Obesity and gynecologic surgery, part 2

As previously reported, obesity poses many challenges to gynecologic surgery, from open to minimally invasive to vaginal surgery (Int. J. Gynecol. Cancer 2012;22:76-81; Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2014;21:259-65). Concerns relevant to operative management in the obese include difficulty with patient positioning, access to the abdominal cavity, visualization, and ventilation. This article will review tips for overcoming these challenges.

Positioning of obese patients often requires specialized equipment including bariatric beds, large padded stirrups, bed extenders, and arm sleds. Extra time and care should be taken while positioning obese patients given the increased propensity for pressure ulcers and nerve injuries. The basics of positioning begin with requesting additional help for patient moving and positioning as needed.

With regard to minimally invasive surgery, the use of antislip devices such as egg crate, gel pad, or a surgical beanbag is important for prevention of slippage when the patient is placed in the Trendelenburg position (J. Minim. Invasive Gynecol. 2014;21:182-95). The best laparoscopic positioning for these patients is in low lithotomy, with both arms tucked at the side in the military position and with liberal corporeal padding (Am. J. Obstet. Gynecol. 2004;191:669-74). When placing the patient in lithotomy, care should be taken to avoid hyperflexion of the hip, as obese patients are particularly prone to femoral nerve stretch injuries in this position.

Access to the abdominal cavity can be difficult because of the thickness of the abdominal wall in these patients. In open surgery, this is overcome with deep blades on retractors. In minimally invasive surgery, this requires longer trocars and Veress needles, which are now routinely available. If there is difficulty accessing the abdominal cavity with a Veress needle, a Hassan entry technique or ports with see-through trocars also can be used to ensure safe entry into the abdomen.

It is important to remember that the abdominal wall is the thinnest at the umbilical stalk. Additionally, using the upper abdomen can help assist with entry as the abdominal wall is often thinner above the umbilicus than below. For this reason, a left upper quadrant entry is often utilized at Palmer’s point. Care should be taken that entry is not so high as to limit the operator’s ability to reach the deep pelvis with laparoscopic instruments. Further, anesthesia must decompress the stomach prior to port placement in order to avoid a gastric injury.

Obese patients have a higher concentration of intraperitoneal and visceral fat, which can cause decreased visualization in the pelvis. In addition, the thick abdominal wall creates more torque on laparoscopic instruments, which can impair a surgeon’s ability to easily maneuver instruments. To decrease torque, trocars should be placed in the direction of the operative field. Draping the omentum over the liver can help to increase visualization, and always consider additional trocar placement to assist in visualization (Am. J. Obstet. Gynecol. 2004;191:669-74). Robotic instruments may further assist with feasibility of laparoscopy in the obese by obviating the role of abdominal wall torque.

Finally, patients can be difficult to ventilate in steep Trendelenburg required for laparoscopic surgery, as the weight of the breasts and abdomen shifts onto the thorax (J. Anesth. 2012;26:758-65; Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). By slowly tilting the patient into steep Trendelenburg, the body has a chance to acclimate to ventilation in this position. One needs to remember to insufflate the abdomen in the supine position prior to proceeding with Trendelenburg.

Of course, one should always consider that vaginal surgery provides a "minimally invasive" approach without the difficulty of ventilating an obese patient in steep Trendelenburg position. A recent review of the effect of obesity on vaginal surgery concludes that obesity increases the difficulty of vaginal surgery and may be best performed by high-volume surgeons, given the difficulties that are often encountered (J. Minim. Invasive Gynecol. 2014;21:168-75).

As the obesity epidemic continues, figuring out safe and effective ways to provide surgical care will continue to remain a challenge to surgeons. Utilizing these tips is a start, but continued innovation and experience will be required to provide optimal care to our ever-growing population.

Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Clark and Dr. Gehrig said they had no relevant financial disclosures.

