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Laparoscopic hysterectomy in obese women: a clinical prospective study
European Journal of Obstetrics & Gynecology and Reproductive Biology 98 (2001) 77±82
Laparoscopic hysterectomy in obese women: a clinical prospective study Z. Holub*, A. Jabor, L. Kliment, D. FischlovaÂ, M. WaÂgnerova Head of Department Obstetrics and Gynaecology, Baby Friendly Hospital, VancÏurova 1548, 272 58 Kladno, Czech Republic Received 18 April 2000; received in revised form 19 June 2000; accepted 10 December 2000
Abstract Objective: To compare perioperative and postoperative outcomes of laparoscopic hysterectomy (LH) in surgical management of gynecological conditions in two groups of different weight. Methods: A prospective comparative clinical study of 271 LH performed for disease of female pelvic organs in a group of 54 obese patients (over 30 body mass index (BMI)) and in a group of 217 non-obese patients (less than 30 BMI). The following criteria were assessed: patient characteristics, indications for surgery, previous surgery, presence of adhesions, duration of procedure, blood loss, weight of specimen, hospital stay and complications. Statistical analysis was performed using the unpaired t-test and non-parametric Chi-square test when appropriate, with a signi®cance level of P 0:05. Results: Three non-obese patients were converted to laparotomy due to operative complications. Laparoscopy in the remaining 268 patients (98.89%) was completed successfully. There was no signi®cant difference in estimated blood loss, presence and degree of adhesions, weight of specimen, length of hospital stay and postoperative complications between women with high BMI and those with low BMI. The rate of major operative complications (5.55% versus 3.22%) was higher in the obese group. The duration of the operation was longer in obese women. However, the signi®cance of the difference was borderline (P 0:06). # 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Obese women; Laparoscopic hysterectomy
1. Introduction Currently, hysterectomy is the most frequently performed procedure in gynecological surgery. Approximately 18± 20 000 hysterectomies are performed annually in the Czech Republic. There has been a signi®cant move away from abdominal hysterectomies to less invasive procedures with laparoscopic and vaginal approaches. Laparoscopic hysterectomy (LH) was introduced into clinical practice by Reich in 1988 [1]. Obesity has been considered by some gynecologists to be a relative contraindication to operative laparoscopy [2]. The feasibility of laparoscopy is often limited by obesity, and laparoscopic procedures are dif®cult in women weighing 180 lb (81.7 kg) or more [3]. Eltabbakh et al. [4], however, suggest in their recent study, that operative laparoscopy is safe and feasible in women with high body mass index (BMI) as well. Based on the above mentioned reason, the primary aim of our study was to verify how obesity changes perioperative parameters and affects the feasibility of laparoscopic procedures performed for different gynecological *
Corresponding author. Tel.: 42-41-312-606-373; fax: 42-41-312-606-417. E-mail address: [email protected] (Z. Holub).
conditions in a group of obese patients with LH. This knowledge is important, because each third woman in our population over 30 is obese. The study is a part of a longterm systematic study conducted within our unit trial [5,6]. 2. Material and methods A comparative prospective clinical study was undertaken at Baby Friendly Hospital Kladno, which included 271 women treated by LH. Patients were selected consecutively upon the physical, ultrasound, laboratory (CA 125) and biopsy examination. Perioperative records were sorted into two groups: the group of obese women (over BMI 30 or 180 lb/81.7 kg) was compared with the group of non-obese women (under BMI 30 or 180 lb/81.7 kg) in whom laparoscopic surgery had been done between January 1998 and December 1999. The BMI showed the proportion between weight and height and divided obese patients into three subgroups: overweight (BMI 25±30), moderately obese (BMI exceeding 30) and severely (morbidly) obese (BMI exceeding 36). The most frequent reasons for the LHs were complaints due to uterine myomas, adenomyosis, endometriosis, adnexal mass, pelvic pain, menometrorrhagia as well
0301-2115/01/$ ± see front matter # 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 1 - 2 1 1 5 ( 0 0 ) 0 0 5 6 5 - 0
78
Z. Holub et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 98 (2001) 77±82
Table 1 Characteristics of womena Group of patients
Non-obese
Obese
P value
Weight (kg) Mean (range) Age (years) Mean (range) Parity Mean (range)
67.21 (45±81) 46, 59 (30±76) 1.97 (0±4)
89.09 (82±121) 47, 50 (32±71) 2 (0±6)
P 0.0001
Menopause Premenopause Postmenopause
170 (78.3%) 47 (21.7%)
43 (79.6%) 11 (20.4%)
NS
Number of previous laparotomies Zero 114 (52.5%) One and more 103 (47.5%)
30 (55.6%) 24 (44.4%)
NS
a b
NSb NS
2.1. Operative technique
Data are presented as n (%). NS: non-significant.
as recurrent intraepithelial neoplasm, endometrial and cervical cancer. The individualized feminine characteristics are listed in Table 1, while Table 2 shows the indications. The following two variants of LH were used: the laparoscopy assisted vaginal hysterectomy with vaginal colpotomy (LAVH-VC) and laparoscopy assisted vaginal hysterectomy with laparoscopic colpotomy (LAVH-LC). We opted for a combination of laparoscopy and vaginal surgery in the patients with pelvic or abdominal surgery in history, those suspected of an adhesive process after the pelvic in¯ammation, ®xation of retro¯exed uterus, uterus size more than 14 weeks, adnexal pathologies or expected dif®culties in removal of adnexa. We preferred the LAVH-LC procedure mostly in smaller uterine sizes, given an important need to perform the uterine removal within a shorter period along with preservation of uterosacral complex. The salpingooophorectomy, omentectomy, vaginal repair and lymphadenectomy were performed according to the diagnoses, ages and histology±pathology ®ndings. We have monitored the following parameters: the duration of surgery, blood loss, weight of specimen, histology±pathology ®ndings, postoperative morbidity, hospital stay and convalescence, patient age and weight. Operative complications were de®ned as a conversion to laparotomy or bowel, ureteral, bladder, vascular injuries or excessive abdominal wall bleeding and Table 2 Indications for laparoscopya Non-obese
Obese
Symptomatic benign uterine pathology Adnexal mass, endometrioma Ovarian cystadenomas Cervical intraepithelial neoplasia III Atypical complex endometrial hyperplasia Endometrial cancer Microinvasive cervical cancer
158 26 11 6 4 11 1
38 5 2 0 1 6 2
Total
217
a
Data are presented as n (%).
