Laparoscopic Mini Gastric Bypass & Crural Repair in a Complex Obesity with PCOS & Insulin Resistance

A 27-year-old female patient with a body mass index (BMI) of 40.14 presented to the Bariatric and Metabolic Surgery Department at PACE Hospitals, Hitech City, Hyderabad, for further evaluation and management of morbid obesity. 

The patient was a known case of morbid obesity, Polycystic ovary syndrome (PCOS) officially renamed Polyendocrine Metabolic Ovarian Syndrome (PMOS), insulin resistance, and bronchial asthma. These associated conditions were considered during preoperative evaluation and bariatric surgery planning.

On general examination, the patient was conscious, coherent, cooperative, and hemodynamically stable. She had morbid obesity. Respiratory examination revealed equal air entry bilaterally, with no active wheeze noted at the time of examination. Cardiovascular examination showed normal heart sounds. Abdominal examination was soft and non-tender, with no guarding or rigidity. No acute abnormality was noted on systemic examination.

Upon admission to PACE Hospitals, the Bariatric and Metabolic Surgery team evaluated the patient for morbid obesity, associated metabolic concerns, and overall suitability for bariatric surgery. A detailed clinical assessment, physical examination, BMI evaluation, obesity-related risk assessment, and required diagnostic investigations were performed.

The patient was diagnosed with morbid obesity with a BMI of 40.14 kg/m², along with polyendocrine metabolic ovarian syndrome (PMOS), insulin resistance, and bronchial asthma. These associated conditions were considered important during preoperative planning, anaesthesia assessment, and postoperative recovery planning.

Routine preoperative investigations, including complete blood count, blood sugar profile, kidney function tests, liver function tests, lipid profile, thyroid profile, electrolyte assessment, coagulation profile, ECG, chest X-ray, abdominal ultrasound, and pre-anaesthesia evaluation, were performed to assess the patient’s overall medical condition and fitness for surgery. In view of morbid obesity, liver assessment was also considered important to evaluate possible obesity-related liver changes.

Based on the confirmed diagnosis and preoperative assessment, the patient was advised to undergo Morbid Obesity Treatment in Hyderabad, India, under the expert care of the Bariatric and Metabolic Surgery Department.

After detailed consultation with Dr. Suresh Kumar S (Consultant Surgical Gastroenterologist and Bariatric Surgeon), a comprehensive clinical evaluation was performed to determine the most appropriate treatment plan for the patient diagnosed with morbid obesity, polyendocrine metabolic ovarian syndrome (PMOS), insulin resistance, and bronchial asthma.

The patient had a BMI of 40.14 kg/m², which is classified as morbid obesity and is associated with increased metabolic risks. Considering the patient’s obesity, insulin resistance, PMOS, and need for effective long-term weight reduction, bariatric surgical management was considered appropriate.

Routine investigations, obesity-related assessment, liver evaluation, respiratory assessment in view of bronchial asthma, and pre-anaesthesia evaluation were completed to assess surgical fitness. Based on the clinical evaluation and preoperative assessment, it was determined that Laparoscopic Mini Gastric Bypass with crural repair and liver biopsy was the most appropriate surgical intervention.

The patient and family were counselled regarding the diagnosis, proposed procedure, expected benefits, possible risks, postoperative diet stages, early ambulation, activity restrictions, bariatric support group participation, regular follow-up, and the importance of long-term lifestyle changes for sustained weight loss and metabolic improvement.

Following the clinical evaluation and confirmation of the diagnosis, the patient was scheduled to undergo Laparoscopic Mini Gastric Bypass with crural repair in Hyderabad at PACE Hospitals, under the expert care of the Bariatric and Metabolic Surgery Department.

The procedure involved the following steps:

• Patient Preparation and Anaesthesia: The patient was taken up for surgery under anaesthesia. Intravenous antibiotics were administered before the procedure.

• Laparoscopic Access and Assessment: The procedure was performed using minimally invasive laparoscopic techniques. The stomach and liver were assessed during surgery and appeared normal.

• Crural Repair: The distal esophagus was mobilised, and crural repair was performed to strengthen the gastroesophageal junction area as part of the planned surgical procedure.

• Creation of Gastric Conduit: A gastric conduit was created from above the incisura angularis up to the gastroesophageal junction using surgical staplers. This helped form a smaller stomach pathway to support reduced food intake after surgery.

• Gastrojejunostomy Formation: Gastrojejunostomy was performed 150 cm from the duodenojejunal flexure using staplers, and the connection was reinforced by oversewing. This allowed food to pass from the gastric conduit into the small intestine, supporting weight loss and metabolic improvement.

• Liver Biopsy: A liver biopsy was taken during the procedure to assess liver health and identify any obesity-related liver changes at an early stage.

• Completion of Procedure: The surgical site was checked, hemostasis was confirmed, and the procedure was completed successfully without reported intraoperative complications. 

The postoperative period was uneventful. The patient received supportive care, including medicines for infection prevention, gastric protection, pain relief, and intravenous fluid support for hydration. She was closely monitored for pain, fever, vomiting, bleeding, wound condition, oral intake tolerance, and overall recovery.

The patient was started on a liquid diet on the second postoperative day, which was gradually increased to full oral liquids by the third postoperative day. Gynaecologist opinion was taken in view of polycystic ovary syndrome (PCOS). The liver biopsy taken during surgery was sent for histopathological evaluation, and further review was planned as part of follow-up care.

Early ambulation was encouraged, and the patient tolerated oral intake well. She was discharged in a hemodynamically stable condition with appropriate postoperative advice and follow-up instructions.

Upon discharge, the patient was prescribed medicines for infection prevention, gastric protection, pain relief, nutritional support, and other supportive care as required. She was advised to take all prescribed medicines as directed by the bariatric surgery team.

The patient was advised to follow the diet plan given by the dietician, including a liquid diet for one week, a puréed diet for one week, followed by a soft diet as advised. She was instructed to take small portions, eat slowly, maintain hydration, and follow dietary instructions carefully.

She was also advised to attend bariatric support group meetings, take bed rest for two weeks, avoid strenuous activities for two months, and follow all lifestyle and recovery instructions provided by the treating team.

The patient was advised to report to the emergency ward at PACE Hospitals in case of development of symptoms such as bleeding, fever, wound discharge, severe abdominal pain, persistent vomiting, severe pain, altered sensorium, breathing difficulty, or any other emergency symptoms after discharge.

The patient was advised to return for a follow-up visit with a Weight Loss Doctor in Hyderabad at PACE Hospitals after 1 week to assess wound healing, diet tolerance, recovery progress, liver biopsy report, weight-loss journey, and further bariatric care guidance.

This case highlights the successful management of morbid obesity with PCOS, insulin resistance, and bronchial asthma through laparoscopic mini gastric bypass with crural repair and liver biopsy. The procedure was completed successfully, and the postoperative period was uneventful. The patient tolerated oral liquids well, was encouraged to ambulate, and was discharged in a hemodynamically stable condition with diet instructions, medications, activity restrictions, support group advice, and follow-up guidance.