Page 24 - Journal of WALS

WJOLS

10.5005/jp-journals-10007-1124
REVIEW ARTICLE Risk of Pneumoperitoneum in Obese: Old Myths and New Realities
Risk of Pneumoperitoneum in Obese:

Old Myths and New Realities

Anaam Majeed Hasson
Al Rahba Hospital, Affiliated to Johns Hopkins Medicine, Abu Dhabi, UAE

ABSTRACT
Objective: To provide an overview of difficulties encountered during laparoscopic entries in obese patients and the contemporary
methods used to establish the safest possible laparoscopic entry in obese.
Methods: Twenty-six articles related to laparoscopy procedures, in general, and associated difficulties in obese patient, in particular,
were examined.
Results: Obesity imposes a challenge for the minimal access surgery procedures; particularly those related to the primary access of
peritoneal cavity. However, closed and open peritoneal entry using blunt or optical instruments, through different sites, have been used
to prevent entry failures or possible complications if difficulties are encountered whenever the surgeon cannot safely use his/her
preferred entry procedure.
Conclusion: Induction of pneumoperitoneum can be a difficult, time-consuming and occasionally hazardous task in a morbidly obese
patient. Different alternatives are possible according to differences in the method of entry, the site or the instruments used. The risk-
benefit and the alternative options must be examined individually by the healthcare provider.
Keywords: Laparoscopic entry, Obesity, Complications, Gynecological laparoscopic surgery, Pneumoperitoneum, Veress needle.

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INTRODUCTION not without risk. The technical modifications imposed by
surgical laparoscopy are obvious (e.g. number and size of
Overweight and obesity are both labels for ranges of weight
that are greater than what is generally considered healthy for a trocars, location of insertion sites, specimen retrieval), and
given height. The weight and height are used to calculate the therefore morbidity may be substantially modified.
body mass index (BMI), which correlates with the amount of Complications such as retroperitoneal vascular injury, intestinal
the body fat. 1 perforation, wound herniation, wound infection, abdominal wall
8
Obesity is an ever-increasing problem. It is now considered hematoma, and trocar site mestastasis have been reported.
an epidemic in the United States. According to a study from the Laparascopic surgery may be of particular benefit to obese 9
Center for Disease Control and Prevention, 30.5% of Americans patients for prevention of postlaparotomy complications.
are considered obese with a body mass index (BMI) greater Nevertheless, in women who are overweight, and even more so
2
than 30 kg/m , and 4.7% of Americans are considered morbidly in those who are obese, every aspect of laparoscopy becomes
2
obese (BMI 40). Prevalence of obesity in India is up to 50% in more difficult and potentially more risky. Placement of
women in the upper strata of the society. In Delhi, the prevalence laparoscopic instruments becomes much more difficult and often
of obesity stands at 33.4 % in women. 3 requires special techniques. Bleeding from abdominal wall
The prevalence of obesity in USA and throughout the vessels may become more common since these vessels become
industrialized world is such that the practicing surgeon cannot difficult to locate. Many intra-abdominal procedures become
reasonably expect to avert its many implications for patient increasingly difficult because of a restricted operative field
care. 4 secondary to retroperitoneal fat deposits in the pelvic sidewalls
Laparoscopic surgery has developed rapidly over the last and increased bowel excursion into the operative field. This
few years, and many surgical procedures formerly carried out second problem probably is related to increased volume of
through large abdominal incisions are now performed bowel, decreased elevation of a heavier anterior abdominal wall
laparoscopically. Laparoscopic techniques have revolutionized by the pneumoperitoneum, and the inability to place many obese
the field of surgery with benefits that include decreased patients in steep trendelenburg because of ventilation
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postoperative pain, earlier return to normal activities following considerations. Unique complications are associated with
surgery and fewer postoperative complications (e.g. wound gaining access to the abdomen for laparoscopic surgery,
infection, hernia). 5 resulting in an inadvertent injury to the internal organs. 5
Reduction of the trauma of access by avoidance of large Generally, laparoscopic surgery has a complication rate of
wounds has been the driving force for such development. 6 5.7 per 1000; about one-half of these complications are
However, the insertion of needles and trocars necessary for the associated with initial entry into the peritoneal cavity and this
pneumoperitoneum and the performance of the procedure are happens within the first few minutes of the laparoscopic

World Journal of Laparoscopic Surgery, May-August 2011;4(2):97-102 97