Page 32 - Journal of WALS

WJOLS

Risk of Pneumoperitoneum in Obese: Old Myths and New Realities

(Palmer’s point). Percutaneous induction of a pneumo- an inherently increased risk of conversion to laparotomy, as
peritoneum with the Veress needle in the left upper quadrant is confirmed by several authors. In a subsequent review of 2,530
a safe and effective technique in morbidly obese patients. 17 attempted gynecologic laparoscopic surgeries, Sokol et al
2
Other approaches have been advocated as suprapubic determined that a BMI greater than 30 kg/m placed patients at
entry, and access through the natural orifices as uterus or a more than two-fold risk of unintended laparotomy. Eltabbakh
posterior vaginal fornix (cul-de-sac) by using a long Veress et al noted similar findings in a review of 47 obese patients who
needle (17 cm). 11,15 The technique of vaginal approach should underwent operative gynecologic laparoscopies.
not be used in the presence of a cul-de-sac mass, severe Despite these challenges, a laparoscopic approach is well
rectovaginal endometriosis, fixed uterine retroversion, or suited to the obese patient, who is inherently less mobile and,
whenever vaginal vault surgery has been performed. Regarding therefore, more susceptible to thromboembolic events and
uterine approach, it has been found that the safety is maximized suboptimal wound healing following laparotomy. One
by directing this step with the aid of intraoperative sonography. randomized, prospective trial comparing outcomes of
This technique should not be used in the presence of laparoscopic with abdominal hysterectomy found less operative
leiomyomata, possible pelvic infection or pregnancy, and blood loss, less postoperative pain, and shorter hospital and
whenever there is a risk of adhesions between the bowel and convalescence times for patients undergoing laparoscopic
fundus of the uterus (e.g. prior myomectomy or hysterotomy). 14 hysterectomy. These same authors concluded that total
On the other hand, it is generally recommended that an laparoscopic hysterectomy may afford significant benefit to
open (Hasson) technique should be performed for primary entry society in the form of indirect costs related to recovery time,
in patients who are morbidly obese, although even this when compared with abdominal hysterectomy. 4
technique may be difficult. 7 Jansen et al in a study on 25,764 patients found that 83 of
Optical access trocars have been first introduced in 1994, 145 complications were related to primary access. Similarly,
21
and developed as an alternative method of peritoneal entry to Champault et al in a French survey of 1,03,852 laparoscopic
decrease the risk of injury to intra-abdominal organs. The operations found that 83% of vascular injury, 75% of bowel
theoretical advantage of these trocars is that each layer can be injury and 50% of local hemorrhage were caused during primary
identified prior to transection. 7, 18 trocar insertion. The impact of Veress needle injury has been
22
Obesity had generally been thought to increase the risk of highlighted in another big literature review. Thirty-eight selected
4
laparoscopic surgery. Primary prevention of entry articles included 6,96,502 laparoscopies with 1,575 injuries
complications is beneficial to the patient, the treating physician (0.23%), 126 (8%) of which involved blood vessels or hollow
and the society, given the negative health implications, the fear viscera (0.018% of all laparoscopies). Of the 98 vascular injuries,
and costs of litigation and the negative economic impact on the 8 (8.1%) were injuries to major retroperitoneal vessels. There
health care budget. 12 were 34 other reported retroperitoneal injuries, but the authors
were not specific as to which vessel was injured. Of the 28
METHODOLOGY
injuries to hollow viscera, 17 were considered major injuries,
The study was carried out through a literature search from the i.e. 60.7% (0.0024% of the total cases assessed). 13
electronic library using the following search engines: Google, In an attempt to facilitate access to peritoneal cavity in
Springer online, PubMed and other linked references. obese patient which can help in decreasing the entry
23
Publications used were searched by using relevant complications; Phillips et al reported a peritoneal hyper-
combinations of medical subject headings (laparoscopy; distention to 25 mm Hg as against 12 to 15 mm Hg, noting that
obesity; gynecological surgical procedures; intraoperative a downward force of 3 kg umbilically with an intra-abdominal
complications; postoperative complications) and free text words. distension pressure of 10 mm Hg resulted in a distance of only
The literatures were critically appraised according to a 0.6 cm between the trocar and abdominal contents. However,
standardized grading scheme used by the RCOG. this distance increased to 5.6 cm with insufflation pressure of
25 mm Hg. Reich et al reported no specific or vascular
Findings complications in 3,041 cases using this technique. Tsaltas et al,
Technical obstacles associated with open pelvic surgery in the in 1150 consecutive operative laparoscopies using the 25 mm
obese are primarily those related to exposure of the operative Hg hyperdistention technique, similarly reported no entry
field and access to deep pelvic structures. These obstacles complications or adverse clinical events.
present similar challenges when laparoscopy is attempted, as Prediction of laparoscopy outcome in obese patient had
have been previously described. 19,20 Loffer and Pent discussed been made by Lamvu et al through a Tilt Test, which involves
at length the additional, unique difficulty of establishing placing the patient in steep trendelenburg for 2 to 5 minutes
pneumoperitoneum in obese patients. Together, all of these following intubation and positioning, observing the patient’s
limitations place the obese patient undergoing laparoscopy at cardiac and respiratory indices. Patients who remain

World Journal of Laparoscopic Surgery, May-August 2011;4(2):97-102 99