- Email: [email protected]
Laparoscopic sleeve gastrectomy in patients with abdominoplasty: a case-control study
1 2 3 Surgery for Obesity and Related Diseases ] (2016) 00–00 4 5 6 Original article 7 8 9 10 Q3 11 Alan A. Saber, M.D.a,*, Saeed Shoar, M.D.a, Moamena El-Matbouly, M.D.b, 12 13 Mohsen Karem, M.D.b, Moataz M. Bashah, M.D.b, Ahmad Al Najjar, M.D.b, 14 Q1 Mohammad J. Alkuwari, M.D.b, Hooman Soltanian, M.D.c 15 a Bariatric and Metabolic Institute, Department of Surgery, The Brooklyn Hospital Center, Icahn School of Medicine at Mount Sinai, Brooklyn, New York b 16 Department of Surgery, Hamad Medical Corporation, Weill Cornell Medical College, Doha, Qatar c 17 Department of Plastic Surgery, University Hospitals, Case Medical Center, Cleveland, Ohio 18 Received May 3, 2016; accepted August 19, 2016 19 20 Abstract Background: Abdominoplasty is increasingly performed after weight loss surgery. However, 21 performing a laparoscopic sleeve gastrectomy (LSG) after abdominoplasty poses technical 22 challenges. 23 Objective: The present study aimed to compare operative events and postoperative outcomes 24 between LSG patients with and without a history of prior abdominoplasty. 25 Setting: University hospital, Qatar. 26 Methods: A case-control study was conducted on 2 groups of patients with (n ¼ 33) and without 27 (n ¼ 69) prior abdominoplasty who were undergoing LSG. Patient demographic characteristics, 28 baseline characteristics, as well as operative and postoperative events were compared between the 29 2 groups. 30 Results: A total of 102 patients with an average age of 39.6 ⫾ 7.7 years and body mass index 31 (BMI) of 42.8 ⫾ 5.9 kg/m2 were included. There were no significant differences between the 2 groups in terms of demographic characteristics, preoperative BMI, and co-morbidities. The number 32 of ports required was significantly higher in the LSG patients with a history of prior abdominoplasty 33 than in the nonabdominoplasty patients. The operation time was also significantly longer in the 34 abdominoplasty patients than in the nonabdominoplasty patients (90.3 ⫾ 36.7 minutes versus 35 57.1 ⫾ 17.7 minutes; P o .0001). However, no significant differences were observed in terms of 36 postoperative complications, length of hospital stay, and weight loss results. 37 Conclusion: LSG after abdominoplasty is associated with longer operative times and the need for 38 additional port placement to overcome the decreased working space. However, operative strategies 39 should be considered to overcome the technical challenges during LSG in patients who underwent a 40 prior abdominoplasty. (Surg Obes Relat Dis 2016;]:00–00.) r 2016 Published by Elsevier Inc. on 41 behalf of American Society for Metabolic and Bariatric Surgery. 42 43 Keywords: Laparoscopy sleeve gastrectomy; Abdominoplasty; Technical considerations; Weight loss 44 45 46 Bariatric surgery plays an important role in the treatment 47 of morbid obesity [1,2]. The number of bariatric procedures 48 performed in the United States has increased from 158,000 * 49 Correspondence: Alan A Saber M.D., MS, FACS, FASMBS, Weight in 2011 to 193,000 in 2014 [3]. Meanwhile, the number of 50 Loss Center, The Brooklyn Hospital, 121 DeKalb Ave, Brooklyn, NY abdominoplasty procedures has increased by 79% over the 11201. 51 last decade [4]. With the increasing number of weight loss E-mail: [email protected] 52 53 http://dx.doi.org/10.1016/j.soard.2016.08.489 54 1550-7289/r 2016 Published by Elsevier Inc. on behalf of American Society for Metabolic and Bariatric Surgery. 55
Laparoscopic sleeve gastrectomy in patients with abdominoplasty: a case-control study
56 57 58 59 60 61 62 63 64
2
65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119
A. A. Saber et al. / Surgery for Obesity and Related Diseases ] (2016) 00–00
surgeries and increasing number of abdominoplasties, more morbidly obese patients with a history of prior abdominal wall body contouring are undergoing bariatric surgery. A history of a prior abdominoplasty poses technical challenges during laparoscopic procedure. The challenges are attributed to decreased abdominal wall compliance and the resultant narrower working space available during laparoscopy. Morbid obesity can worsen the situation by increasing the abdominal wall thickness. A few reports address laparoscopic techniques in patients with prior abdominal wall reconstruction [5–9]. However, there is no published study comparing the laparoscopic outcomes of these patients with the outcomes of patients with no prior abdominoplasty. The present study aimed to evaluate the operative and clinical outcomes in patients with prior abdominoplasty undergoing laparoscopic sleeve gastrectomy (LSG) and compare them with the results in patients undergoing weight loss surgery with intact abdomens. Methods and materials Study design In this case control study, our hospital database was retrospectively reviewed to retrieve data on patients who underwent LSG between July 2014 and April 2015 in the metabolic and bariatric department of Hamad Medical Corporation in Doha, Qatar. The institutional review board of our hospital approved the study protocol. All the surgeries were performed by fellowship-trained surgeons, who were well beyond their learning curve, using a standardized technique. Patients The inclusion criteria were morbidly obese women aged between 18 and 65 years old who underwent LSG. Consecutive patients with prior abdominoplasty who underwent LSG (study group) and patients with no prior abdominal wall reconstruction who underwent the same weight loss procedure (control group) were recruited. Revisions or conversions to another procedure were excluded from analysis. Surgical technique of abdominoplasty All of the patients underwent surgery using the same abdominoplasty technique. After marking the anatomic features in an upright position, the patient assumed a supine position. General anesthesia was administered. A Pfannenstiel incision was made and the superior skin flap and subcutaneous tissue were undermined all the way up to the costal margin laterally and the xiphoid process medially. The umbilicus was circumscribed and exteriorized. A vertical rectus fascial plication was achieved to correct the
