When deciding whether to get into bariatric surgery, a critical question is will it pay? Since virtually everything about the procedure - from volume to technique to fees to expenses - differs widely, each facility must answer the question for itself. For starters, though, here are a few ballpark figures from facilities that have done it.

Instruments and equipment
Experts say you'll need at least two sets of extra-long instruments per room consistent with the style of procedure your surgical team will be doing. Sets at Medical Center East, a Birmingham, Ala., hospital that now does 2,500 cases per year, include a McKernan grasper, Hunter bowel clamps (33cm and 45cm), a laparoscopic Glassman atraumatic grasper, an esophageal retractor and a 32cm Jarit needle holder. The cases also require flexible graspers, but the hospital already owned those, says Denene Cofield, surgical services director. For each tray, Ms. Cofield budgeted $15,000.

Some surgeons may also need a long liver retractor and a long knot pusher, says Christine Pappas, marketing manager for V. Mueller. She also points out that there should be a basic tray on hand with extra long instruments if the surgeons have to convert to an open procedure. "You're still talking a deep pelvis," says Ms. Pappas. This set also needs to include retractors that can handle a bariatric patient.

Jennifer Gianos, RN, a first assistant and a frequent lecturer on bariatric surgery for the American Society for Bariatric Surgery, recommends two backup trays "in case you drop one." If money is tight, she adds, some companies offer financing for the instruments.

If your facility doesn't already own one, you'll also need a 35- or 45-degree laparoscope, says Ms. Gianos.

Experts say beginners don't need to immediately invest in a heavy-duty bariatric surgery table, which can cost well over $100,000 or even $200,000. Ms. Cofield stresses that facilities should follow the 50/50 rule. "At least the first fifty patients should have a BMI under 50 while your surgeons develop technique and get into the comfort zone. Complications do go up with patients' BMIs. Most patients are women and weigh 300 lbs on average. That is a rated weight for all our equipment."

Once you're ready to try heavier patients, adds Ms. Gianos, you can buy more time by inviting table makers to demo their products. They may leave them at your facility for up to a month, she says.

You'll also need heavy-duty beds for these patients; these can cost from $2,000 to $25,000 for the kind that convert to a chair. If you need to buy time, rent beds, says Ms. Gianos. "It costs about $90 per day, and the average patient stays about a day-and-a-half."

Because wall-mounted toilets are rated for only 250 lbs., you should invest in a bariatric commode, advises Ms. Cofield. These sturdy chairs, which fit over toilets, can hold nearly any patient and cost very little. One such device from Invacare is rated for 700 lbs and costs just a little more than $200.

If you don't already have one, you need an excellent patient transfer mechanism. You'll also need an extra-wide wheelchair if your facility doesn't already have one. These also can hold 700 lbs and cost from $1,000 to $2,000.

And finally, in all areas that bariatric patients will frequent, including the lobby and preadmission testing, install extra wide chairs and benches. Vic Convertino, the OR manager at Highland Hospital in Rochester, N.Y., says his facility completely remodeled to cater to obese patients.

Figuring your case costs
About six months ago, at the request of Alan C. Wittgrove, MD, a prominent bariatric surgeon who at that time operated at her hospital, Tamara Rasoumoff, RN, of Alvarado Hospital in San Diego, compiled a list of the disposables used in the procedure, complete with costs to the hospital. She agreed to share it with Outpatient Surgery readers. All told, the disposables cost a minimum of $3,007.46 for each case.

A few caveats:

• Dr. Wittgrove happened to have used mostly Ethicon products. U.S. Surgical, a competitor, also makes a complete system for bariatric surgery.
• With more than 3,000 procedures under his belt, Dr. Wittgrove is more efficient than most; he completed procedures in about 90 minutes and used half the stapler reloads as some surgeons, reports Ms. Rasoumoff.
• Dr. Wittgrove's technique is one of many, and costs vary by technique.
• Facility costs will obviously vary by volume.

All that said, here were the costs of disposables for one surgeon in one hospital.

Miscellaneous set-up items: $89.01
These included:

• 1 laparotomy sheet for draping: $5.82
• 1 standard basin set: $5.86
• 1 ground pad for the electrocautery: $3.13
• 1 package of leggings to cover the patient's arms, since the laparotomy drape often does not cover the arms: $2.77
• 1 custom basic pack, including two gowns and towels: $26.97
• FRED defogger for the camera: $8.31
• 1 drape for the voice-controlled robotic device (Aesop) which holds the camera: $16.95
• 5 extra gowns and five extra pairs of gloves for when the surgeon goes to the head of the table for endoscopy and back again: $2.90 $.94 x 5 = $19.20