(72.8%) (12.0%) (5.1%) (2.8%) (1.8%) (5.1%) (0.5%)
54
estimated blood loss exceeding 1000 ml or requiring blood transfusion. Postoperative complications were considered major if they resulted in readmission or a secondary surgical procedure and were considered minor if they did not result in these sequels. Only four experienced gynecologic laparoscopists performed all procedures. Preoperatively, all patients gave their informed consent to a surgery and the study was approved by the Local Independent Ethics Committee.
(70.4%) (9.3%) (3.70%) (00%) (1.9%) (11.1%) (3.7%)
Closed laparoscopy was performed in the lithotomy position using videomonitoring equipment. The telescope was inserted subumbilically and one 10 mm port was opened suprapubically and medially. Two or three 5 mm ports were placed in each of the lower quadrants at the lateral edge of the direct abdominal muscle. No special techniques were used in obese patients except that primary trocars and the lateral trocars were inserted more vertically to the skin and were longer than usual (5 mm trocar 10 cm, 10 mm trocar 15 cm, Ethicon Surgery, Johnson±Johnson, Summerwille, NJ, USA). The electrosurgery (bipolar and monopolar procedures) or the harmonic scalpel were used as a primary method of hemostasis and discission. All operations were performed under general anesthesia with endotracheal intubation. Prophylactic antibiotics were administered intraoperatively. Laparoscopically assisted surgical staging required a complete inspection of the whole peritoneal cavity and intraperitoneal ¯uid was aspirated in each of the four quadrants and examined for cytology. 2.2. Laparoscopy assisted vaginal hysterectomy with vaginal colpotomy (LAVH-VC) The hysterectomy was started by laparoscopy. These made within the laparoscopic phase were steps with severing the round ligament, dissection of the upper portion of the broad ligament, severing the tubouterine junction and the uteroovarian ligament or severing the infundibulopelvic ligament, preparation of the bladder ¯ap, and severing the bladder pillars. Those ®nalized vaginally were steps consisting in severing the uterine vessels, cardinal-uterosacral ligament complex, performing anterior and posterior culdotomy, and closure of the vaginal cuff. 2.3. Laparoscopy assisted vaginal hysterectomy with laparoscopic colpotomy (LAVH-LC) All steps were performed laparoscopically except those with severing the uterine vessels and closure of the vaginal cuff, which were completed vaginally. The cul-de-sac was opened during laparoscopic procedure, but the connection of uterosacral ligament remained preserved in the vaginal vault. The cup of Koh was placed over the cervix in the LAVH-LC patients only. The cup was used either alone with uterine manipulator or as a part of a new system described by
Z. Holub et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 98 (2001) 77±82
Koh in 1998 [7]. In principal, this system consists ®rstly in lifting the neck and straining vaginal vaults with the manipulator of plastic vaginal cuff. Subsequently, distancing uterine vessels from ureter and safe dissection of uterine vessels and vaginal vaults are performed. 2.4. Transperitoneal pelvic lymph node dissection (PLN) and infraaortic lymph node dissection (IALN) Incising the peritoneum, which lies over the right common iliac artery, and extending this incision caudally along the external iliac artery towards the round and broad ligaments started the dissection. Lymph nodes bearing adipose tissue were excised from the obturator fossa after mobilization of the external and internal iliac vessels and obturator nerve. We disected lymph nodes up to the level of bifurcation of iliac vessels superiorly and to the femoral canal inferiorly. Paravesical and pararectal spaces were opened with blunt and sharp dissection. The ureter was visualized along the medial leaf of the peritoneum at the level of the bifurcation of common iliac artery. We dissected the lymph nodes up to level of bifurcation of the iliac vessels and/or to the level of the meseneteric inferior artery. 2.5. Statistical analysis An independent biostatistician evaluated and compared differences in perioperative and postoperative outcomes. The results of the obese group were compared with outcomes of the non-obese group. We tested the difference between both studied groups through the unpaired t-test and non-parametrical Chi-square test. P < 0:05 was considered statistically signi®cant.
79
3. Results Subject characteristics and indications for LH are listed in Tables 1 and 2, respectively. Laparoscopic hysterectomy (LH) was successful and completed in 268 women (successful laparoscopic procedure rate 98.89%). The difference in body weight between groups was substantial (mean 67.21 and 88.09 kg, P < 0:0001). A total of 54 women (19.92%) had BMI exceeding 30 and 217 women (80.08%) had BMI 30 or less. The heaviest woman (121 kg) underwent LH for endometrial cancer. The BMI of obese patients varied between 30 and 40 in most cases. In ®ve patients (9.26%) the BMI was localized to the group with severe obesity (Fig. 1). As shown in Tables 2, 3 and 4 there were no statistically signi®cant differences in a frequency of individual types of hysterectomy, indications, estimated blood loss, presence and degree of adhesions, weight of specimen, operative and postoperative complications, or length of hospital stay between women with high and low BMI. The duration of operation was longer in obese women. However, the signi®cance of the difference was borderline (P < 0:06). No statistically signi®cant difference between the groups was found in the proportion of operative and postoperative complications. Conversions were included in operative complications. Three of the obese patients had operative complications: incidental cystotomy (n 2) and injury of epigastric artery (n 1). One non-obese woman sustained an injury to the epigastric artery and three other had these complications: injury of the bladder, transfusion and relaparoscopy for excessive bleeding from the Redon's drain. Major postoperative complications in the non-obese group included pulmonary microembolism (n 1), fever (n 2) and bleeding from the vaginal vault (n 2). Minor complications included urinary tract infection (n 7),
Fig. 1. Distribution of the body mass index (BMI) of obese women.
