In the 1950s through the early 2000s, the procedure was performed through a sizable incision. "You can imagine, with the health risks associated with [the people seeking surgery] that it was often very risky," said Robin Blackstone, president of the American Society for Metabolic and Bariatric Surgery.
Around 2000, surgeons began to perform the surgery laparoscopically with tiny cameras through incisions less than a centimeter long. Now, about 93 percent of bariatric procedures are done laparoscopically.
Proponents say the death rate is now about 1 in 400 patients, but critics say that ratio includes lap-band surgeries that do not involve cutting the stomach. For bariatric surgery alone, the death rate can be as high as 1 in 200, critics say.
"The biggest problem with it is our inability to predict who is going to do well and who is not," Neiman-Hart said. "It's not a decision that I encourage my patients to take lightly."
Other nonfatal risks include infection, ulcers, heart attack, hernias and wound reopening. "Any time people elect to go in to have surgery, they're weighing individually the risks and benefits," said Blackstone.
Robinson's desire to have a child outweighed possible dangers in her mind, even though she had to pay $16,500 out of her own pocket for the surgery. Her insurance company, United Health Care, would not pay for it.
Nationwide, such surgeries cost between $20,000 and $40,000.
Most major insurance carriers include provisions for weight-loss surgery, but in practice they rarely cover the procedure, a survey of insurance guidelines shows. Aetna's guidelines, for example, say certain Aetna plans exclude coverage of bariatric surgery altogether and that "most" plans require that the procedure to be "approved by Aetna." Cigna and United Health Care include similar notes.
"It nearly broke us," Robinson said. "I mean, we were digging into places we didn't even know were there looking for money." To save on food costs, she even extended the required two-week presurgery diet of liquids and protein shakes to three weeks.
"I had to make up that extra cash somewhere," she said. "There was nowhere else left to find it.
"I said we couldn't afford it, but my husband just said, 'We can't afford not to,'" Robinson said. Without the surgery, they reasoned, they wouldn't be able to live out the lives they had planned. They wanted children and the mobility to travel.
"We decided we had to do it, spend the money," she said. "But it was so hard for us."
Blackstone said, "I always tell my patients that if you can lose 100 pounds and you keep it off, that's the holy grail. It's just that a lot of people can't do that without the surgery. They need tinkering."
Researchers at the Catholic University of Rome compared 30 patients who had gastric bypass surgery with 30 who received conventional medical therapy for diabetes. After two years, 75 percent of the gastric-bypass patients no longer had blood sugar in the diabetic range. All the patients who had medical therapy were still diabetic.
How does the surgery bring blood sugar down into normal range? Experts now realize that effective surgeries affect the body's metabolic processes. "They change the way your hormones work with the brain. They change your preference for food," Blackstone said.
Since her surgery, Robinson has overhauled her life. Her diet and exercise habits have improved substantially, partly because of a change in taste, she said, but also because of a lot of hard work.
Weight-loss surgery isn't a silver bullet for the country's obesity epidemic overall, Blackstone said. "For now, we're using obesity surgery as a window to figure this all out," Blackstone said. "There may always be people who need this kind of surgery, but I'm hoping it will just be in very extreme cases."
Now Robinson is considering teaching Zumba, something she could not do a year ago. "The exercise, not the surgery, got me in shape," she said. "It would be a big mistake to think surgery alone can fix the problem."
She is not yet pregnant, "but it's a lot more fun trying, now that I'm in shape," she said.
Shay Maunz is a West Virginia University journalism student. She wrote this story as part of the "West Virginia Uncovered" class, in cooperation with the Charleston Gazette series "The Shape We're In." Series coordinator Kate Long contributed to this story.