diastasis of the rectus abdominis muscles using permanent monofilament sutures. In a semiflexed position, the excess skin and adipose tissue were excised, and the flap was then sutured to the inferior skin incision in 2 layers. Two closed drains were placed. Laparoscopic sleeve gastrectomy in patients without prior abdominoplasty. A 1.5-cm skin incision was made in the umbilicus for the initial 15-mm port using an open technique. Pneumoperitoneum was achieved to a pressure of 15 mm Hg. A 12-mm trocar was inserted in the left upper quadrant and a 5-mm trocar in the right upper quadrant. A Nathanson liver retractor was inserted through a 5-mm subxiphoid skin puncture without port placement. When necessary, an additional 5-mm port was employed in the left upper quadrant. The technique of the sleeve gastrectomy was similar as previously described [10,11]. Using a 5-mm LigaSure (Medtronic, Minneapolis, MN), the greater curvature of the stomach was mobilized, beginning from a point 6 cm proximal to the pylorus, staying close to the wall of the stomach, going all the way up the greater curvature to the angle of His, and dividing both the gastrocolic and gastrosplenic ligaments. Retrogastric adhesions were taken down to allow complete mobilization of the stomach, eliminate any redundant posterior wall of the sleeve, and exclude the fundus from the gastric sleeve. Once the stomach was completely mobilized, a 34 F orogastric tube was inserted orally into the pylorus and placed against the lesser curvature. This calibrated the size of the gastric sleeve, prevented constriction at the gastroesophageal junction and incisura angularis, and provided a uniform shape for the entire stomach. The gastric transection was initiated at a point 6 cm proximal to the pylorus, leaving the antrum, and preserving gastric emptying. A long laparoscopic reticulating 60-mm XL endo-GIA stapler with green cartridge 4.8-mm staples and a synthetic absorbable buttressing material was inserted through the 15-mm trocar in a cephalad direction. The stapler was fired consecutively along the length of the orogastric tube until the angle of His was reached. Care was taken not to narrow the stomach at the incisura angularis and to inspect the stomach anteriorly and posteriorly to ensure there was no redundant posterior stomach. Approximately 80% of the stomach was separated. The entire staple line was inspected for bleeding and tested for leakage. The integrity of the staple line was tested by insufflating air under saline and infusing methylene blue into the remaining stomach. The resected stomach was extracted through the 15-mm umbilical port incision without the need for an Endobag. The fascial defect of the umbilical port site was closed with a figure-of-eight 2-0 nonabsorbable suture to prevent port site hernia formation. Deep vein thrombosis prophylaxis was achieved using anticoagulation, compression stockings, and an intermittent venous compression device. Once the patient was hemodynamically stable, afebrile, ambulating, able to maintain
120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
Laparoscopic Sleeve Gastrectomy in Patients with Abdominoplasty / Surgery for Obesity and Related Diseases ] (2016) 00–00
175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229
hydration and tolerate a full liquid diet, and their pain was managed appropriately with oral analgesics, the patient was discharged. Laparoscopic sleeve gastrectomy in patients with prior abdominoplasty. To overcome the technical challenges due to the previous abdominoplasty, we placed the patient in an exaggerated reverse Trendelenburg position. The instrumentation was similar to that used for the patients without abdominoplasty, except for the 12-mm optic trocar, which was inserted in the left upper quadrant for initial entry. Additional 5-mm ports were inserted in the epigastric region, and the right upper quadrant. A 5-mm skin incision was made at the subxiphoid area for liver retraction. Since placement of the Nathanson retractor needs an adequate space, we inserted the retractor after achieving an adequate working space. Pneumoperitoneum was established to a pressure of 20 mm Hg. Moreover, muscle relaxation was aggressively induced during the procedure. The details of the laparoscopic procedure are otherwise as described above. These modifications were necessary because of previous tightening of the anterior abdominal fascia by plication during the abdominoplasty procedure. Outcome measures Data were gathered on the patient’s demographic characteristics, preoperative body mass index (BMI), type of surgery, time between abdominoplasty and laparoscopic bariatric procedure, operative time, length of hospital stay, number of ports, postoperative complications, and percent of excess weight loss. Statistical analysis Data were analyzed using the statistical package for social sciences (SPSS, version 17; SPSS, Chicago, IL). The Kolmogrov-Smirnov test was used to determine the normal distribution of continuous variables. For normally distributed data, the analysis was performed by Student t test, and for nonparametric data, the Mann-Whitney U test was applied. Categorical variables were compared between groups using the χ2 test. Data are presented as mean ⫾ standard deviation or number (%), and a significance level was set at P o .05. Results Demographic data A total of 102 patients were enrolled in this study, with 33 patients in the abdominoplasty group (study group) and 69 patients in the nonabdominoplasty group (control group). No patient was excluded from our study. The patients’ ages ranged between 20 and 57 years and their BMIs were between and 35 and 62 kg/m2, with an average of 39.5 ⫾ 7.7 years and 42.8 ⫾ 5.9 kg/m2, respectively. All
3
of the patients were women and LSG was the sole procedure performed. Patients in the study group underwent the LSG between 1 and 18 months after their primary abdominoplasty. Only 1 patient underwent LSG 1 month after abdominoplasty. She presented to us after abdominal wall plication with signs of abdominal hypertension. We discussed with her the 2 available options for weight loss, LSG and lifestyle modification, which could decrease her visceral adipose tissue and help to improve abdominal hypertension. Table 1 compares the demographic characteristics and baseline characteristics between the study groups. No significant differences were observed between the 2 groups in terms of age, preoperative BMI, and co-morbidities (P 4 .05). Operative data The operative time varied from 28 to 180 minutes with an overall mean of 67.8 ⫾ 29.7 minutes. The abdominoplasty group patients had a significantly longer operative time compared to the control group (90.3 ⫾ 36.7 minutes versus 57.1 ⫾ 17.7 minutes, P o 0.0001). In the abdominoplasty group, the total number of ports required during surgery varied; the LSG was performed most often with 5 ports (66.7%), followed by 6 ports (27.3%), and then 4 ports (3%). All of the surgeries were performed using 4 ports in the nonabdominoplasty group. There was a statistically significant difference in the number of ports between these 2 groups (P o .0001). No intraoperative pneumoperitoneum-related cardiovascular, pulmonary, or renal compromises were noted in both groups. Postoperative outcomes The length of stay ranged between 2 and 6 days, and there was no significant difference between the 2 groups Table 1 Demographic characteristics and baseline characteristics of patients Variables
Abdominoplasty group (n ¼ 33)
Control group P (n ¼ 69) value
Age, yr Gender, n (%) Male Female BMI, kg/m2 Preoperative co-morbidities, n (%) Diabetes Hypertension Hyperlipidemia Obstructive sleep apnea Interval between abdominoplasty and SG (mo)
41.5 ⫾ 6.2
38.6 ⫾ 8.3
0 33 (100) 41.2 ⫾ 8.7
0 69 (100) 42.2 ⫾ 7.6
9 (27.3) 10 (30.3) 6 (18.2) 1 (.03) 8.6 ⫾ 4.1
23 (33.3) 23 (33.3) 9 (13) 3 (.04) NA
.6 NA
.5 NS .5 .8 .5 .7 NA
BMI ¼ body mass index; NA ¼ not applicable; NS ¼ not significant; SG ¼ sleeve gastrectomy.
