Best Practice & Research Clinical Obstetrics & Gynaecology
11Obesity in laparoscopic surgery
Introduction
The worldwide prevalence of obesity has reached epidemic proportions, and recent figures have shown that 26% of the UK population has a body mass index (BMI) ≥30 kg/m2 [1]. The health implication of obesity has been well established, and it is associated with a variety of medical conditions, in addition to adversely affecting morbidity and quality of life. Physicians of all backgrounds and specialties have had to adapt their practice to manage the specific challenges posed by obesity, and gynaecology is no exception. Modern laparoscopy has continued to evolve enabling more complex procedures to be successfully performed using minimally invasive techniques. Laparoscopy is particularly well suited for treatment of gynaecological diseases in obese patients due to faster recovery and lower rates of wound infections.
Section snippets
Obesity – a health burden
Obesity is a term most commonly used to define an excess of body fat, usually relating to increased weight for height. The most common method of measuring obesity is the BMI, a universally recognized scale allowing for comparisons between different countries and populations. The World Health Organization distinguishes between different categories of BMI and defines class 1 obesity as BMI >30, class II obesity BMI 35–40 and class III or morbidly obese as those with a BMI >40 (Table 1) [2].
Physiological considerations in the obese patient
Obesity is often associated with hypertension, which may lead to left ventricular hypertrophy. Cardiac response is often altered in patients with an increased BMI due to increased metabolic demands and resultant increased preload and resting cardiac output. Larger cardiac stroke volume and raised cardiac output can lead to additional strain on the heart resulting in hypertension, cardiomegaly and eventual congestive cardiac failure. Studies have demonstrated a higher risk of death in patients
Exposure techniques and patient positioning
Exposure of the operative field is one of the single most important steps when performing laparoscopy in obese patients. Careful preoperative planning is important to optimize patients from a cardiorespiratory perspective to ensure patients can tolerate Trendelenburg positioning for even long periods of time. Equal importance is placed on ensuring sufficient bowel preparation is given so as to optimize exposure, thereby enabling more complex procedures to be successfully performed
Entry techniques in obese patients
One of the main obstacles in obese patients is accessing the abdominal cavity. Major complications although rare can occur during laparoscopic entry with the incidence of bowel perforation reported as 1.8 per 1000 and of major abdominal vessel injury as 0.9 per 1000 cases [23]. Different laparoscopic entry methods have been evaluated with no reported difference in major complication rates between the different techniques. Direct trocar entry, however, when compared to Veress needle entry was
Feasibility and outcomes of laparoscopic surgery in obese patients
Historically, obesity was often regarded a relative contraindication to laparoscopy, despite it being particularly well suited for obese patients by minimizing surgical morbidity related to poor healing of wounds.
Since the first laparoscopic hysterectomy reported by Reich et al., many surgeons worldwide have demonstrated that this technique is both feasible and reproducible [27]. The risk of major operative complications in laparoscopic hysterectomy remains low, and it is considered suitable
Surgical management of malignancy in obese women
Over the years, studies have shown that laparoscopic surgical management of early-stage endometrial cancer is both feasible and cost-effective. Although patients having a higher tendency for obesity often suffer from other medical co-morbidities, laparoscopy remains a viable option despite posing certain technical challenges, specifically regarding lymphadenectomy procedures. In a study of 240 patients, there was no difference regarding blood loss, rate of lapro-conversion or number of
Conclusion
There is now increasing evidence that laparoscopy is safe and feasible for the management of gynaecological diseases in obese patients, providing a suitable alternative to laparotomy whilst achieving similar results with minimal complications. In fact, when compared with open procedures, a laparoscopic approach results in fewer operative complications such as wound infections, post-operative ileus, shorter hospital stay, faster recovery and lesser need for pain medication. Nowadays,
Summary
Obesity is on the rise and gynaecological surgeons are more than likely expected to treat an increasing number of obese patients. Laparoscopy is not contraindicated in obese patients, and despite being associated with increased operating times in cases of complex surgical procedures there are numerous advantages of using minimally invasive techniques. Complication rates in obese patients are comparable to their non-obese counterparts, and patients experience reduced post-operative pain, faster
Conflict of interest statement
None of the authors have any conflict of interest.
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Cited by (20)
Challenges of morbid obesity in gynecological practice
2023, Best Practice and Research: Clinical Obstetrics and GynaecologyComparison of complications in very obese women undergoing hysterectomy – Abdominal vs laparoscopic approach with short- and long-term follow-up
2022, European Journal of Obstetrics and Gynecology and Reproductive BiologyCitation Excerpt :The authors concluded that major operative morbidity following minimally invasive hysterectomy is rare regardless of the surgical approach [15]. A strong positive association was found between BMI and the risk of wound dehiscence after LT, with 5–10-fold higher risk for women with BMI > 40 kg/m2 [15,18,19]. There were no significant differences in the adjusted odds ratio of wound dehiscence between women of various BMIs following LS hysterectomy, but a strong positive association was found between BMI and the odds ratio of wound dehiscence following abdominal hysterectomy.
Class III Obesity and Other Factors Associated with Longer Wait Times for Endometrial Cancer Surgery: A Population-Based Study
2020, Journal of Obstetrics and Gynaecology CanadaCitation Excerpt :In many health care settings, there is often a lack of appropriate equipment for individuals with obesity.13 Patients with obesity are known to benefit from MIS because it confers lower rates of wound infection and other complications without compromising oncologic outcomes,23,24 but access to MIS remains suboptimal on a population level.25,26 In our study, laparoscopic or robotic surgery was associated with a longer wait time compared to open surgery.
Directive clinique N<sup>o</sup> 386 - Chirurgie gynécologique chez les patientes obèses
2019, Journal of Obstetrics and Gynaecology CanadaCitation Excerpt :Après l'entrée laparoscopique initiale, des trocarts supplémentaires devraient être insérés sous visualisation directe. Il n'y a pas de position standard pour les trocarts auxiliaires, mais il est généralement pratique de les situer en direction céphalique et latérale chez les patientes obèses en raison du pannicule et de la difficulté à visualiser les artères épigastriques inférieures6, 40, 41. Il convient d'insérer des trocarts supplémentaires, idéalement de 5 mm, durant l'intervention au besoin aux fins de rétraction ou pour favoriser une intervention efficace.
Guideline No. 386-Gynaecologic Surgery in the Obese Patient
2019, Journal of Obstetrics and Gynaecology CanadaCitation Excerpt :Candy-cane stirrups permit excessive abduction at the hip and knee joints, which increases the risk of injury. Extra padding around potential pressure points (shoulders, knees, ankles) is recommended to decrease the risk of injury.5,40–42 An important component of positioning is assessment of the patient's weight distribution and the mobility of the panniculus.
Implications of obesity on gynaecological surgery
2019, Obstetrics, Gynaecology and Reproductive Medicine