As previously reported, obesity poses many challenges to gynecologic surgery, from open to minimally invasive to vaginal surgery (Int. J. Gynecol. Cancer 2012;22:76-81; Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2014;21:259-65). Concerns relevant to operative management in the obese include difficulty with patient positioning, access to the abdominal cavity, visualization, and ventilation. This article will review tips for overcoming these challenges.

Positioning of obese patients often requires specialized equipment including bariatric beds, large padded stirrups, bed extenders, and arm sleds. Extra time and care should be taken while positioning obese patients given the increased propensity for pressure ulcers and nerve injuries. The basics of positioning begin with requesting additional help for patient moving and positioning as needed.

With regard to minimally invasive surgery, the use of antislip devices such as egg crate, gel pad, or a surgical beanbag is important for prevention of slippage when the patient is placed in the Trendelenburg position (J. Minim. Invasive Gynecol. 2014;21:182-95). The best laparoscopic positioning for these patients is in low lithotomy, with both arms tucked at the side in the military position and with liberal corporeal padding (Am. J. Obstet. Gynecol. 2004;191:669-74). When placing the patient in lithotomy, care should be taken to avoid hyperflexion of the hip, as obese patients are particularly prone to femoral nerve stretch injuries in this position.

Access to the abdominal cavity can be difficult because of the thickness of the abdominal wall in these patients. In open surgery, this is overcome with deep blades on retractors. In minimally invasive surgery, this requires longer trocars and Veress needles, which are now routinely available. If there is difficulty accessing the abdominal cavity with a Veress needle, a Hassan entry technique or ports with see-through trocars also can be used to ensure safe entry into the abdomen.

It is important to remember that the abdominal wall is the thinnest at the umbilical stalk. Additionally, using the upper abdomen can help assist with entry as the abdominal wall is often thinner above the umbilicus than below. For this reason, a left upper quadrant entry is often utilized at Palmer’s point. Care should be taken that entry is not so high as to limit the operator’s ability to reach the deep pelvis with laparoscopic instruments. Further, anesthesia must decompress the stomach prior to port placement in order to avoid a gastric injury.

Obese patients have a higher concentration of intraperitoneal and visceral fat, which can cause decreased visualization in the pelvis. In addition, the thick abdominal wall creates more torque on laparoscopic instruments, which can impair a surgeon’s ability to easily maneuver instruments. To decrease torque, trocars should be placed in the direction of the operative field. Draping the omentum over the liver can help to increase visualization, and always consider additional trocar placement to assist in visualization (Am. J. Obstet. Gynecol. 2004;191:669-74). Robotic instruments may further assist with feasibility of laparoscopy in the obese by obviating the role of abdominal wall torque.

Finally, patients can be difficult to ventilate in steep Trendelenburg required for laparoscopic surgery, as the weight of the breasts and abdomen shifts onto the thorax (J. Anesth. 2012;26:758-65; Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). By slowly tilting the patient into steep Trendelenburg, the body has a chance to acclimate to ventilation in this position. One needs to remember to insufflate the abdomen in the supine position prior to proceeding with Trendelenburg.

Of course, one should always consider that vaginal surgery provides a "minimally invasive" approach without the difficulty of ventilating an obese patient in steep Trendelenburg position. A recent review of the effect of obesity on vaginal surgery concludes that obesity increases the difficulty of vaginal surgery and may be best performed by high-volume surgeons, given the difficulties that are often encountered (J. Minim. Invasive Gynecol. 2014;21:168-75).

As the obesity epidemic continues, figuring out safe and effective ways to provide surgical care will continue to remain a challenge to surgeons. Utilizing these tips is a start, but continued innovation and experience will be required to provide optimal care to our ever-growing population.

Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Clark and Dr. Gehrig said they had no relevant financial disclosures.