230 231 232 233 234 235 236 237 238 T1239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284
A. A. Saber et al. / Surgery for Obesity and Related Diseases ] (2016) 00–00
4
285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339
T2
(P 4 .05). One patient in the abdominoplasty group experienced postoperative bleeding requiring transfusion of 2 units of blood and reoperation for hemostasis. The patient did well after the surgery. Although there were 4 cases of postoperative complications in the control group (5.7%) and 1 case in the abdominoplasty group (3%), the difference was not statistically significant (P 4 .05). The patients in the 2 groups achieved similar percent of excess weight loss at 1 year (Table 2). Discussion Qatar currently holds the highest prevalence of obesity in the Middle East region [12]. Currently, the country leaders are supportive of bariatric surgery as a solution to combat this blooming condition. Bariatric surgery has proved to be the only effective treatment for morbid obesity that produces durable substantial weight loss and resolution of obesity-related morbidities [13]. Laparoscopic procedures have been shown to correlate with reduced morbidity and mortality rates compared with open surgeries [14,15]. However, in certain cases, laparoscopic bariatric surgeries may pose challenges. According to the American Society of Plastic Surgeons Statistics Report, the number of cosmetic surgeries and abdominal reconstruction procedures has been increasing in recent years [4]. A similar trend has been observed in the utilization of bariatric surgeries due to the increasing number of morbidly obese patients [3]. Our study involved only female patients, which is similar to previous studies and reflects the higher proportion of women who undergo abdominoplasty [6–9,16]. Table 2 Comparison of operative and postoperative features between study groups Variables
Abdominoplasty group (n ¼ 33)
Control group (n ¼ 69)
P value
Number of ports, mean ⫾ SD 3 ports, n (%) 4 ports, n (%) 5 pots, n (%) 6 ports, n (%) Operation time, min Intraoperative complication Length of hospital stay, d Postoperative complications, n (%) Postoperative bleeding Deep venous thrombosis Misfire %EWL, mean ⫾ SD
5.2 ⫾ .6
4
o.0001
1 (3) 1 (3) 22 (66.7) 9 (27.3) 90.3 ⫾ 36.7 0
0 69 (100) 0 0 57.1 ⫾ 17.7 0
o.0001 NA
3.8 ⫾ .8
3.5 ⫾ .9
.1
1 (3)
4 (5.7)
.8
1 (3)
2 (2.9)
0
1 (1.4)
0 46.6 ⫾ 12.6
1 (1.4) 44.2 ⫾ 12.6
.3
%EWL¼ percent of excess weight loss; NA ¼ not applicable; SD ¼ standard deviation.
Technical considerations A history of a previous abdominoplasty poses several technical challenges during subsequent laparoscopic procedures, including LSG. First, an abdominoplasty distorts the anatomic landmarks of the abdominal wall, particularly the umbilicus. The circumferential umbilical scar makes it difficult to access the umbilicus, and thus eliminates the use of the umbilicus as the initial abdominal entry site during laparoscopy. We opted to insert the initial trocar in the left upper quadrant to avoid the tough scarring near the umbilicus. Second, the midline rectus sheath plication increases the thickness and scarring of the midline abdominal wall. This scarring interferes with the smooth entry of trocars in the midline of the anterior abdominal wall. This factor needs to be considered when placing trocars in the midline in patients with prior abdominoplasty. Third, the rectus sheath plication tightens the abdominal wall and decreases the abdominal wall compliance, with a resultant decrease in the available abdominal cavity workspace during laparoscopy. The thickening and fibrosis of the abdominal wall can be global, and it can prevent peritoneal entry and result in failed pneumoperitoneum [6]. There are 2 factors affecting the abdominal wall elasticity after abdominoplasty: 1) postoperative swelling, and 2) tightening of the muscle fascia in patients with muscle plication. The swelling primarily involves the skin and subcutaneous tissue and subsides weeks later. However, the tightening related to the fascial plication will remain relatively stable in the postoperative period unless there are gradual tensile forces such has slow weight gain and pregnancy stretching the overlying tissues. The short duration of pneumoperitoneum does not change the abdominal wall elasticity. Hence, the shorter the interval between primary abdominoplasty and LSG, the more challenging it is to do the laparoscopic procedure due to the swelling-induced decreased abdominal wall elasticity and tensibility. Although no significant correlation was found between BMI and difficulty of port placement in our LSG patients, surgery was more likely to encounter an intraoperative difficulty in super-obese patients (BMI 450 kg/m2) due to a smaller working space. We utilized several maneuvers to counteract the narrow abdominal work space to facilitate exposure and provide room for instrumentation during the LSG. We placed the patient in an exaggerated reverse Trendelenburg position to provide adequate exposure of the upper abdomen. This approach has been also used by Karip et al. during 2 cases of LSG and during robotic Roux-en-Y gastric bypass, using the abdominal wall counter traction technique [5]. In addition, we administrated high doses of a muscle relaxant and increased the intra-abdominal pressure to 20 mm Hg of pneumoperitoneum to expand the abdominal wall, increase workspace, and facilitate the laparoscopic
340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394
NA 4F NA 4 Muller et al. [16]
BMI ¼ body mass index; F ¼ female; LSG ¼ laparoscopic sleeve gastrectomy; M ¼ male; NA ¼ not available; RRYGB ¼ robotic Roux-en-Y gastric bypass.
