Laparoscopic Surgery In Obese Patients Research Articles

The effect of inverse ratio ventilation on cardiopulmonary function in obese laparoscopic surgery patients: A systematic review and meta-analysis.

This study aimed to evaluate the effect of inverse ratio ventilation (IRV) strategy on cardiopulmonary function in obese patients under general anesthesia. Databases such as China National Knowledge Infrastructure (CNKI), Wangfang, WeiP, Web of Science, the Cochrane Library, and PubMed were systematically searched. All randomized controlled trials' literature on IRV during laparoscopic surgery in obese patients under general anesthesia was collected. After data were extracted and cross-checked, Rev Man 5.3 software was used for meta-analysis. Finally, five randomized controlled clinical trials (RCTs) were included in the meta-analysis, with a total of 312 patients. Compared with the conventional ventilation group, the inspiratory peak pressure was lower at pneumoperitoneum 30 min and pneumoperitoneum 60 min; the PaO2 and oxygenation index were higher at pneumoperitoneum 60 min, and mean airway pressure was higher at pneumoperitoneum 30 min and pneumoperitoneum 60 min; the dynamic lung compliance was superior at pneumoperitoneum 30 min and pneumoperitoneum 60 min. IRV applied to laparoscopic surgery in obese patients under general anesthesia not only reduces peak airway pressure and improves intraoperative oxygenation index and PaO2 but also enhances mean airway pressure and dynamic lung compliance, which has a specific lung protective effect. It can be used as an option for the mechanical ventilation model in obese patients in clinical practice.

Cysatracurium dosing in gynecological laparoscopic surgery in obese patients

Aim. Substantiation of cisatracurium dosing in routine gynaecological laparoscopic surgery in obese patients based on comparative development time and duration of the neuromuscular block.Materials and methods. The assay included 24 women with class II-III obesity and routine laparoscopic gynaecological surgery divided into two cohorts. In cohort 1, cisatracurium was dosed at 0.15 mg/kg ideal body weight estimated with the Lorentz formula. In cohort 2, cisatracurium dosing was 0.15 mg/kg real body weight.Results. Tracheal intubation and total operation doses of the relaxant were higher when rated for real body weight. Time between cysatracurium administration and maximal neuromuscular transmission inhibition was less in cohort 2, and recovery time of the first response to stimulation — in cohort 1. Neuromuscular block recovery time to 25% TOF count and the recovery index did not differ significantly between the cohorts.Conclusion. Cysatracurium dosage rated for ideal body weight resulted in a better controlled course of the neuromuscular block, whilst rating for real body weight resulted in a dose-dependent increase of the duration of action and total consumption rate of the relaxant.

Laparoscopy versus laparotomy for surgical treatment of obese women with endometrial cancer: A cost-benefit comparative analysis.

The aim of the present study was to demonstrate the cost of obese patients affected by endometrial cancer undergoing open surgery compared with minimally invasive surgery. In the retrospective cohort study (Canadian Task Force classification II-2), the economic expenditure in pre-operative, intra-operative and post-operative phases of the selected patients was evaluated. Costs were analyzed for all blood tests, instrumental examinations, consultations, operating materials, drugs, gynecological examinations, hospital stay, intensive care hospitalization and management of operative complications. The average length of stay was longer for patients who underwent laparotomy, with an almost double median hospitalization cost in the open abdominal group compared with the laparoscopic group (€4,805.37 vs. €2,589.25; P<0.0001). Evaluation by another specialist (cardiologist, diabetologist, internist) was necessary in 30.9% of laparotomies vs. 10.4% of laparoscopies (P=0.003). A respiratory support was applied to 38 patients (28.8%), of whom 23 (41.8%) were in the open abdominal arm (P=0.011). Antibiotic and pain-relief therapies resulted in a significantly higher cost for the open abdominal than for the minimally-invasive approach (P=0.027). Considering all the pre-, intra- and post-operative course, the expenses for an obese patient operated by laparoscopy was €4,412.41 vs. €7,323.17 by open surgery, with an average saving of €2,911.03 in favor of minimally-invasive surgery. This study revealed that in obese patients with endometrial cancer, minimally invasive surgery is more advantageous both in terms of costs and post-operative complications. To conclude, laparoscopic surgery in obese patients allows an economic saving of ~60% less than open surgery.