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Z. Holub et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 98 (2001) 77±82
Table 3 Types of surgerya
4. Discussion
Type of surgery
Non-obese b
Obese
LAVH-VC LAVH-VC, BSO (including USO) LAVH-LC LAVH-LC, BSO (including USO)
36 85 26 70
(16.58) (39.17) (11.98) (32.25)
10 17 8 19
Additional procedures PLN PLN, IALN Lysis of adhesion Omentectomy Vaginal repair
7 3 78 1 2
(3.22) (1.38) (35.94) (0.45) (0.92)
5 (9.25) 1 (1.85) 21 (38.88) ± ±
(18.51) (31.48) (14.81) (35.18)
a Abrevation: LAVH: laparoscopic assisted vaginal hysterectomy; BSO (USO): bilateral (unilateral) salpingo-oophorectomy; PLN: pelvic lymphadenectomy; IALN: infraaortic lymphadenectomy; VC: vaginal colpotomy; LC: laparoscopic colpotomy. b Data are presented as n (%).
wound cellulitis (n 1) and urinary retention (n 1). Out of the women with BMI exceeding 30 (obese group), one had a major complication (fever) and three (5.55%) had minor postoperative complications, such as urinary tract infection (n 2) and wound cellulitis (n 1). We had to convert to laparotomy in three patients in the non-obese group. In one case we decided to switch over to laparotomy, as during the LAVH-LC preparation we had to counteract a rupture of ¯at-scarred synechia in the vaginal vault resulting from in¯ation of the pneumoocluder Ð a part of the Koh system. The suture was applied to stop bleeding from the scari®ed area. In two other cases there were the following reasons for conversion: injury of bowel and larger ®bromyoma (880 g) with extensive ®brotic adhesions. There was no case converted in the obese group. Table 4 Outcomes and complicationsa Non-obese
Obese
P value
Operative time (min) Mean (range) S.D.b Estimated blood loss (ml) Mean (range) Weight of specimen (g) Mean (range) Hospital stay (day) Mean (range)
90.95 (45±180) 29.99 184.67 (50±1600) 239.81 (80±880) 3.18 (1±9)
99.54 (40±200) 27.77 170.37 (50±400) 236.94 (80±610) 3.07 (1±6)
P 0.06
Operative complications Yes No
7 (3.2%) 210 (96.8%)
3 (5.6%) 51 (94.5%)
NS
Postoperative complications None Minor Major
203 (93.5%) 11 (5.1%) 3 (1.4%)
50 (92.6%) 3 (5.6%) 1 (1.9%)
NS
a b
Data are presented as n (%). S.D.: standard deviation.
NS NS NS
The role of minimally invasive surgery continues to expand in all the specialities and subspecialities of surgery. At one time, obesity and pregnancy were considered as relative contraindication to laparoscopic surgery. With improved technology and skills, surgeons are nowadays able to operate patients who would have been considered to be at too high risk for laparoscopic surgery in the past [8]. Nezhat et al. [9] include obese women to the group of patients in high risk and suggest to perform some special measures. The most signi®cant dif®culty are establishment of pneumoperitoneum, because insertion of Veres' needle and trocar is almost vertical, and abdominal wall thickness and preperitoneal fat. Overdistending the abdomen with CO2 before trocar insertion is safer [2]. Some authors believe, that use of open technique for entering abdominal cavity may in obese patients reduce the risk of complications [4,10]. Pelosi and Pelosi [11] studied alignment of the umbilical axis as an effective maneuver for laparoscopic entry in obese patient. They concluded, that the laparoscopic entry by this technique was successful and rapid in all cases and was not complicated by preperitoneal insuf¯ation, subcutaneous emphysema, visceral injury, vascular injury, penetration of an underlying skin fold, or postoperative wound complications. In the recent editorial focused on ``evidence-based laparoscopic entry techniques'' Garry states [12], that ``none of the existing techniques or technologies completely eliminates the risk of type two lesions (structures adherent to abdominal wall)''. The following risk factors must be necessarily identi®ed prior to each laparoscopy: previous abdominal surgery particularly one with midline incisions, and obesity or thinness of a patient. In two cases of our 271 women the injury of epigastric artery occurred during laparoscopic entry, one of each non-obese and obese group. The classic closed technique of laparoscopic entry was used in all our patients, no special techniques were used in obese patients except that the lateral cannulas were longer than usual and inserted more vertical to the skin (5 mm cannula 10 cm, 10 mm cannula 15 cm). Obesity causes certain technical dif®culties not only in gynecological laparoscopy, but also in general or urologic laparoscopy [13±17]. Those studies showed that laparoscopic cholecystectomy in obese women was not associated with increased operative morbidity, there was only an increased risk of procedure conversion to laparotomy in women with high BMI [14,15]. Mendoza et al. [17] describe in their review, that complication rates for urologic laparoscopic surgery on massively obese patients were higher than in the general population undergoing laparoscopic surgery. Successful gynecologic laparoscopic surgeries in obese women have been reported [3,4,6,18±20]. However, in most studies the weight was used as the index of obesity and the numbers of patients were small. Only in the recent study of Eltabbakh et al. [4], the BMI was used as the criterion of obesity in the group of 47 patients with laparoscopic surgery.