1 insufflation tubing set: $12.73

1 bioenteric gastric balloon suction catheter: $135

• Surgeons use this for emptying the stomach and for creating the pouch. Inserting the tube in the stomach and inflating the bulb at the distal end to 15cc makes it easy to gauge the proper size of a pouch

1 lap-gastric procedure pack: $1,040.11
The pack made for the surgeon, from Ethicon Endosurgical, included the following items:

• 15mm trocar, for use in the epigastric area to enable the surgeon to retract the liver
• 4 10mm-12mm trocars (with universal adapters to prevent deflation) for the camera, graspers and staplers
• 1 pneumo needle to insufflate the peritoneal cavity
• 1 circular stapler to secure the anastomosis between the stomach pouch and the small bowel
• 1 35mm stapler and one reload for this stapler for the bowel to bowel anastomosis. The surgeon preferred using two 35mm cartridges rather than one 45mm cartridge because he felt it would help prevent stenosis of the opening.
• 1 harmonic scalpel, for cutting and cautery. Ms. Rasou-moff says the kit reduced the frustration of pulling supplies.

1 long 45mm stapler $289.60

• The surgeon preferred this stapler for transecting the stomach.

6 reloads for long 45mm stapler @ $107.21 each: $643.26

• Dr. Wittgrove typically transected the stomach with three staple cartridges and used three loads for the remainder of the case. Ms. Rasoumoff warns that some surgeons use many more staple loads for transection.

35cm vascular stapler: $196.20

Reload for stapler: $87.95

Disposable scissors: $72.16

• The model used cost $72.16. You may use reusable scissors.

1 14-gauge angiocath: $3.09

• The surgeons used this stiff-walled catheter to assist in the process of bringing the head of the circular stapler to the anastomosis site. Once the peritoneum was insufflated, the surgeons stabbed through the peritoneum to the stomach pouch. As the assistant surgeon watched through the gastroscope, the principal surgeon poked and prodded the pouch until the two found the best anastomosis site. Then the principal surgeon poked through the pouch wall with the catheter and the assistant surgeon grabbed the catheter with a snare from a Ponsky PEG gastrostomy kit.

Ponsky PEG gastrostomy kit: $79.50

• This kit contains the above-mentioned snare and also a blue wire which the surgeon inserted through the catheter after withdrawing the needle. Once the blue wire emerged from the catheter, the assistant surgeon let go of the catheter, snared the blue wire, pulled it through the mouth and attached the circular stapler's anvil tip so that it could be pulled to the anastomosis site. The PEG kit also contained lubricant to help the stapler head slide past the esophagus without causing trauma.

1 taut Penrose drain: $6.05

• This let the surgeon pull the small bowel up through the mesentery to the anastomosis. This is a necessary step in the retrocolic technique.

4 Endostitch sutures @ $36.79 each = $147.16 The surgeons used this for oversewing the gastric staple line to prevent leaks and also to reinforce areas prone to herniation.

1 packet Laparo-Tys (Ethicon): $28.05

• These clip-on ties replace suture knots; this surgeon found them easier to place.

Irrigation and cautery items: $88.43
Items included:

• A Conmed suction/irrigation/electrosurgery device, $46.80. This particular device had long and short electrodes available at $36.40 each. Some cases required just one, some both, at a total cost of $72.80.
• 3000ccs of saline, $4.42. While insufflating via the gastroscope, the surgeon submerged the pouch in irrigation fluid and watched for bubbles, a sign of leakage.
• 1000ccs of saline for Asepto syringe: $.81

Closure and case completion items: $89.96

• 1 Endoclose needle to close the port through which the stapler was passed: $46.56. The facility has since switched to Allez Medical's 4closure suture- passing device.
• 1 PDS suture for use in this same port: $1.22
• Blake drain: $26.13, bulb: $4.42, 2.0 nylon suture for drain: $1.22 (the surgeon placed this at the procedure's end to drain the peritoneal cavity)
• Skin stapler: $9.23
• Water to wash instruments: $1.18

Variable costs

• Surgeons occasionally used an Endocatch to reduce the chance for wound infection during the removal of small bowel segments. Cost: $92.35. When the surgeon suspected leakage at the pouch transection, he introduced Tisseal tissue glue, cost unknown. Although no surgeons at Alvarado do so, many surgeons use staple-line reinforcement to prevent leaks, another relatively pricey item. When patients had hepatitis or high liver enzymes, another trocar may be necessary for a needle biopsy.

Adding it all up
Just as morbidly obese patients must ask themselves if bariatric surgery is worth the $25,000, facility managers must carefully consider whether adding a bariatric surgery program is a wise investment. Ms. Cofield compares the difficulty to that of adding an open heart program, but says for her part the effort was worthwhile and the satisfaction she gets is worth it.

"If you treat them correctly," she says, "these patients will love you. This surgery lets them regain their health and their life."