Laparoscopy in obesity Dr.Nutan Jain India

1. Dr. Nutan Jain M.S.
Director, Vardhman Trauma & Laparoscopy Centre Pvt. Ltd

3. jainnutan@gmail.com
Gynae OT Complex

6. I do not have any relevant financial
relationship to disclose.

7.  WHO defines obesity as abnormal or excessive
fat accumulation that may impair health.
 BMI is defined as a person's weight in
kilograms divided by the square of his height in
meters (kg/m2).
 Obesity is a BMI greater than or equal to 30.

8. A condition defined as a BMI of greater than 40
kg/m2.

9. Gynecoid obesity/Central
 Adipose tissue mainly distributed over
the sub-umbilical area hip and thigh.
 These patients are at particular risk for
complications of obesity
Android obesity/ Trunkal
 Adipose tissue with mainly distributed
over the supra-umbilical area trunk and
arms.

14.  Less amount of blood loss.
 Shorter hospital stay.
 Less wound infection and Surgical site infections
 Reduced risk of Venous thromboembolism
 Reduced analgesic requirements
 Superior quality of life scores
 Early resumption of daily activities

16.  An evaluation of underlying co morbid
conditions that could affect intra-operative
and postoperative care.
 Coronary artery disease (CAD)
 Hypertension
 DM
 Obstructive sleep apnea( can be associated
with postoperative respiratory
complications (pneumonia, postoperative
hypoxemia, and unplanned re-intubation)
 Obstructed airway

17.  Stabilizing co-morbidities
 Identifying Obstructive sleep apnea and SA symptoms
 Previous surgeries and previous anesthetics
 Difficult airway anticipation
 NECK CIRCUMFERENCE!!:*
 40 cm  5% risk
 60 cm  35% risk
 BMI perse is not a predictor of a difficult airway!
*Brodsky JB, Lemmens HJ, Brock-Utne JG, Vierra M, Saidman LJ. Morbid obesity and tracheal
intubation. Anesth Analg 2002; 94:732-6
PREOPERATIVE ASSESSMENT

18.  Anesthesia
 Patient positioning
 Creation of Pneumoperitoneum
 Trocar entry

20.  Difficult airway
 Pulmonary vital capacity is low in obese patients
especially expired volume
 Operating in the pelvis requires the Trendelenburg
position, which may cause difficulty in ventilating the
patient.
 A higher pneumoperitoneal pressure may be required,
but the higher pressure may hamper the ability to
provide adequate ventilation.
 LONGER OPERATING TIME

21.  Head-up position
 Stocking
 Good pre-oxygenation
 Tidal volumes < 10 ml/kg
 Peak End Expiratory Pressure
and recruitment maneuvers

22. PRE-OXYGENATION
 Adequate pre-oxygenation is vital in obese patient
 Pre-oxygenation using 25-degree head-up (back inclined)
 Application of positive pressure ventilation during pre-oxygenation
 3 – 5 minute pre-oxygenation with 100% oxygen is usually practiced

23. VENTILATION
 PEEP (positive end-expiratory pressure) is the only
ventilatory parameter that consistently has been shown to
improve respiratory function in obese subjects.
 After induction, it is reasonable to maintain 10 to 12 cm
H2O PEEP intraoperatively, but care must be taken to treat
any hypotension that may occur

25.  Should safely accommodate the patient’s weight while avoiding pressure
on points that could lead to nerve injury.
 The candy cane-shaped stirrup allows more operating space, but they
may lead to extreme knee and hip abduction in obese patients.


26. Left thigh
Left Arm
Foot end
Head end

27.  Hassons technique is not preferred in morbidly
obese as one has to penetrate 8 to 10 cm of
adipose tissue before fascia which is
impractical.
 Direct trocar entry is hazardous as its hard to
grasp and elevate the abdominal wall.

28.  Angle of thrust
 Varies with BMI

29. Trocar insertion in obese patients. Standard 45-degree angle insertion is not suitable in obese patients.
When using a 45-degree angle the tip of the trocar slides through preperitoneal fat without entering the
peritoneal cavity. For obese women with a thick anterior abdominal wall, the angle should be close to 90
degrees.

