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Dr Roger McMaster-Fay

Gynaecologist and Endoscopic Surgeon - Clinical Lecturer, Sydney University



The issue of obesity in hysterectomy patients


Laparoscopic hysterectomy in patients weighing 100 Kg or more

   [Dr Roger A. McMaster-Fay     Gynecol Surg 2004; 1: 233-235.]

Abstract: Obesity is an increasingly prevalent condition in our society. The majority of hysterectomies are still being undertaken abdominally. Obese patients have a high rate of complications from abdominal surgery. Laparo-vaginal hysterectomy has a faster recovery than abdominal hysterectomy. If the uterine vessels are ligated laparoscopically at laparo-vaginal hysterectomy, there is a low conversion rate to abdominal hysterectomy.

The aim of this study was to establish whether laparoscopic hysterectomy is a feasible alternative in obese patients.

A seven-year audit of patients requiring a hysterectomy identified 27 women weighing 100 Kg or more. All patients gave informed consent to an initial laparoscopic procedure, having been assessed as suitable for such and then had a laparoscopic hysterectomy performed. Data regarding their operation was prospectively collected and retrospectively reviewed.

All patients had successful laparoscopic hysterectomies with none requiring conversion to open operation, reoperation or readmission. There were no major complications. Post-operative stay was short (mean 2.4 days) but operation times were long (mean 175 minutes).

Laparoscopic hysterectomy is a feasible alternative to abdominal hysterectomy in obese patients weighing 100 kilograms or more with low morbidity and fast recovery with short hospital stay.

Introduction:The prevalence of obesity in Australia has more than doubled in the past 20 years.1 Abdominal hysterectomy on obese patients is associated with increased peri-operative morbidity with slower recovery and wound complications.2 A major factor in abdominal wound dehiscence is obesity.3 A recent review of hysterectomy in the United States between 1990 and 1997 found that the majority were performed were abdominally.4 Patients who have a laparo-vaginal hysterectomy recover more quickly than patients having an abdominal hysterectomy.5 With laparoscopic hysterectomy, where the uterine vessels are secured laparoscopically6, the rate for conversion to an abdominal procedure can be as low as 2%7.

Methods: From 1997 to 2003, of 399 patients requiring a hysterectomy, 27 (6.75%) weighed 100 Kg or more. All were appropriate candidates for laparoscopic hysterectomy. Inclusion criteria were patient informed consent and fitness for general anaesthesia for laparoscopic surgery. The operative technique didn’t vary from that in non-obese patients8. Pneumatic calf compressors were used but anticoagulants were not. Cephtriaxone 1g was given intravenously at the beginning of the operation and repeated after 24 hours. As this review conforms to the standards established by the NHMRC for ethical quality review9, ethics approval was not sought.

Operative Procedure: The initial approach is transvaginal with the patient in lithotomy position; the cervico-vaginal reflection of the vaginal skin is incised to open the utero-vaginal space is opened to permit mobilization of the bladder off the uterus. The vagina is then sutured closed and a Sairges uterine elevator (Richard Wolf) inserted into the uterine cavity is clamped onto the cervix.

Having established a pneumoperitoneum with a Veress cannula, inserted through the umbilicus, a four-port laparoscopy is performed. A 5-12mm port is inserted through the umbilicus and a 5mm port is inserted suprapubically. Two lateral 5-12mm ports are inserted midway between the first two ports and lateral to the inferior epigastric vessels visualised laparoscopically. The anatomy is identified and any adhesions are divided. In particular, the ovaries are fully mobilized and the ureters, in their course along the pelvic sidewall, are identified. The Endo GIA device (United States Surgical Corporation [USSC], a division of the Tyco Healthcare Group LP) device was used on the vascular pedicles. This disposable and reloadable instrument delivers two triple rows of staples and simultaneously divides the tissues between the two sets of rows. The ovarian and uterine vessels were divided using the device. To secure the uterine vessels, the device is inserted through the umbilical port with the laparoscope moved to the ipsilateral port as previously described.8 One uterus required debulking with the S.E.M.M. Moto-Drive 15mm mechanical morcellator (WISAP), through the left hand port as previously described.7 The debulked uterus is the cut off the vagina and the delivered through the vagina. The vagina is then sutured laparoscopically under direct vision using the Endo Stitch (USSC). Any port site bleeding was controlled by sutures placed with the Endo Close (disposable suture carrier, USSC)10.

Results: In addition to the problem of their obesity, these were complex patients. Nine (33.3%) had surgical specimens weighing at least 250g and two (7.4%) weighed 450g and 780g (Table 1); the later case required trans-abdominal morcellation to remove the mass. There was one case of endometrial cancer (low grade with minimal myometrial invasion: Stage I). One patient had undergone six previous lower abdominal laparotomies. One patient required a laparoscopic enterocele repair and a bladder neck suspension with suprapubic catheterisation for 12 days as an in-patient.

