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Obesity Books

Operation Primer

The Operation Primers will be produced with the aim of describing the various operations in the simplest possible manner, but without over-simplifying. Although most time has been spent on the establishment of the scientific basis behind the operations the main focus has always been on the practical relevance of the Primers. With this Operation Primer we hope we have met our own as well as the readers’ highest expectations.

The Editors


“It is difficult to make it simple” – I think about this quotation from Pablo Picasso every day in surgery. It is a matter of summarizing complex working steps and treatments “simply”. Obesity surgery is not only a craft but it also signifies consideration of the disease as a whole. This Operation Primer undertakes the task of communicating basic surgical techniques. Only someone who knows all the technical possibilities and procedures is in a position to react flexibly and adequately in different situations. About 50 different surgical methods have been developed in obesity surgery in the past 50 years. It is obvious from this that the optimal surgical method for the obese patient does not exist. Among the stomach-narrowing surgical methods, the adjustable gastric band has become established as a very effective and minimally invasive surgical method. Experience has shown that peri- and postoperative complications can be reduced with different band placements and also with simplified working steps. This Operation Primer is an ideal format for communicating new operative methods but it does not replace training by an experienced surgeon. A surgeon cannot rest on his laurels but must always keep up with the latest techniques. I would therefore like to take this opportunity to thank the European Surgical Institute (ESI) for making Mental Training, training on the computer simulator and operations in the laboratory possible. First-class surgery is possible only through careful acquisition of knowledge, regular training and quality control.

Karl Miller, May 2006



Guest Preface, Nicola Scopinaro November 2005
Honorary President of the International Federation for the Surgery of Obesity (IFSO)

If, after crossing the Gran San Bernardo Pass, you go through the Aosta Valley heading for the fertile Pianura Padana, you will notice that at a certain point the valley becomes very narrow. There is a high steep rock in the middle of it and an almost inaccessible castle has been built on top of the rock. That is the Bard Castle, built there as a last defense of the Pianura Padana against the invading armies. However, the Castle needed in turn to be defended. Gastric banding is the extreme defense of our
field against the wild, uncultured surgical armies aimed at invading our discipline, and Karl Miller’s book is the defense of gastric banding. Gastric banding is not only the most commonly performed obesity operation in Europe; much more importantly, it is the operation that the vast majority of new obesity surgeons will encounter as their first bariatric experience. This confers a tremendous
responsibility on the gastric banding operation. In fact, not only all the possible damage that can be done with gastric banding, as with any other bariatric operations, will depend on how the new obesity surgeon will approach this procedure, but also
the future type of attitude he will have towards the obesity surgery discipline will be largely influenced by that approach. Gastric banding is the perfect operation with which to enter the field of bariatric surgery, provided that a very dangerous misunderstanding be immediately clarified: gastric banding is the perfect first bariatric operation not because it is an easy operation,
but because it entails the least possible risk of causing major damage while learning how to do it. Misunderstanding must be further clarified by explaining that:
1) gastric banding is in fact a difficult operation, whose correct execution, differently from other bariatric operations, requires millimetric precision, and
2) gastric banding is not simply a starting operation but is a very good procedure that, if correctly performed and followed up, can be used over a lifetime with excellent results. All this is very clearly explained in Karl Miller’s book.
The reader should clearly understand that minimal invasiveness does not authorize anyone to neglect the follow-up, which as with all gastric restriction bariatric procedures, is the real key to success. Thanks to the concept of the Operation Primer, the reader is guided through all the steps necessary to acquire full familiarity with the procedure. The illustrations are
clear and exhaustive. Nothing is forgotten. Nothing is left to chance or imagination. Every smallest detail is given the importance it deserves, as it should always be in teaching.

In conclusion, Karl Miller’s book returns gastric banding to the place it deserves in our discipline. Not a Cinderella among other operations, but one offering complete guidance to the basic principles of bariatric surgery. Not, or not necessarily, a transition
step, but a fully established obesity surgery operation which can give total satisfaction to its user, provided that he devotes to it at least as much attention and respect as to other major bariatric procedures, which have their natural defenders due
to their perceived greater technical difficulty and perceived greater potential nutritional problems. Not having these natural defenders, gastric banding was liable to be treated with superficiality, carelessness and lack of the necessary respect. It needed an advocate, a godfather, a pioneer. All these were eventually found in Karl Miller, with this outstanding book. Let us hope that in the years to come the Bard Castle will not be overwhelmed whenever a group of tourists want to have a look at the Pianura Padana.

Nicola Scopinaro November 2005
Honorary President of the International Federation for the Surgery of Obesity (IFSO)