32.  Jain point lies in the left
paraumbilical region, in a
straight line drawn vertically
upward from a point 2.5 cm
medial to the anterior superior
iliac spine.
 Basic aim is to avoid –V V A B
Vessels Viscera Adhesions and
Bowel at umbilicus.

33.  Avoids lifting of abdominal wall.
 In obese patients, surface marking of other non-umbilical entry
ports is difficult but we have single prominent bony land mark,
ASIS.
 Going laterally as in Jain Point we can avoid central obesity.
 In obese patients distance of umbilicus to peritoneum could be 12
cm on an average so it needs a longer veress needle and trocar.
 Beneficial in previous surgery cases.
 Umbilicus moves caudally in relation to aortic bifurcation, hence a
direct, 90° insertion with long trocar is suggested but the risk to
major retroperitoneal vessel risk with a long trocar. (hurd et al)

34.  CREATION OF PNEUMOPERITONEUM-
Veress needle of 150 mm length is used

35. 1. Longer ancillary trocars (up to 150 mm)
2. Placement of ancillary trocars can be more challenging
because of the suboptimal visualization of the inferior
epigastric vessels and abnormal landmarks.
10mm
trocar

36. Number of Total obese cases No.
Total cases entered by Jain Point 8103
Only Obese cases 1136
With Previous Surgery 402
A. Prev. Laparoscopy 166
A. Prev. Laparotomy 236
Transverse Scar 144
Vertical Scar 79
Kocher’s Incision 8
Mc Burney Scar 4
Other (Nephretomy 1

44.  Long needle holders

46. Dense adhesions

47. BOWEL ADHERENT

49. ADHESIOLYSIS

52. uterus
uterus

54. Right Ureter Left Ureter

55. pararectal space
Ureter
Ureter

56. Right Para-rectal space

57. Rumi Cup
Uterus

58. Colpotomy

60.  Pt weight 110 kg
 Previous 3 LSCS
 Rupture uterus in 3rd labour
Ventral hernia
 Very big cervical myoma like
 Lantern top uterus
Big cervical myoma
Uterus

61.  Laparoscopic Intra-peritoneal Onlay Mesh (IPOM)

62. Laparoscopy can be more complicated in the obese
patient, and the risk of conversion to laparotomy is
higher, but the conversion rate tends to decrease
over time with surgical experience
Donnez O, Jadoul P, Squifflet J, Donnez J. A series of 3190 laparoscopic hysterectomies for benign disease from 1990
to 2006: evaluation of complications compared with vaginal and abdominal procedures. BJOG 2009;116:492–500

63.  O2 supplementation to combat
hypoxemia
 Aggressive pulmonary care in semi
recumbent position
 Pain control by regional anaesthesia to
avoid breathing difficulty
 Sequential compression devises for
lower extremity or prophylactic anti-
coagulation needed
 Early ambulation

64. 10-12 ml/kg/hour

66.  Publish date: October 4, 2016
Ob.Gyn. News
 Dr. Mikhail and his coinvestigators identified 2,002 patients in the
American College of Surgeons National Surgical Quality
Improvement Program (ACS-NSQIP) database, all of whom had a
diagnosis of uterine cancer and had undergone a hysterectomy
between 2005 and 2013
 “As the BMI goes up, MIS [minimally invasive surgery] is adopted,
which is a great finding,” Dr. Mikhail said.

67.  GLOBOCAN 2020-
- 2ND most common gynaecological cancer
- 4th most leading cause of death due to
the same
 most commonly diagnosed in USA
 78% is disease is disease confined to
uterus
 surgical staging with lymphadenectomy
defines risk and decides adjuvant treatment
 treatment without staging leads to increased use
of EBRT

68.  SLNB in endometrial cancer is associated
with a reduction in morbidity compared with
a full node dissection.

70.  Benefits of SLNB over Nodal Dissection
I. Dissection difficult with increasing obesity.
II. Less risk of vascular or nerve injury.
III. Less risk of leg lymphoedema
I. With single drug:
II. Pooled detection rate 77.8%.
III. Pooled sensitivity rate 89%.
IV. With 3 drug SLNB,
 Specificity is therefore considered 100%.