Feasible if reviewing prior reconstruction technique Superficial skin allergy to adhesive in 1 patient 3 Periumbilical and paramedian incisions and left upper quadrant access in relation to previous scars and transverse incisions
Similar to primary cases
Oophorectomy þ ovarian cystectomy þ diagnostic laparoscopy Transvaginal hysterectomy with salpingoophorectomy NA 8F NA 8 Tsahalina and Crawford [7]
38 1
1F
NA
Oophorectomy
Surgery canceled Uneventful
Modified midline open Hasson technique NA under direct vision Subumbilical incision þ failed NA pneumoperitoneum Midline and hypogastric port insertion under 3 direct vision Cholecystectomy NA 24
Cassaro and Leitman [9] Bisson et al. [6]
24 F
NA
Uneventful
2–4 Pre-existing scars as port site, additional port, and avoiding the midline Colorectal surgery 10 F:1 M 11 Atallah et al. [8]
50.2 (30–60)
LSG and RRYGB 35.6–43.2 38–44 2 Karip et al. [5]
2F
NA
Uneventful 2 Overretraction
Cellulitis in 1 patient
Well tolerated and feasible Feasible with aesthetic outcome of the most importance Well tolerated and expeditious Not possible
Postoperative event No. of ports Technique Laparoscopic procedure BMI, kg/m2 Gender Age, yr No of patients Study
Table 3 Summary of study data on laparoscopic procedure in patients with prior abdominoplasty
395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449
Conclusion
Laparoscopic Sleeve Gastrectomy in Patients with Abdominoplasty / Surgery for Obesity and Related Diseases ] (2016) 00–00
5
approach. No cardiovascular, pulmonary, or renal compromise occurred in relation to this increased pneumoperitoneum probably due to the short operative time. These technical challenges in patients with prior abdominoplasty are the reason for the significantly higher number of ports required for LSG in our study group compared with the nonabdominoplasty patients. In an attempt to minimize scarring when performing laparoscopic colorectal surgeries, Attalah et al. have described a “no visible scar technique” they used in 11 patients [8]. Depending on the site of colorectal surgery, they accessed the preexisting abdominoplasty scars for trocar insertion and avoided the midline so as not to compromise the aesthetic outcome. In contrast, Cassaro et al. used a modified midline open Hasson technique for peritoneal entry in 24 consecutive patients undergoing elective laparoscopic cholecystectomy [9]. Although their technique employed small incisions to insert the cannula, vertical incisions should be applied to the fascial plication scar and previous suture materials should be excised. Postoperative outcomes The weight loss outcome was similar between the 2 groups. One patient in the abdominoplasty group developed postoperative bleeding requiring blood transfusion and surgical intervention for hemostasis. However, no major complication occurred in the nonabdominoplasty patients and the adverse events were conservatively managed. There was no mortality among our patients at 1-year follow-up. As outlined in Table 3, only minor complications have been reported after laparoscopic surgeries in abdominoplasty patients [8,16]. The minor complication included 1 case of cellulitis [8] and 1 patient with a skin reaction to an adhesive agent [16]. Limitations Although this is the first case control study comparing operative and postoperative outcomes of LSG between abdominoplasty and nonabdominoplasty patients, its findings should be interpreted in the light of its limitations. First, this was a retrospective review of prospectively collected data, and there is need for a future prospective randomized controlled trial. Second, follow-up data after the first year were not available for our patients. Due to the increased abdominal pressure in LSG patients with previous abdominoplasty, the potential for the development of cardiovascular complications and hernias should always be considered. Conclusion LSG after abdominoplasty is associated with longer operative times and the need for additional port placement to overcome the decreased working space. However,
450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 T3 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504
6
505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 Q4 526 527 528 529 Q5 530 531 532
A. A. Saber et al. / Surgery for Obesity and Related Diseases ] (2016) 00–00
operative strategies should be considered to overcome the technical challenges during LSG in patients who underwent a prior abdominoplasty. Acknowledgments We would like to extend our appreciation to Drs. Davit Sargsyan, Mohamed Rizwan, and Nasreen Mahmoud for their contribution to this work. References [1] Dicker D, Yahalom R, Comaneshter DS, Vinker S. Long-term outcomes of three types of bariatric surgery on obesity and type 2 diabetes control and remission. Obes Surg 2016;26(8):1814–20. [2] Mahawar KK, De Alwis N, Carr WR, Jennings N, Schroeder N, Small PK. Bariatric surgery in type 1 diabetes mellitus: a systematic review. Obes Surg 2016;26(1):196–204. [3] American Society for Metabolic and Bariatric Surgery. ASMBS Professional Resource Center. Estimate of Bariatric Surgery Numbers, 2011-2015 [cited xxxx]. Available from: https://asmbs.org/resourcecategories/estimate-of-bariatric-surgery-numbers. [4] American Society of Plastic Surgeons. ASPS National Clearinghouse of Plastic Surgery Procedural Statistics. 2013 Plastic Surgery Statistics Report [cited xxxx]. Available from: 〈〈http://www.plasticsur gery.org/news/plastic-surgery-statistics/2013-plastic-surgery-statistics. html〉〉. [5] Karip B, Altun H, Işcan Y, et al. Difficulties of bariatric surgery after abdominoplasty. Case Rep Surg 2014;2014:620175. [6] Bisson MA, Breeson AJ, Henderson HP. Failed pneumoperitoneum post abdominoplasty. Eur J Plast Surg 2007;30:147–8.