Z. Holub et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 98 (2001) 77±82
Many studies evaluated open radical surgery in obese women with gynecological malignancies [21,22]. The depth of subcutaneous tissue was the most signi®cant risk factor associated with wound infection. The laparoscope allows a surgeon to avoid abdominal incisional wound infection in these patients. Kadar [3] and Holub et al. [5] illustrated in previous studies that laparoscopic surgery in obese women is feasible and may be considered in women with endometrial cancer, which predominantly occurs in obese, high-risk women. The reason for conversion of one patient in our previous multicentric study was the dif®culty in anesthesia due to obesity [6]. In this context it is necessary to draw attention to some anesthetic complications in obese women. The vital pulmonary capacity is lowered in obese women, especially in expired volume portion. Disproportion of ventilation, perfusion and decrease in functional residual capacity in changed position is always higher in obese women [23]. In this connection we believe that co-operation of an anesthesiologist with a surgeon is essential. The anesthesia of laparoscopically operated women cannot be performed without continual monitoring of blood gasses and vital functions. Endotracheal intubation and maintenance of body temperature are necessary [24]. Hypothermia is very frequent in longer laparoscopic procedures and its development is connected with application of irrigation ¯uid. In our study, compared with 217 non-obese women, no signi®cant differences were observed in 54 obese patients, of whose benign and malignant diseases were treated by LH: blood loss, weight of specimen, and hospital stay were not statistically different. Only the duration of surgery was longer in obese women. However, the signi®cance of the difference was borderline (P < 0:06). The rate of operative complications was lower in non-obese patients (3.22% versus 5.55%), the rate of major postoperative complications was almost identical (1.38% versus 1.85%). Surprisingly, no conversion of laparoscopic procedure to laparotomy was found in obese patients. In three non-obese patients LH was converted due to intraoperative complications. Although the total number of 271 women in our group represents the largest evaluated group in recent publications focused on laparoscopy in obese women, we believe that further extensive, multicentric and meta-analytical studies will have to be carried out. The majority of obese women in our study were classi®ed to medium obese category, morbid obesity was only con®rmed in 9.26% of the obese women group. Literary information from the pilot study in 11 patients with laparoscopic total abdominal hysterectomy demonstrates favorable results also in this category [19]. Observation and results of our prospective study allow expressing below mentioned assessments and recommendations. In conclusion, our study illustrates that laparoscopic approach to hysterectomy in obese women is feasible and may be recommended for both gynecologic benign and some malign conditions. However, we think that the selection of obese patients for laparoscopy should be
81
performed with reference to optimal usefulness and safety. Critical are not only the absolute body weight but also symmetry and distribution of subcutaneous fat in anterior abdominal wall and retroperitoneum. The expected effect of the operation should be balanced with risks, which in the case of obese women is not only the type of operation approach but also anesthesia and postoperative period complications. Laparoscopic surgery can also alter the relationship between vaginal and abdominal hysterectomy in obese women. References [1] Reich H, DeCaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg 1989;5:213±6. [2] Gomel V, Taylor PJ. Indications and contraindications of diagnostic laparoscopy. In: Gomel V, Taylor PJ, editors. Diagnostic and operative gynecologic laparoscopy. 1st ed. St. Louis: Mosby-Year Book, 1995. p. 68±70. [3] Kadar N. Laparoscopic pelvic lymphadenectomy in obese women with gynecologic malignancies. J Am Assoc Gynecol Laparosc 1995;2:163±7. [4] Eltabbakh GH, Piver MS, Hempling RE, et al. Laparoscopic surgery in obese women. Obstet. Gynecol. 1999;99:704±8. [5] Holub Z, Jabor A, Fischlova D, et al. V. Assessment of tissue damage associated with laparoscopic and conventional hysterectomies. Gynaec. Endosc. 1998;7:243±9. [6] Holub Z, Bartos P, Jabor A, et al. Laparoscopic surgery in obese women with endometrial cancer. J Am Assoc Gynecol Laparosc 2000;7:83±8. [7] Koh Ch. A new technique and system for simplifying total laparoscopic hysterectomy. J Am Assoc Gynecol Laparosc 1998;5:187±92. [8] Hoey BA, Chapman WH. Laparoscopic splenectomy at caesarean section. J Laparoendosc Adv Surg Tech A 1999;9:419±23. [9] Nezhat CR, Nezhat FR, Luciano AA, et al. Operative gynecologic laparoscopy: principles and techniques. 1st ed. New York: McGrawHill, 1995. [10] Hasson HM. Open laparoscopy as a method of access in laparoscopy surgery. Gynaec Endosc 1999;8:353±62. [11] Pelosi MA III, Pelosi MA. Alignment of the umbilical axis: an effective maneuver for laparoscopic entry. Obstet Gynecol 1998;92:869±72. [12] Garry R. Towards evidence-based laparoscopic entry techniques: clinical problems and dilemmas. Gynaec Endosc 1999;8:315±26. [13] Halpern NB. Access problem in laparoscopic cholecystectomy: postoperative adhesions, obesity, and liver disorders. Semin Laparosc Surg 1998;5:92±106. [14] Schrimer BD, Dix J, Edge SB, et al. Laparoscopic cholecystectomy in obese patients. Ann Surg 1992;216:146±52. [15] Miles RH, Carballo RE, Prinz RA, et al. The preferred method of cholecystectomy in the morbidly. Obese Surg 1992;112:818±22. [16] Wolf JS. Laparoscopic access with a visualizing trocar. Tech Urol 1997;3:34±7. [17] Mendoza D, Newman RC, Albala D, et al. Laparoscopic complications in markedly obese urologic patients (a multi-institutional review). Urology 1996;48:562±67. [18] Loffer FD, Pent D. Laparoscopy in obese patient. Am J Obstet Gynecol 1976;125:104±7. [19] Ostrzenski A. Laparoscopic total abdominal hysterectomy in morbidly obese women. A pilot phase report. J Reprod Med 1999;44:853±8. [20] Canestrelli M, Canni M, Mori R, et al. Celio-assisted vaginal surgery. Minerva Gynecol 1998;50:359±65.
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[21] Kalogirou D, Antoniou G, Karaksitos P, et al. Radical hysterectomy: is obesity a comorbid condition. J Gynecol Surg 1997;13:7±12. [22] Soisson AP, Olt G, Soper JT, et al. Prevention of superficial wound separation with subcutaneous retention sutures. Gynecol Oncol 1993;51:330±4.
[23] DraÂbkova J. ZaÂklady anestesiologie (Basic of anaesthesiology). Prague, Avicenum, 1981. [24] Lorencz Ch, Hucke J. Probleme gynakologischen Endoskopien aus der Sicht der Gynakologie und Anesthesiologie. Gynakolgie 1997;38:826±34.
