 00:57:55:00 It is a nice option with the band in that if you needed to access a GI tract for an endoscopy, you can take the saline out of the band and you have relatively minimal restriction to the stomach with the scope. MALCOLM ROBINSON, M.D. 00:58:08:00 So if somebody has appendicitis, for example, you don’t necessarily feel that the band needs to be deflated? ASHLEY VERNON, M.D. 00:58:15:00 No. MALCOLM ROBINSON, M.D.

00:58:21:00 Okay, we have a couple more questions here. What happens if the port flips and why does this happen, can it be prevented? ASHLEY VERNON, M.D. 00:58:29:00 Yeah, port—one of the reasons we suture the port to the—the access port, you’re talking about—to the abdominal wall is to prevent the port from flipping. Obviously, it can still happen, especially if the sutures either don’t hold on the abdominal wall or for any other reasons, I don’t really—can’t quite understand why it happens, but what it does—It can usually be taken care of with a local procedure, i.e. you don’t have to go to the operating room for a laparoscopic procedure, it’s just a— DAVID LAUTZ, M.D. 00:59:00:00 You don’t have to enter the abdomen. You can essentially just give some local, reincise this incision, go down and find the port and put it back into place. ASHLEY VERNON, M.D. 00:59:08:00 Right. MALCOLM ROBINSON, M.D. 00:59:11:00 And then, one more question. The person says that he or she is grossly overweight, but 63 years old and would that person still be a candidate for the LAPBAND procedure? ASHLEY VERNON, M.D. 00:59:23:00 Certainly. The LAP-BAND device was approved by the FDA for use in any patients over 18 years old. So, assuming that they were a candidate and that the insurance company would help them pay for it, we would be able to do it. MALCOLM ROBINSON, M.D. 00:59:46:00 All right, as we’re finishing up here, Dr. Vernon and Dr. Lautz, do you have any final thoughts? DAVID LAUTZ, M.D. 00:59:51:00 Well, I think that the LAP-BAND is a very nice option for a lot of patients and it’s something that more and more people are considering and there’s a lot of advantages over some of the other types of procedures available. MALCOLM ROBINSON, M.D.

01:00:08:00 Do you have any time when you advise it, Dr. Vernon? ASHLEY VERNON, M.D. 01:00:12:00 Excuse me? MALCOLM ROBINSON, M.D. 01:00:13:00 Do you have any thoughts about when you think that it’s best for a patient to have a LAP-BAND? ASHLEY VERNON, M.D. 01:00:19:00 I think that being a safer procedure than the Roux-en-Y gastric bypass, I think that in any patient that’s at high risk that this is a better option. As I always tell the patient, sometimes it requires close follow-up and they have to be dedicated and make sure that they come in for their adjustments, otherwise it’s not going to work. But as long as they are a compliant patient who can come in for that, then I think it’s an excellent option. MALCOLM ROBINSON, M.D. 01:00:46:00 So, we’re getting close to concluding our live webcast. I would say that the LAP-BAND procedure, like any other weight-loss operation is just one of the full amount of things that need to be done to help people successfully lose weight. You’ll note that there’s a fair amount of pre-operative education and post-operative follow-up, but assuming a patient is able and willing to do that, the LAP-BAND procedure is an excellent procedure and we have found to be quite effective for weight loss. 01:01:15:00 I want to thank Dr. Vernon and her team for allowing us to witness this operation and, of course, her patient for allowing us to perform the procedure and film the procedure on her. We certainly have a forum that will allow people to continue to ask questions. This will be posted and up and running for about a week’s time. We will monitor the forum and hopefully answer your questions as quickly as possible. Of course, anybody who is interested in calling us to find out more about the weight-loss operations, and particularly the LAP-BAND, we would be very happy to do that. So, from Brigham and Women's Hospital, thank you for watching and we look forward to helping those people who would like achieve their weight loss goals. NARRATOR 01:02:07:00 Thank you for watching the Laparoscopic Adjustable Banding Procedure from Brigham and Women's Hospital in Boston, Massachusetts. To make an appointment, make a physician referral, or request more information, please click the

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