[7] Tsahalina E, Crawford R. Laparoscopic surgery following abdominal wall reconstruction: description of a novel method for safe entry. BJOG 2004;111(12):1452–3. [8] Atallah S, Albert M, Felix O, Izfar S, Debeche-Adams T, Larach S. The technical approach to laparoscopic colectomy in patients who have undergone prior abdominoplasty. Tech Coloproctol 2013;17 (1):111–6. [9] Cassaro S, Leitman IM. A technique for laparoscopic peritoneal entry after abdominoplasty. J Laparoendosc Adv Surg Tech A 2013;23 (12):990–1. [10] Saber AA, El-Ghazaly TH. Feasibility of single-access laparoscopic sleeve gastrectomy in super-super obese patients. Surg Innov 2010;17 (1):36–40. [11] Saber AA, El-Ghazaly TH, Dewoolkar AV, Slayton SA. Singleincision laparoscopic sleeve gastrectomy versus conventional multiport laparoscopic sleeve gastrectomy: technical considerations and strategic modifications. Surg Obes Relat Dis 2010;6(6):658–64. [12] Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014;384(9945):766–81. [13] Inge TH, Courcoulas AP, Jenkins TM, et al. Weight loss and health status 3 years after bariatric surgery in adolescents. N Engl J Med 2016;374(2):113–23. [14] Shabanzadeh DM, Sorensen LT. Laparoscopic surgery compared with open surgery decreases surgical site infection in obese patients: a systematic review and meta-analysis. Ann Surg 2012;256(6):934–45. [15] Brolin RE, Cody RP, Marcella SW. Differences in open versus laparoscopic gastric bypass mortality risk using the Obesity Surgery Mortality Risk Score (OS-MRS). Surg Obes Relat Dis 2015;11 (6):1201–6. [16] Muller CY, Coleman RL, Adams WP Jr. Laparoscopy in patients following transverse rectus abdominis myocutaneous flap reconstruction. Obstet Gynecol 2000;96(1):132–5.
533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560
Laparoscopic sleeve gastrectomy in patients with abdominoplasty: a case-control study
56 57 58 59 60 61 62 63 64
2
65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119
A. A. Saber et al. / Surgery for Obesity and Related Diseases ] (2016) 00–00
surgeries and increasing number of abdominoplasties, more morbidly obese patients with a history of prior abdominal wall body contouring are undergoing bariatric surgery. A history of a prior abdominoplasty poses technical challenges during laparoscopic procedure. The challenges are attributed to decreased abdominal wall compliance and the resultant narrower working space available during laparoscopy. Morbid obesity can worsen the situation by increasing the abdominal wall thickness. A few reports address laparoscopic techniques in patients with prior abdominal wall reconstruction [5–9]. However, there is no published study comparing the laparoscopic outcomes of these patients with the outcomes of patients with no prior abdominoplasty. The present study aimed to evaluate the operative and clinical outcomes in patients with prior abdominoplasty undergoing laparoscopic sleeve gastrectomy (LSG) and compare them with the results in patients undergoing weight loss surgery with intact abdomens. Methods and materials Study design In this case control study, our hospital database was retrospectively reviewed to retrieve data on patients who underwent LSG between July 2014 and April 2015 in the metabolic and bariatric department of Hamad Medical Corporation in Doha, Qatar. The institutional review board of our hospital approved the study protocol. All the surgeries were performed by fellowship-trained surgeons, who were well beyond their learning curve, using a standardized technique. Patients The inclusion criteria were morbidly obese women aged between 18 and 65 years old who underwent LSG. Consecutive patients with prior abdominoplasty who underwent LSG (study group) and patients with no prior abdominal wall reconstruction who underwent the same weight loss procedure (control group) were recruited. Revisions or conversions to another procedure were excluded from analysis. Surgical technique of abdominoplasty All of the patients underwent surgery using the same abdominoplasty technique. After marking the anatomic features in an upright position, the patient assumed a supine position. General anesthesia was administered. A Pfannenstiel incision was made and the superior skin flap and subcutaneous tissue were undermined all the way up to the costal margin laterally and the xiphoid process medially. The umbilicus was circumscribed and exteriorized. A vertical rectus fascial plication was achieved to correct the
diastasis of the rectus abdominis muscles using permanent monofilament sutures. In a semiflexed position, the excess skin and adipose tissue were excised, and the flap was then sutured to the inferior skin incision in 2 layers. Two closed drains were placed. Laparoscopic sleeve gastrectomy in patients without prior abdominoplasty. A 1.5-cm skin incision was made in the umbilicus for the initial 15-mm port using an open technique. Pneumoperitoneum was achieved to a pressure of 15 mm Hg. A 12-mm trocar was inserted in the left upper quadrant and a 5-mm trocar in the right upper quadrant. A Nathanson liver retractor was inserted through a 5-mm subxiphoid skin puncture without port placement. When necessary, an additional 5-mm port was employed in the left upper quadrant. The technique of the sleeve gastrectomy was similar as previously described [10,11]. Using a 5-mm LigaSure (Medtronic, Minneapolis, MN), the greater curvature of the stomach was mobilized, beginning from a point 6 cm proximal to the pylorus, staying close to the wall of the stomach, going all the way up the greater curvature to the angle of His, and dividing both the gastrocolic and gastrosplenic ligaments. Retrogastric adhesions were taken down to allow complete mobilization of the stomach, eliminate any redundant posterior wall of the sleeve, and exclude the fundus from the gastric sleeve. Once the stomach was completely mobilized, a 34 F orogastric tube was inserted orally into the pylorus and placed against the lesser curvature. This calibrated the size of the gastric sleeve, prevented constriction at the gastroesophageal junction and incisura angularis, and provided a uniform shape for the entire stomach. The gastric transection was initiated at a point 6 cm proximal to