Laparoscopic hysterectomy in obese women: a clinical prospective study Z. Holub*, A. Jabor, L. Kliment, D. FischlovaÂ, M. WaÂgnerova Head of Department Obstetrics and Gynaecology, Baby Friendly Hospital, VancÏurova 1548, 272 58 Kladno, Czech Republic Received 18 April 2000; received in revised form 19 June 2000; accepted 10 December 2000
Abstract Objective: To compare perioperative and postoperative outcomes of laparoscopic hysterectomy (LH) in surgical management of gynecological conditions in two groups of different weight. Methods: A prospective comparative clinical study of 271 LH performed for disease of female pelvic organs in a group of 54 obese patients (over 30 body mass index (BMI)) and in a group of 217 non-obese patients (less than 30 BMI). The following criteria were assessed: patient characteristics, indications for surgery, previous surgery, presence of adhesions, duration of procedure, blood loss, weight of specimen, hospital stay and complications. Statistical analysis was performed using the unpaired t-test and non-parametric Chi-square test when appropriate, with a signi®cance level of P 0:05. Results: Three non-obese patients were converted to laparotomy due to operative complications. Laparoscopy in the remaining 268 patients (98.89%) was completed successfully. There was no signi®cant difference in estimated blood loss, presence and degree of adhesions, weight of specimen, length of hospital stay and postoperative complications between women with high BMI and those with low BMI. The rate of major operative complications (5.55% versus 3.22%) was higher in the obese group. The duration of the operation was longer in obese women. However, the signi®cance of the difference was borderline (P 0:06). # 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Obese women; Laparoscopic hysterectomy
1. Introduction Currently, hysterectomy is the most frequently performed procedure in gynecological surgery. Approximately 18± 20 000 hysterectomies are performed annually in the Czech Republic. There has been a signi®cant move away from abdominal hysterectomies to less invasive procedures with laparoscopic and vaginal approaches. Laparoscopic hysterectomy (LH) was introduced into clinical practice by Reich in 1988 [1]. Obesity has been considered by some gynecologists to be a relative contraindication to operative laparoscopy [2]. The feasibility of laparoscopy is often limited by obesity, and laparoscopic procedures are dif®cult in women weighing 180 lb (81.7 kg) or more [3]. Eltabbakh et al. [4], however, suggest in their recent study, that operative laparoscopy is safe and feasible in women with high body mass index (BMI) as well. Based on the above mentioned reason, the primary aim of our study was to verify how obesity changes perioperative parameters and affects the feasibility of laparoscopic procedures performed for different gynecological *
Corresponding author. Tel.: 42-41-312-606-373; fax: 42-41-312-606-417. E-mail address: [email protected] (Z. Holub).
conditions in a group of obese patients with LH. This knowledge is important, because each third woman in our population over 30 is obese. The study is a part of a longterm systematic study conducted within our unit trial [5,6]. 2. Material and methods A comparative prospective clinical study was undertaken at Baby Friendly Hospital Kladno, which included 271 women treated by LH. Patients were selected consecutively upon the physical, ultrasound, laboratory (CA 125) and biopsy examination. Perioperative records were sorted into two groups: the group of obese women (over BMI 30 or 180 lb/81.7 kg) was compared with the group of non-obese women (under BMI 30 or 180 lb/81.7 kg) in whom laparoscopic surgery had been done between January 1998 and December 1999. The BMI showed the proportion between weight and height and divided obese patients into three subgroups: overweight (BMI 25±30), moderately obese (BMI exceeding 30) and severely (morbidly) obese (BMI exceeding 36). The most frequent reasons for the LHs were complaints due to uterine myomas, adenomyosis, endometriosis, adnexal mass, pelvic pain, menometrorrhagia as well
0301-2115/01/$ ± see front matter # 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 1 - 2 1 1 5 ( 0 0 ) 0 0 5 6 5 - 0
78
Z. Holub et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 98 (2001) 77±82
Table 1 Characteristics of womena Group of patients
Non-obese
Obese
P value
Weight (kg) Mean (range) Age (years) Mean (range) Parity Mean (range)
67.21 (45±81) 46, 59 (30±76) 1.97 (0±4)
89.09 (82±121) 47, 50 (32±71) 2 (0±6)
P 0.0001
Menopause Premenopause Postmenopause
170 (78.3%) 47 (21.7%)
43 (79.6%) 11 (20.4%)
NS
Number of previous laparotomies Zero 114 (52.5%) One and more 103 (47.5%)
30 (55.6%) 24 (44.4%)
NS
a b
NSb NS
2.1. Operative technique
Data are presented as n (%). NS: non-significant.
as recurrent intraepithelial neoplasm, endometrial and cervical cancer. The individualized feminine characteristics are listed in Table 1, while Table 2 shows the indications. The following two variants of LH were used: the laparoscopy assisted vaginal hysterectomy with vaginal colpotomy (LAVH-VC) and laparoscopy assisted vaginal hysterectomy with laparoscopic colpotomy (LAVH-LC). We opted for a combination of laparoscopy and vaginal surgery in the patients with pelvic or abdominal surgery in history, those suspected of an adhesive process after the pelvic in¯ammation, ®xation of retro¯exed uterus, uterus size more than 14 weeks, adnexal pathologies or expected dif®culties in removal of adnexa. We preferred the LAVH-LC procedure mostly in smaller uterine sizes, given an important need to perform the uterine removal within a shorter period along with preservation of uterosacral complex. The salpingooophorectomy, omentectomy, vaginal repair and lymphadenectomy were performed according to the diagnoses, ages and histology±pathology ®ndings. We have monitored the following parameters: the duration of surgery, blood loss, weight of specimen, histology±pathology ®ndings, postoperative morbidity, hospital stay and convalescence, patient age and weight. Operative complications were de®ned as a conversion to laparotomy or bowel, ureteral, bladder, vascular injuries or excessive abdominal wall bleeding and Table 2 Indications for laparoscopya Non-obese
Obese
Symptomatic benign uterine pathology Adnexal mass, endometrioma Ovarian cystadenomas Cervical intraepithelial neoplasia III Atypical complex endometrial hyperplasia Endometrial cancer Microinvasive cervical cancer
158 26 11 6 4 11 1
38 5 2 0 1 6 2
Total
217
a
Data are presented as n (%).