71.  Reconstitute with 5ml of distilled
water.
 Do not dilute with solutions
containing salts (Saline, Ringer’s
solution)
 Shake well for atleast 3 minutes
 Direction for use :- Dilute in 20 ml
of distilled water
 Inject at superficial and deep point
in cervix
 Superficial injection upto 3mm
 And deeper injection upto 2cm
 Inject 1ml at each site.
 3 and 9’o clock position
Cervix
9’o clock 3’o clock

72.  The STRYKER 1588 AIM platform
includes IRIS (Infra Red Illuminating
System)
 ENV (Endoscopic Near Infra vision
system)
 DRE (Dynamic Range Enhancement)
 DSAT (Desaturation) designed to
enable surgeons to see and do
more.

73.  63yrs old patient 110 kg
 Menopause 8 yrs
 Post menopausal bleeding
 Hysteroscopy:- Multiple polypoidal
endometrium all over increased
vascularity
 Endometrial biopsy done HPE report
showing adenosquamous carcinoma-
endometrium
 TVS showing:- Uterus
globular,enlarged.Both ovaries atrophic
heterogeneous

75.  Stryker 1688 Advanced Imaging Modalities (AIM) 4K Platform

76.  Pt. 65yrs/F
 Menopause x20yrs
 PV-cx uterus post menopausal
atrophic
 PS-sticky discharge
 Uterus size-39x24mm,right ovary
difficult visualized, collection ++
 P/H -Lap cholecystectomy done

82. Society of Gynecologic Oncology to issue a
consensus statement regarding robotic
surgery in gynecologic oncology.
The task force concluded that the current
evidence supports the equivalence of robotic
surgery with laparoscopy for the treatment of
endometrial cancer.
Minimally Invasive Surgery in Endometrial Cancer Recent Updates
Kemi M Doll; Anuj Suri; Paola A Gehrig DISCLOSURES Expert Rev of Obstet
Gynecol. 2013;8(3):271-283.

83.  From the AAGL Annual Meeting
Surgical outcomes of robotic-assisted hysterectomy did not
differ significantly for women whether they were non-obese,
obese, or morbidly obese, in a study of 442 women classified
according to body mass index.
 COST ONLY ISSUE
Robotic Hysterectomy Safe in Morbidly Obese Publish date: January 1, 2012 By: Damian McNamara Ob.Gyn.
News

84.  Our Patients usually do not exceed a BMI of 50
 Morbidly obese are just 10% of our routine work load.
 It takes about 20-27 min. more than a normal BMI patient.
 More time is spent on positioning, strapping and deciding
ports.
 Anesthetist experience in advance laparoscopic surgery cases
is paramount for safe outcome.

85.  Intra-op usually no difference after the veress needle and
first port is in.
 Peritoneal fat and bowel fat at times are bothersome and
an extra port either suprapubic or right upper para-
umbilical is needed for extra retraction.
 Articulating Vessel sealer instruments are much useful to
reach in difficult sites in obese patients.

86.  Pre operative work up for other systemic / metabolic disease.
 Thorough counseling.
 Weight adjusted dose for antibiotics and DVT prophylaxis
 Long veress needle
 Long trocars.
 Perpendicular insertion of trocars.
 Senior input for intra-operative monitoring.
 Plan for longer operative time
 Proper ICU support

87.  Laparoscopy needs more time in obese patients
 Technical difficulties during initiation must be
anticipated
 Laparoscopy is as safe in obese women as in non-
obese women WITH ALL DUE PRECAUTIONS
 Postoperative complications and hospital stay
after laparoscopy for obese are as minimal as in
non-obese women .
 Minimally invasive surgery to stage and
treat endometrial cancer and SLN ,
dramatically reduces the morbidity of surgery.