the pylorus, leaving the antrum, and preserving gastric emptying. A long laparoscopic reticulating 60-mm XL endo-GIA stapler with green cartridge 4.8-mm staples and a synthetic absorbable buttressing material was inserted through the 15-mm trocar in a cephalad direction. The stapler was fired consecutively along the length of the orogastric tube until the angle of His was reached. Care was taken not to narrow the stomach at the incisura angularis and to inspect the stomach anteriorly and posteriorly to ensure there was no redundant posterior stomach. Approximately 80% of the stomach was separated. The entire staple line was inspected for bleeding and tested for leakage. The integrity of the staple line was tested by insufflating air under saline and infusing methylene blue into the remaining stomach. The resected stomach was extracted through the 15-mm umbilical port incision without the need for an Endobag. The fascial defect of the umbilical port site was closed with a figure-of-eight 2-0 nonabsorbable suture to prevent port site hernia formation. Deep vein thrombosis prophylaxis was achieved using anticoagulation, compression stockings, and an intermittent venous compression device. Once the patient was hemodynamically stable, afebrile, ambulating, able to maintain
120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
Laparoscopic Sleeve Gastrectomy in Patients with Abdominoplasty / Surgery for Obesity and Related Diseases ] (2016) 00–00
175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229
hydration and tolerate a full liquid diet, and their pain was managed appropriately with oral analgesics, the patient was discharged. Laparoscopic sleeve gastrectomy in patients with prior abdominoplasty. To overcome the technical challenges due to the previous abdominoplasty, we placed the patient in an exaggerated reverse Trendelenburg position. The instrumentation was similar to that used for the patients without abdominoplasty, except for the 12-mm optic trocar, which was inserted in the left upper quadrant for initial entry. Additional 5-mm ports were inserted in the epigastric region, and the right upper quadrant. A 5-mm skin incision was made at the subxiphoid area for liver retraction. Since placement of the Nathanson retractor needs an adequate space, we inserted the retractor after achieving an adequate working space. Pneumoperitoneum was established to a pressure of 20 mm Hg. Moreover, muscle relaxation was aggressively induced during the procedure. The details of the laparoscopic procedure are otherwise as described above. These modifications were necessary because of previous tightening of the anterior abdominal fascia by plication during the abdominoplasty procedure. Outcome measures Data were gathered on the patient’s demographic characteristics, preoperative body mass index (BMI), type of surgery, time between abdominoplasty and laparoscopic bariatric procedure, operative time, length of hospital stay, number of ports, postoperative complications, and percent of excess weight loss. Statistical analysis Data were analyzed using the statistical package for social sciences (SPSS, version 17; SPSS, Chicago, IL). The Kolmogrov-Smirnov test was used to determine the normal distribution of continuous variables. For normally distributed data, the analysis was performed by Student t test, and for nonparametric data, the Mann-Whitney U test was applied. Categorical variables were compared between groups using the χ2 test. Data are presented as mean ⫾ standard deviation or number (%), and a significance level was set at P o .05. Results Demographic data A total of 102 patients were enrolled in this study, with 33 patients in the abdominoplasty group (study group) and 69 patients in the nonabdominoplasty group (control group). No patient was excluded from our study. The patients’ ages ranged between 20 and 57 years and their BMIs were between and 35 and 62 kg/m2, with an average of 39.5 ⫾ 7.7 years and 42.8 ⫾ 5.9 kg/m2, respectively. All
3
of the patients were women and LSG was the sole procedure performed. Patients in the study group underwent the LSG between 1 and 18 months after their primary abdominoplasty. Only 1 patient underwent LSG 1 month after abdominoplasty. She presented to us after abdominal wall plication with signs of abdominal hypertension. We discussed with her the 2 available options for weight loss, LSG and lifestyle modification, which could decrease her visceral adipose tissue and help to improve abdominal hypertension. Table 1 compares the demographic characteristics and baseline characteristics between the study groups. No significant differences were observed between the 2 groups in terms of age, preoperative BMI, and co-morbidities (P 4 .05). Operative data The operative time varied from 28 to 180 minutes with an overall mean of 67.8 ⫾ 29.7 minutes. The abdominoplasty group patients had a significantly longer operative time compared to the control group (90.3 ⫾ 36.7 minutes versus 57.1 ⫾ 17.7 minutes, P o 0.0001). In the abdominoplasty group, the total number of ports required during surgery varied; the LSG was performed most often with 5 ports (66.7%), followed by 6 ports (27.3%), and then 4 ports (3%). All of the surgeries were performed using 4 ports in the nonabdominoplasty group. There was a statistically significant difference in the number of ports between these 2 groups (P o .0001). No intraoperative pneumoperitoneum-related cardiovascular, pulmonary, or renal compromises were noted in both groups. Postoperative outcomes The length of stay ranged between 2 and 6 days, and there was no significant difference between the 2 groups Table 1 Demographic characteristics and baseline characteristics of patients Variables
Abdominoplasty group (n ¼ 33)
Control group P (n ¼ 69) value
Age, yr Gender, n (%) Male Female BMI, kg/m2 Preoperative co-morbidities, n (%) Diabetes Hypertension Hyperlipidemia Obstructive sleep apnea Interval between abdominoplasty and SG (mo)
41.5 ⫾ 6.2
38.6 ⫾ 8.3
0 33 (100) 41.2 ⫾ 8.7
0 69 (100) 42.2 ⫾ 7.6
9 (27.3) 10 (30.3) 6 (18.2) 1 (.03) 8.6 ⫾ 4.1
23 (33.3) 23 (33.3) 9 (13) 3 (.04) NA
.6 NA
.5 NS .5 .8 .5 .7 NA
BMI ¼ body mass index; NA ¼ not applicable; NS ¼ not significant; SG ¼ sleeve gastrectomy.