(72.8%) (12.0%) (5.1%) (2.8%) (1.8%) (5.1%) (0.5%)
54
estimated blood loss exceeding 1000 ml or requiring blood transfusion. Postoperative complications were considered major if they resulted in readmission or a secondary surgical procedure and were considered minor if they did not result in these sequels. Only four experienced gynecologic laparoscopists performed all procedures. Preoperatively, all patients gave their informed consent to a surgery and the study was approved by the Local Independent Ethics Committee.
(70.4%) (9.3%) (3.70%) (00%) (1.9%) (11.1%) (3.7%)
Closed laparoscopy was performed in the lithotomy position using videomonitoring equipment. The telescope was inserted subumbilically and one 10 mm port was opened suprapubically and medially. Two or three 5 mm ports were placed in each of the lower quadrants at the lateral edge of the direct abdominal muscle. No special techniques were used in obese patients except that primary trocars and the lateral trocars were inserted more vertically to the skin and were longer than usual (5 mm trocar 10 cm, 10 mm trocar 15 cm, Ethicon Surgery, Johnson±Johnson, Summerwille, NJ, USA). The electrosurgery (bipolar and monopolar procedures) or the harmonic scalpel were used as a primary method of hemostasis and discission. All operations were performed under general anesthesia with endotracheal intubation. Prophylactic antibiotics were administered intraoperatively. Laparoscopically assisted surgical staging required a complete inspection of the whole peritoneal cavity and intraperitoneal ¯uid was aspirated in each of the four quadrants and examined for cytology. 2.2. Laparoscopy assisted vaginal hysterectomy with vaginal colpotomy (LAVH-VC) The hysterectomy was started by laparoscopy. These made within the laparoscopic phase were steps with severing the round ligament, dissection of the upper portion of the broad ligament, severing the tubouterine junction and the uteroovarian ligament or severing the infundibulopelvic ligament, preparation of the bladder ¯ap, and severing the bladder pillars. Those ®nalized vaginally were steps consisting in severing the uterine vessels, cardinal-uterosacral ligament complex, performing anterior and posterior culdotomy, and closure of the vaginal cuff. 2.3. Laparoscopy assisted vaginal hysterectomy with laparoscopic colpotomy (LAVH-LC) All steps were performed laparoscopically except those with severing the uterine vessels and closure of the vaginal cuff, which were completed vaginally. The cul-de-sac was opened during laparoscopic procedure, but the connection of uterosacral ligament remained preserved in the vaginal vault. The cup of Koh was placed over the cervix in the LAVH-LC patients only. The cup was used either alone with uterine manipulator or as a part of a new system described by
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Koh in 1998 [7]. In principal, this system consists ®rstly in lifting the neck and straining vaginal vaults with the manipulator of plastic vaginal cuff. Subsequently, distancing uterine vessels from ureter and safe dissection of uterine vessels and vaginal vaults are performed. 2.4. Transperitoneal pelvic lymph node dissection (PLN) and infraaortic lymph node dissection (IALN) Incising the peritoneum, which lies over the right common iliac artery, and extending this incision caudally along the external iliac artery towards the round and broad ligaments started the dissection. Lymph nodes bearing adipose tissue were excised from the obturator fossa after mobilization of the external and internal iliac vessels and obturator nerve. We disected lymph nodes up to the level of bifurcation of iliac vessels superiorly and to the femoral canal inferiorly. Paravesical and pararectal spaces were opened with blunt and sharp dissection. The ureter was visualized along the medial leaf of the peritoneum at the level of the bifurcation of common iliac artery. We dissected the lymph nodes up to level of bifurcation of the iliac vessels and/or to the level of the meseneteric inferior artery. 2.5. Statistical analysis An independent biostatistician evaluated and compared differences in perioperative and postoperative outcomes. The results of the obese group were compared with outcomes of the non-obese group. We tested the difference between both studied groups through the unpaired t-test and non-parametrical Chi-square test. P < 0:05 was considered statistically signi®cant.
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3. Results Subject characteristics and indications for LH are listed in Tables 1 and 2, respectively. Laparoscopic hysterectomy (LH) was successful and completed in 268 women (successful laparoscopic procedure rate 98.89%). The difference in body weight between groups was substantial (mean 67.21 and 88.09 kg, P < 0:0001). A total of 54 women (19.92%) had BMI exceeding 30 and 217 women (80.08%) had BMI 30 or less. The heaviest woman (121 kg) underwent LH for endometrial cancer. The BMI of obese patients varied between 30 and 40 in most cases. In ®ve patients (9.26%) the BMI was localized to the group with severe obesity (Fig. 1). As shown in Tables 2, 3 and 4 there were no statistically signi®cant differences in a frequency of individual types of hysterectomy, indications, estimated blood loss, presence and degree of adhesions, weight of specimen, operative and postoperative complications, or length of hospital stay between women with high and low BMI. The duration of operation was longer in obese women. However, the signi®cance of the difference was borderline (P < 0:06). No statistically signi®cant difference between the groups was found in the proportion of operative and postoperative complications. Conversions were included in operative complications. Three of the obese patients had operative complications: incidental cystotomy (n 2) and injury of epigastric artery (n 1). One non-obese woman sustained an injury to the epigastric artery and three other had these complications: injury of the bladder, transfusion and relaparoscopy for excessive bleeding from the Redon's drain. Major postoperative complications in the non-obese group included pulmonary microembolism (n 1), fever (n 2) and bleeding from the vaginal vault (n 2). Minor complications included urinary tract infection (n 7),
Fig. 1. Distribution of the body mass index (BMI) of obese women.