As previously reported, obesity poses many challenges to gynecologic surgery, from open to minimally invasive to vaginal surgery (Int. J. Gynecol. Cancer 2012;22:76-81; Gynecol. Oncol. 2008;111:41-5; J. Minim. Invasive Gynecol. 2014;21:259-65). Concerns relevant to operative management in the obese include difficulty with patient positioning, access to the abdominal cavity, visualization, and ventilation. This article will review tips for overcoming these challenges.

Positioning of obese patients often requires specialized equipment including bariatric beds, large padded stirrups, bed extenders, and arm sleds. Extra time and care should be taken while positioning obese patients given the increased propensity for pressure ulcers and nerve injuries. The basics of positioning begin with requesting additional help for patient moving and positioning as needed.

With regard to minimally invasive surgery, the use of antislip devices such as egg crate, gel pad, or a surgical beanbag is important for prevention of slippage when the patient is placed in the Trendelenburg position (J. Minim. Invasive Gynecol. 2014;21:182-95). The best laparoscopic positioning for these patients is in low lithotomy, with both arms tucked at the side in the military position and with liberal corporeal padding (Am. J. Obstet. Gynecol. 2004;191:669-74). When placing the patient in lithotomy, care should be taken to avoid hyperflexion of the hip, as obese patients are particularly prone to femoral nerve stretch injuries in this position.

Access to the abdominal cavity can be difficult because of the thickness of the abdominal wall in these patients. In open surgery, this is overcome with deep blades on retractors. In minimally invasive surgery, this requires longer trocars and Veress needles, which are now routinely available. If there is difficulty accessing the abdominal cavity with a Veress needle, a Hassan entry technique or ports with see-through trocars also can be used to ensure safe entry into the abdomen.

It is important to remember that the abdominal wall is the thinnest at the umbilical stalk. Additionally, using the upper abdomen can help assist with entry as the abdominal wall is often thinner above the umbilicus than below. For this reason, a left upper quadrant entry is often utilized at Palmer’s point. Care should be taken that entry is not so high as to limit the operator’s ability to reach the deep pelvis with laparoscopic instruments. Further, anesthesia must decompress the stomach prior to port placement in order to avoid a gastric injury.

Obese patients have a higher concentration of intraperitoneal and visceral fat, which can cause decreased visualization in the pelvis. In addition, the thick abdominal wall creates more torque on laparoscopic instruments, which can impair a surgeon’s ability to easily maneuver instruments. To decrease torque, trocars should be placed in the direction of the operative field. Draping the omentum over the liver can help to increase visualization, and always consider additional trocar placement to assist in visualization (Am. J. Obstet. Gynecol. 2004;191:669-74). Robotic instruments may further assist with feasibility of laparoscopy in the obese by obviating the role of abdominal wall torque.

Finally, patients can be difficult to ventilate in steep Trendelenburg required for laparoscopic surgery, as the weight of the breasts and abdomen shifts onto the thorax (J. Anesth. 2012;26:758-65; Ann. Surg. 2005;241:219-26; Anesth. Analg. 2002;94:1345-50). By slowly tilting the patient into steep Trendelenburg, the body has a chance to acclimate to ventilation in this position. One needs to remember to insufflate the abdomen in the supine position prior to proceeding with Trendelenburg.

Of course, one should always consider that vaginal surgery provides a "minimally invasive" approach without the difficulty of ventilating an obese patient in steep Trendelenburg position. A recent review of the effect of obesity on vaginal surgery concludes that obesity increases the difficulty of vaginal surgery and may be best performed by high-volume surgeons, given the difficulties that are often encountered (J. Minim. Invasive Gynecol. 2014;21:168-75).

As the obesity epidemic continues, figuring out safe and effective ways to provide surgical care will continue to remain a challenge to surgeons. Utilizing these tips is a start, but continued innovation and experience will be required to provide optimal care to our ever-growing population.

Dr. Clark is a chief resident in the department of obstetrics and gynecology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Clark and Dr. Gehrig said they had no relevant financial disclosures.