230 231 232 233 234 235 236 237 238 T1239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284
A. A. Saber et al. / Surgery for Obesity and Related Diseases ] (2016) 00–00
4
285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339
T2
(P 4 .05). One patient in the abdominoplasty group experienced postoperative bleeding requiring transfusion of 2 units of blood and reoperation for hemostasis. The patient did well after the surgery. Although there were 4 cases of postoperative complications in the control group (5.7%) and 1 case in the abdominoplasty group (3%), the difference was not statistically significant (P 4 .05). The patients in the 2 groups achieved similar percent of excess weight loss at 1 year (Table 2). Discussion Qatar currently holds the highest prevalence of obesity in the Middle East region [12]. Currently, the country leaders are supportive of bariatric surgery as a solution to combat this blooming condition. Bariatric surgery has proved to be the only effective treatment for morbid obesity that produces durable substantial weight loss and resolution of obesity-related morbidities [13]. Laparoscopic procedures have been shown to correlate with reduced morbidity and mortality rates compared with open surgeries [14,15]. However, in certain cases, laparoscopic bariatric surgeries may pose challenges. According to the American Society of Plastic Surgeons Statistics Report, the number of cosmetic surgeries and abdominal reconstruction procedures has been increasing in recent years [4]. A similar trend has been observed in the utilization of bariatric surgeries due to the increasing number of morbidly obese patients [3]. Our study involved only female patients, which is similar to previous studies and reflects the higher proportion of women who undergo abdominoplasty [6–9,16]. Table 2 Comparison of operative and postoperative features between study groups Variables
Abdominoplasty group (n ¼ 33)
Control group (n ¼ 69)
P value
Number of ports, mean ⫾ SD 3 ports, n (%) 4 ports, n (%) 5 pots, n (%) 6 ports, n (%) Operation time, min Intraoperative complication Length of hospital stay, d Postoperative complications, n (%) Postoperative bleeding Deep venous thrombosis Misfire %EWL, mean ⫾ SD
5.2 ⫾ .6
4
o.0001
1 (3) 1 (3) 22 (66.7) 9 (27.3) 90.3 ⫾ 36.7 0
0 69 (100) 0 0 57.1 ⫾ 17.7 0
o.0001 NA
3.8 ⫾ .8
3.5 ⫾ .9
.1
1 (3)
4 (5.7)
.8
1 (3)
2 (2.9)
0
1 (1.4)
0 46.6 ⫾ 12.6
1 (1.4) 44.2 ⫾ 12.6
.3
%EWL¼ percent of excess weight loss; NA ¼ not applicable; SD ¼ standard deviation.
Technical considerations A history of a previous abdominoplasty poses several technical challenges during subsequent laparoscopic procedures, including LSG. First, an abdominoplasty distorts the anatomic landmarks of the abdominal wall, particularly the umbilicus. The circumferential umbilical scar makes it difficult to access the umbilicus, and thus eliminates the use of the umbilicus as the initial abdominal entry site during laparoscopy. We opted to insert the initial trocar in the left upper quadrant to avoid the tough scarring near the umbilicus. Second, the midline rectus sheath plication increases the thickness and scarring of the midline abdominal wall. This scarring interferes with the smooth entry of trocars in the midline of the anterior abdominal wall. This factor needs to be considered when placing trocars in the midline in patients with prior abdominoplasty. Third, the rectus sheath plication tightens the abdominal wall and decreases the abdominal wall compliance, with a resultant decrease in the available abdominal cavity workspace during laparoscopy. The thickening and fibrosis of the abdominal wall can be global, and it can prevent peritoneal entry and result in failed pneumoperitoneum [6]. There are 2 factors affecting the abdominal wall elasticity after abdominoplasty: 1) postoperative swelling, and 2) tightening of the muscle fascia in patients with muscle plication. The swelling primarily involves the skin and subcutaneous tissue and subsides weeks later. However, the tightening related to the fascial plication will remain relatively stable in the postoperative period unless there are gradual tensile forces such has slow weight gain and pregnancy stretching the overlying tissues. The short duration of pneumoperitoneum does not change the abdominal wall elasticity. Hence, the shorter the interval between primary abdominoplasty and LSG, the more challenging it is to do the laparoscopic procedure due to the swelling-induced decreased abdominal wall elasticity and tensibility. Although no significant correlation was found between BMI and difficulty of port placement in our LSG patients, surgery was more likely to encounter an intraoperative difficulty in super-obese patients (BMI 450 kg/m2) due to a smaller working space. We utilized several maneuvers to counteract the narrow abdominal work space to facilitate exposure and provide room for instrumentation during the LSG. We placed the patient in an exaggerated reverse Trendelenburg position to provide adequate exposure of the upper abdomen. This approach has been also used by Karip et al. during 2 cases of LSG and during robotic Roux-en-Y gastric bypass, using the abdominal wall counter traction technique [5]. In addition, we administrated high doses of a muscle relaxant and increased the intra-abdominal pressure to 20 mm Hg of pneumoperitoneum to expand the abdominal wall, increase workspace, and facilitate the laparoscopic
340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394
NA 4F NA 4 Muller et al. [16]
BMI ¼ body mass index; F ¼ female; LSG ¼ laparoscopic sleeve gastrectomy; M ¼ male; NA ¼ not available; RRYGB ¼ robotic Roux-en-Y gastric bypass.