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Table 3 Types of surgerya
4. Discussion
Type of surgery
Non-obese b
Obese
LAVH-VC LAVH-VC, BSO (including USO) LAVH-LC LAVH-LC, BSO (including USO)
36 85 26 70
(16.58) (39.17) (11.98) (32.25)
10 17 8 19
Additional procedures PLN PLN, IALN Lysis of adhesion Omentectomy Vaginal repair
7 3 78 1 2
(3.22) (1.38) (35.94) (0.45) (0.92)
5 (9.25) 1 (1.85) 21 (38.88) ± ±
(18.51) (31.48) (14.81) (35.18)
a Abrevation: LAVH: laparoscopic assisted vaginal hysterectomy; BSO (USO): bilateral (unilateral) salpingo-oophorectomy; PLN: pelvic lymphadenectomy; IALN: infraaortic lymphadenectomy; VC: vaginal colpotomy; LC: laparoscopic colpotomy. b Data are presented as n (%).
wound cellulitis (n 1) and urinary retention (n 1). Out of the women with BMI exceeding 30 (obese group), one had a major complication (fever) and three (5.55%) had minor postoperative complications, such as urinary tract infection (n 2) and wound cellulitis (n 1). We had to convert to laparotomy in three patients in the non-obese group. In one case we decided to switch over to laparotomy, as during the LAVH-LC preparation we had to counteract a rupture of ¯at-scarred synechia in the vaginal vault resulting from in¯ation of the pneumoocluder Ð a part of the Koh system. The suture was applied to stop bleeding from the scari®ed area. In two other cases there were the following reasons for conversion: injury of bowel and larger ®bromyoma (880 g) with extensive ®brotic adhesions. There was no case converted in the obese group. Table 4 Outcomes and complicationsa Non-obese
Obese
P value
Operative time (min) Mean (range) S.D.b Estimated blood loss (ml) Mean (range) Weight of specimen (g) Mean (range) Hospital stay (day) Mean (range)
90.95 (45±180) 29.99 184.67 (50±1600) 239.81 (80±880) 3.18 (1±9)
99.54 (40±200) 27.77 170.37 (50±400) 236.94 (80±610) 3.07 (1±6)
P 0.06
Operative complications Yes No
7 (3.2%) 210 (96.8%)
3 (5.6%) 51 (94.5%)
NS
Postoperative complications None Minor Major
203 (93.5%) 11 (5.1%) 3 (1.4%)
50 (92.6%) 3 (5.6%) 1 (1.9%)
NS
a b
Data are presented as n (%). S.D.: standard deviation.
NS NS NS
The role of minimally invasive surgery continues to expand in all the specialities and subspecialities of surgery. At one time, obesity and pregnancy were considered as relative contraindication to laparoscopic surgery. With improved technology and skills, surgeons are nowadays able to operate patients who would have been considered to be at too high risk for laparoscopic surgery in the past [8]. Nezhat et al. [9] include obese women to the group of patients in high risk and suggest to perform some special measures. The most signi®cant dif®culty are establishment of pneumoperitoneum, because insertion of Veres' needle and trocar is almost vertical, and abdominal wall thickness and preperitoneal fat. Overdistending the abdomen with CO2 before trocar insertion is safer [2]. Some authors believe, that use of open technique for entering abdominal cavity may in obese patients reduce the risk of complications [4,10]. Pelosi and Pelosi [11] studied alignment of the umbilical axis as an effective maneuver for laparoscopic entry in obese patient. They concluded, that the laparoscopic entry by this technique was successful and rapid in all cases and was not complicated by preperitoneal insuf¯ation, subcutaneous emphysema, visceral injury, vascular injury, penetration of an underlying skin fold, or postoperative wound complications. In the recent editorial focused on ``evidence-based laparoscopic entry techniques'' Garry states [12], that ``none of the existing techniques or technologies completely eliminates the risk of type two lesions (structures adherent to abdominal wall)''. The following risk factors must be necessarily identi®ed prior to each laparoscopy: previous abdominal surgery particularly one with midline incisions, and obesity or thinness of a patient. In two cases of our 271 women the injury of epigastric artery occurred during laparoscopic entry, one of each non-obese and obese group. The classic closed technique of laparoscopic entry was used in all our patients, no special techniques were used in obese patients except that the lateral cannulas were longer than usual and inserted more vertical to the skin (5 mm cannula 10 cm, 10 mm cannula 15 cm). Obesity causes certain technical dif®culties not only in gynecological laparoscopy, but also in general or urologic laparoscopy [13±17]. Those studies showed that laparoscopic cholecystectomy in obese women was not associated with increased operative morbidity, there was only an increased risk of procedure conversion to laparotomy in women with high BMI [14,15]. Mendoza et al. [17] describe in their review, that complication rates for urologic laparoscopic surgery on massively obese patients were higher than in the general population undergoing laparoscopic surgery. Successful gynecologic laparoscopic surgeries in obese women have been reported [3,4,6,18±20]. However, in most studies the weight was used as the index of obesity and the numbers of patients were small. Only in the recent study of Eltabbakh et al. [4], the BMI was used as the criterion of obesity in the group of 47 patients with laparoscopic surgery.