No patient required laparotomy, reoperation or readmission. Patients weighed up to a maximum 175 Kg (mean weight 116.7 Kg). The mean operating time was 175 minutes (range: 105 –360), the longest being on the largest patient who was only the second in the series. The mean post-operative stay was 2.4 days with one patient with an inadvertent cystotomy (4 days) and the other requiring a suprapubic catheter (12 days). Excessive bleeding from lateral port sites occurred in five (22%) patients, for which the Endo Close (USSC) was utilized to successfully obtain haemostasis. Four of these five cases were amongst the first seven patients in the series (Table 1). Three patients (11%) required blood transfusions, again with two being in the first seven of the series. There was one inadvertent bladder perforation during the vaginal aspect of the operation that was attributable to fibrotic endometriosis. The perforation was diagnosed and repaired laparoscopically. Two patients developed vaginal vault infections postoperatively, one with Pseudomonas; both were treated as outpatients with oral antibiotic therapy.

Discussion: Kadar and Pelosi published the first series of laparoscopic hysterectomies on obese patients11. They operated successfully, without major operative complications, on 24 patients weighing 200lb (91Kg) or more but only half their patients weighed 100 Kg or more. One patient had a blood transfusion and two developed infections. Ostrzenski performed successful laparoscopic hysterectomies on 11 women weighing from 119 to 140 Kg without complications12. Eltabbakh et al. in a controlled study, compared laparoscopic and abdominal hysterectomy in obese patients (BMI>28) with early stage endometrial cancer. Of these the 40 patients who had laparoscopic hysterectomies had longer operating times but had less blood loss, needed less analgesia, and had a shorter hospital stay compared with the patient who had abdominal hysterectomies13. Holub et al. performed laparoscopically-assisted vaginal hysterectomies (where the uterine vessels are secured vaginally5) on 54 obese patients (BMI >30); of these only 10 weighed 100 Kg or more and the largest was 121 Kg14. In their series there were two inadvertent cystotomies and one lateral port site bleed. None were converted to laparotomy.

Two larger series of laparoscopic hysterectomies on obese patients have recently been published15, 16. Both define obsess as a BMI of 30 Kg/m2. In the series of O’Hanlan et al15 23.6% (n=78) of their patients were obese. The mean weight of their obese patients was less than 100 Kg (214.6 lb). In the series of Heinberg et al16 39.3% (n=106) were obese, whereas this series reports on the outcomes of the largest 6.75% of a hysterectomy population.

O’Hanlan et al15 had one cystotomy and one adhesive bowel obstruction. Heinberg et al16 had exclusion criteria but these and the numbers involved were not detailed. Compared to their non-obese patients, the obese patients had longer operating times, higher rates of conversion to an open procedure and more blood loss. There were two cystotomies, one small bowel injury, two intraoperative haemorrhages and four other major intraoperative complications (not detailed) in the obese group. They had three readmissions and three reoperations and one thromboembolic event. The mean postoperative stay was 1.1 days.

Lateral port site bleeding was more common in this series of obese patients. The impression is that the bleeding comes from vessels in the muscle layer that are supplying the thicker than normal fat layer and are thus dilated and more prone to injury. The Endo Close (USSC) is primarily a laparoscopic wound closure device used to prevent wound hernias, but has not been previously described as a haemostatic device.

Complications in this series were minor and consistent with those reviewed above11-16 and similar to those reported for laparoscopic hysterectomy generally17. Laparoscopic hysterectomy in experienced hands appears a reasonable alternative to abdominal hysterectomy for obese patients with few complications and fast recovery. Operating times remain long but with no apparent adverse effect on patient wellbeing.

To establish any advantage for obese patients from laparoscopic hysterectomy over abdominal (or vaginal) hysterectomy, a prospective randomised trial would be necessary. From the data reported and discussed here, such a trial would be now indicated.


Table 1: Patient and Operation Details

Patient No.

Operation time (mins)

Post-op stay (days)

Patient's weight (Kg)

Speciment > 250g

Comments

1

210 3 120     Endo Close

2

360 2 175     Endo Close*, transfusion

3

105 1 104    

4

135 1 127     7cm cervix

5

155 2 120    

6

165 4 130 275g   Endo Close*, bladder perforations

7

230 2 130     Transfusion (X6 previous laparotomies)

8

140 3 103    

9

135 1 106    

10

150 2 100    

11

105 3 111    

12

135 1 117 255g   Endometriosis obliterating Pouch of Douglas

13

150 1 140 295g  

14

155 3 106 265g  

15

240 12 105     Laparovaginal repair with SPC for 12 days

16

125 2 130    

17

220 2 105 450g   Cervical fibroid (post-op Hb 82)

18

225 2 127 255g  

19

260 2 107 780g   Morcellation of uterus

20

160 2 102     Endometrial cancer

21

135 1 102    

22

140 2 100    

23

135 2 115     Endo Close*

24

255 3 125 275g   Transfusion; vault Pseudomonas infection

25

195 2 120    

26

160 3 100 255g   Vault infection

27

135 1 124    

* Endo Close (United States Surgical Corporation, division of Tyco Healthcare Group LP) utilised to obtain port site haemostasis.

References:

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  9. National Health and Medical Research Council (2003). When does quality assurance in health care require independent ethical review? (http://www.nhmrc.gov.au/issues/pdfcover/qualassu.htm).
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