Feasible if reviewing prior reconstruction technique Superficial skin allergy to adhesive in 1 patient 3 Periumbilical and paramedian incisions and left upper quadrant access in relation to previous scars and transverse incisions
Similar to primary cases
Oophorectomy þ ovarian cystectomy þ diagnostic laparoscopy Transvaginal hysterectomy with salpingoophorectomy NA 8F NA 8 Tsahalina and Crawford [7]
38 1
1F
NA
Oophorectomy
Surgery canceled Uneventful
Modified midline open Hasson technique NA under direct vision Subumbilical incision þ failed NA pneumoperitoneum Midline and hypogastric port insertion under 3 direct vision Cholecystectomy NA 24
Cassaro and Leitman [9] Bisson et al. [6]
24 F
NA
Uneventful
2–4 Pre-existing scars as port site, additional port, and avoiding the midline Colorectal surgery 10 F:1 M 11 Atallah et al. [8]
50.2 (30–60)
LSG and RRYGB 35.6–43.2 38–44 2 Karip et al. [5]
2F
NA
Uneventful 2 Overretraction
Cellulitis in 1 patient
Well tolerated and feasible Feasible with aesthetic outcome of the most importance Well tolerated and expeditious Not possible
Postoperative event No. of ports Technique Laparoscopic procedure BMI, kg/m2 Gender Age, yr No of patients Study
Table 3 Summary of study data on laparoscopic procedure in patients with prior abdominoplasty
395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449
Conclusion
Laparoscopic Sleeve Gastrectomy in Patients with Abdominoplasty / Surgery for Obesity and Related Diseases ] (2016) 00–00
5
approach. No cardiovascular, pulmonary, or renal compromise occurred in relation to this increased pneumoperitoneum probably due to the short operative time. These technical challenges in patients with prior abdominoplasty are the reason for the significantly higher number of ports required for LSG in our study group compared with the nonabdominoplasty patients. In an attempt to minimize scarring when performing laparoscopic colorectal surgeries, Attalah et al. have described a “no visible scar technique” they used in 11 patients [8]. Depending on the site of colorectal surgery, they accessed the preexisting abdominoplasty scars for trocar insertion and avoided the midline so as not to compromise the aesthetic outcome. In contrast, Cassaro et al. used a modified midline open Hasson technique for peritoneal entry in 24 consecutive patients undergoing elective laparoscopic cholecystectomy [9]. Although their technique employed small incisions to insert the cannula, vertical incisions should be applied to the fascial plication scar and previous suture materials should be excised. Postoperative outcomes The weight loss outcome was similar between the 2 groups. One patient in the abdominoplasty group developed postoperative bleeding requiring blood transfusion and surgical intervention for hemostasis. However, no major complication occurred in the nonabdominoplasty patients and the adverse events were conservatively managed. There was no mortality among our patients at 1-year follow-up. As outlined in Table 3, only minor complications have been reported after laparoscopic surgeries in abdominoplasty patients [8,16]. The minor complication included 1 case of cellulitis [8] and 1 patient with a skin reaction to an adhesive agent [16]. Limitations Although this is the first case control study comparing operative and postoperative outcomes of LSG between abdominoplasty and nonabdominoplasty patients, its findings should be interpreted in the light of its limitations. First, this was a retrospective review of prospectively collected data, and there is need for a future prospective randomized controlled trial. Second, follow-up data after the first year were not available for our patients. Due to the increased abdominal pressure in LSG patients with previous abdominoplasty, the potential for the development of cardiovascular complications and hernias should always be considered. Conclusion LSG after abdominoplasty is associated with longer operative times and the need for additional port placement to overcome the decreased working space. However,
450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 T3 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504
6
505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 Q4 526 527 528 529 Q5 530 531 532
A. A. Saber et al. / Surgery for Obesity and Related Diseases ] (2016) 00–00
operative strategies should be considered to overcome the technical challenges during LSG in patients who underwent a prior abdominoplasty. Acknowledgments We would like to extend our appreciation to Drs. Davit Sargsyan, Mohamed Rizwan, and Nasreen Mahmoud for their contribution to this work. References [1] Dicker D, Yahalom R, Comaneshter DS, Vinker S. Long-term outcomes of three types of bariatric surgery on obesity and type 2 diabetes control and remission. Obes Surg 2016;26(8):1814–20. [2] Mahawar KK, De Alwis N, Carr WR, Jennings N, Schroeder N, Small PK. Bariatric surgery in type 1 diabetes mellitus: a systematic review. Obes Surg 2016;26(1):196–204. [3] American Society for Metabolic and Bariatric Surgery. ASMBS Professional Resource Center. Estimate of Bariatric Surgery Numbers, 2011-2015 [cited xxxx]. Available from: https://asmbs.org/resourcecategories/estimate-of-bariatric-surgery-numbers. [4] American Society of Plastic Surgeons. ASPS National Clearinghouse of Plastic Surgery Procedural Statistics. 2013 Plastic Surgery Statistics Report [cited xxxx]. Available from: 〈〈http://www.plasticsur gery.org/news/plastic-surgery-statistics/2013-plastic-surgery-statistics. html〉〉. [5] Karip B, Altun H, Işcan Y, et al. Difficulties of bariatric surgery after abdominoplasty. Case Rep Surg 2014;2014:620175. [6] Bisson MA, Breeson AJ, Henderson HP. Failed pneumoperitoneum post abdominoplasty. Eur J Plast Surg 2007;30:147–8.
[7] Tsahalina E, Crawford R. Laparoscopic surgery following abdominal wall reconstruction: description of a novel method for safe entry. BJOG 2004;111(12):1452–3. [8] Atallah S, Albert M, Felix O, Izfar S, Debeche-Adams T, Larach S. The technical approach to laparoscopic colectomy in patients who have undergone prior abdominoplasty. Tech Coloproctol 2013;17 (1):111–6. [9] Cassaro S, Leitman IM. A technique for laparoscopic peritoneal entry after abdominoplasty. J Laparoendosc Adv Surg Tech A 2013;23 (12):990–1. [10] Saber AA, El-Ghazaly TH. Feasibility of single-access laparoscopic sleeve gastrectomy in super-super obese patients. Surg Innov 2010;17 (1):36–40. [11] Saber AA, El-Ghazaly TH, Dewoolkar AV, Slayton SA. Singleincision laparoscopic sleeve gastrectomy versus conventional multiport laparoscopic sleeve gastrectomy: technical considerations and strategic modifications. Surg Obes Relat Dis 2010;6(6):658–64. [12] Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014;384(9945):766–81. [13] Inge TH, Courcoulas AP, Jenkins TM, et al. Weight loss and health status 3 years after bariatric surgery in adolescents. N Engl J Med 2016;374(2):113–23. [14] Shabanzadeh DM, Sorensen LT. Laparoscopic surgery compared with open surgery decreases surgical site infection in obese patients: a systematic review and meta-analysis. Ann Surg 2012;256(6):934–45. [15] Brolin RE, Cody RP, Marcella SW. Differences in open versus laparoscopic gastric bypass mortality risk using the Obesity Surgery Mortality Risk Score (OS-MRS). Surg Obes Relat Dis 2015;11 (6):1201–6. [16] Muller CY, Coleman RL, Adams WP Jr. Laparoscopy in patients following transverse rectus abdominis myocutaneous flap reconstruction. Obstet Gynecol 2000;96(1):132–5.
533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560