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Many studies evaluated open radical surgery in obese women with gynecological malignancies [21,22]. The depth of subcutaneous tissue was the most signi®cant risk factor associated with wound infection. The laparoscope allows a surgeon to avoid abdominal incisional wound infection in these patients. Kadar [3] and Holub et al. [5] illustrated in previous studies that laparoscopic surgery in obese women is feasible and may be considered in women with endometrial cancer, which predominantly occurs in obese, high-risk women. The reason for conversion of one patient in our previous multicentric study was the dif®culty in anesthesia due to obesity [6]. In this context it is necessary to draw attention to some anesthetic complications in obese women. The vital pulmonary capacity is lowered in obese women, especially in expired volume portion. Disproportion of ventilation, perfusion and decrease in functional residual capacity in changed position is always higher in obese women [23]. In this connection we believe that co-operation of an anesthesiologist with a surgeon is essential. The anesthesia of laparoscopically operated women cannot be performed without continual monitoring of blood gasses and vital functions. Endotracheal intubation and maintenance of body temperature are necessary [24]. Hypothermia is very frequent in longer laparoscopic procedures and its development is connected with application of irrigation ¯uid. In our study, compared with 217 non-obese women, no signi®cant differences were observed in 54 obese patients, of whose benign and malignant diseases were treated by LH: blood loss, weight of specimen, and hospital stay were not statistically different. Only the duration of surgery was longer in obese women. However, the signi®cance of the difference was borderline (P < 0:06). The rate of operative complications was lower in non-obese patients (3.22% versus 5.55%), the rate of major postoperative complications was almost identical (1.38% versus 1.85%). Surprisingly, no conversion of laparoscopic procedure to laparotomy was found in obese patients. In three non-obese patients LH was converted due to intraoperative complications. Although the total number of 271 women in our group represents the largest evaluated group in recent publications focused on laparoscopy in obese women, we believe that further extensive, multicentric and meta-analytical studies will have to be carried out. The majority of obese women in our study were classi®ed to medium obese category, morbid obesity was only con®rmed in 9.26% of the obese women group. Literary information from the pilot study in 11 patients with laparoscopic total abdominal hysterectomy demonstrates favorable results also in this category [19]. Observation and results of our prospective study allow expressing below mentioned assessments and recommendations. In conclusion, our study illustrates that laparoscopic approach to hysterectomy in obese women is feasible and may be recommended for both gynecologic benign and some malign conditions. However, we think that the selection of obese patients for laparoscopy should be
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performed with reference to optimal usefulness and safety. Critical are not only the absolute body weight but also symmetry and distribution of subcutaneous fat in anterior abdominal wall and retroperitoneum. The expected effect of the operation should be balanced with risks, which in the case of obese women is not only the type of operation approach but also anesthesia and postoperative period complications. Laparoscopic surgery can also alter the relationship between vaginal and abdominal hysterectomy in obese women. References [1] Reich H, DeCaprio J, McGlynn F. Laparoscopic hysterectomy. J Gynecol Surg 1989;5:213±6. [2] Gomel V, Taylor PJ. Indications and contraindications of diagnostic laparoscopy. In: Gomel V, Taylor PJ, editors. Diagnostic and operative gynecologic laparoscopy. 1st ed. St. Louis: Mosby-Year Book, 1995. p. 68±70. [3] Kadar N. Laparoscopic pelvic lymphadenectomy in obese women with gynecologic malignancies. J Am Assoc Gynecol Laparosc 1995;2:163±7. [4] Eltabbakh GH, Piver MS, Hempling RE, et al. Laparoscopic surgery in obese women. Obstet. Gynecol. 1999;99:704±8. [5] Holub Z, Jabor A, Fischlova D, et al. V. Assessment of tissue damage associated with laparoscopic and conventional hysterectomies. Gynaec. Endosc. 1998;7:243±9. [6] Holub Z, Bartos P, Jabor A, et al. Laparoscopic surgery in obese women with endometrial cancer. J Am Assoc Gynecol Laparosc 2000;7:83±8. [7] Koh Ch. A new technique and system for simplifying total laparoscopic hysterectomy. J Am Assoc Gynecol Laparosc 1998;5:187±92. [8] Hoey BA, Chapman WH. Laparoscopic splenectomy at caesarean section. J Laparoendosc Adv Surg Tech A 1999;9:419±23. [9] Nezhat CR, Nezhat FR, Luciano AA, et al. Operative gynecologic laparoscopy: principles and techniques. 1st ed. New York: McGrawHill, 1995. [10] Hasson HM. Open laparoscopy as a method of access in laparoscopy surgery. Gynaec Endosc 1999;8:353±62. [11] Pelosi MA III, Pelosi MA. Alignment of the umbilical axis: an effective maneuver for laparoscopic entry. Obstet Gynecol 1998;92:869±72. [12] Garry R. Towards evidence-based laparoscopic entry techniques: clinical problems and dilemmas. Gynaec Endosc 1999;8:315±26. [13] Halpern NB. Access problem in laparoscopic cholecystectomy: postoperative adhesions, obesity, and liver disorders. Semin Laparosc Surg 1998;5:92±106. [14] Schrimer BD, Dix J, Edge SB, et al. Laparoscopic cholecystectomy in obese patients. Ann Surg 1992;216:146±52. [15] Miles RH, Carballo RE, Prinz RA, et al. The preferred method of cholecystectomy in the morbidly. Obese Surg 1992;112:818±22. [16] Wolf JS. Laparoscopic access with a visualizing trocar. Tech Urol 1997;3:34±7. [17] Mendoza D, Newman RC, Albala D, et al. Laparoscopic complications in markedly obese urologic patients (a multi-institutional review). Urology 1996;48:562±67. [18] Loffer FD, Pent D. Laparoscopy in obese patient. Am J Obstet Gynecol 1976;125:104±7. [19] Ostrzenski A. Laparoscopic total abdominal hysterectomy in morbidly obese women. A pilot phase report. J Reprod Med 1999;44:853±8. [20] Canestrelli M, Canni M, Mori R, et al. Celio-assisted vaginal surgery. Minerva Gynecol 1998;50:359±65.
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[21] Kalogirou D, Antoniou G, Karaksitos P, et al. Radical hysterectomy: is obesity a comorbid condition. J Gynecol Surg 1997;13:7±12. [22] Soisson AP, Olt G, Soper JT, et al. Prevention of superficial wound separation with subcutaneous retention sutures. Gynecol Oncol 1993;51:330±4.
[23] DraÂbkova J. ZaÂklady anestesiologie (Basic of anaesthesiology). Prague, Avicenum, 1981. [24] Lorencz Ch, Hucke J. Probleme gynakologischen Endoskopien aus der Sicht der Gynakologie und Anesthesiologie. Gynakolgie 1997;38:826±34.