Efficacy of deep neuromuscular blockade combined with low-pressure pneumoperitoneum for gynecological laparoscopic surgery in obese patients

Objective To evaluate the efficacy of deep neuromuscular blockade (NMB) combined with low-pressure pneumoperitoneum for gynecological laparoscopic surgery in the obese patients. Methods Sixty obese patients, aged 34-64 yr, with body mass index 28.7-32.0 kg/m2, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, scheduled for elective laparoscopic hysterectomy, were allocated into 2 groups (n=30 each) using a random number table method: deep NMB plus low-pressure pneumoperitoneum group (group A) and moderate NMB plus high-pressure pneumoperitoneum group (group B). Cis-atracurium sulfamate was intravenously infused to maintain NMB under monitoring in both group.Group A was to maintain train-of-four (TOF) count of 0, post-tetanic count of 1 or 2, and pneumoperitoneum pressure of 10 mmHg.Group B was to maintain TOF count of 1 or 2 and pneumoperitoneum pressure of 14 mmHg.Satisfaction with surgical field was evaluated.The recovery index and time for TOF ratio returning to 0.7 and 0.9 were recorded.Peak airway pressure was recorded at 5 min before pneumoperitoneum (T0), 5 min of pneumoperitoneum-supine position(T1), 5 min of pneumoperitoneum-surgical position (T2), and 5 min after deflation at the end of surgery (T3). The development of hypoxemia, shoulder pain, and abdominal pain was recorded within 48 h after surgery. Results There was no significant difference in the satisfaction with surgical field between the two groups (P>0.05). Compared with group B, the recovery index and time for TOF ratio returning to 0.7 and 0.9 were significantly prolonged, peak airway pressure was decreased at T1 and T2, and the incidence of postoperative shoulder pain and abdominal pain was decreased in group A (P<0.05). Conclusion Compared with moderate NMB combined with high-pressure pneumoperitoneum, deep NMB combined with low-pressure pneumoperitoneum can provide a satisfactory surgical field and reduce postoperative pain, however, it prolongs the recovery time of NMB for gynecological laparoscopic surgery in the obese patients. Key words: Neuromuscular blockade; Pneumoperitoneum, artificial; Obesity; Laparoscopy

Goal-directed use of balanced solutions for laparoscopic surgery in obese patients

Modern guidelines for infusion therapy in laparoscopic surgery of patients with obesity are ambiguous due to insufficient number of clinical researches. The aim of our work was to evaluate the effect of goal-directed infusion therapy with balanced solutions on hemodynamics, electrolyte balance, renal function and incidence of perioperative complications of laparoscopic surgery in obese patients. Materials and methods. The study included 54 obese patients (BMI >30 kg/m 2 ) who were performed laparoscopic surgery in case of the diaphragmatic hernia, colon tumors, postoperative ventral hernia and morbid obesity. In the group A (n = 26) goal-directed infusion therapy by balanced solutions Gelaspan and Sterofundin (B. Braun, Germany) was used. Impedance measuring technology using the monitor Utas 300 (Ukraine) was used to determine the target stroke volume (SV). In the group B (n = 28) infusion therapy was performed by unbalanced solutions (6 % HES and 0.9 % NaCl), focusing on fluid deficiency according to changes in blood pressure (BP), heart rate (HR), and diuresis. The incidence of hypotension and total volume of infusion therapy (TVIT) were evaluated intraoperatively, changes in BP and HR were compared. After surgery diuresis, blood Na + , K + , Cl – and creatinine concentrations, diuretic use frequency and incidence of cardiac, respiratory, hemorrhagic and infectious complications were controlled. Statistical analysis was performed using the Statistica for Windows software version 6.0. Results. The incidence of hypotension in the group B was almost 2 times more than in the group A (P 0.05). Intraoperative TVIT in the group B was 23 % higher due to crystalloid, and diuresis intensity was twice less than in the group A (P < 0.05). Concentrations of electrolytes and creatinine blood level did not change significantly in the study groups. After surgery in the group B 25 % of patients were prescribed diuretic and in the group A diuretic was not prescribed in any case (P < 0.05). In-hospital mortality in both groups was zero, no serious complications were observed. Conclusions. Goal-directed infusion therapy with balanced solutions in laparoscopic surgery in obese patients halved the incidence of intraoperative hemodynamic instability, reduces the volume loading of crystalloids by 23 % during surgery and provides adequate perioperative diuresis without additional stimulation.

Lung protective vs. standard ventilation during laparoscopic surgery in obese patients. preliminary results of a randomized, controlled trial

Two different papers published recently suggested the use of a comprehensive strategy providing low tidal volumes, peep and recruiting maneuvers in patients undergoing open abdominal surgery (1,2). It is unknown whether such ventilatory approach may be feasible in patients undergoing laparoscopy, as pneumoperitoneum and Trendelenburg position may alter lung volumes and chest-wall elastance.

Laparoscopic versus Open Obesity Surgery: A Meta-Analysis of Pulmonary Complications

The clinical effects of laparoscopy in the pulmonary function of obese patients have been poorly investigated in the past. A systematic review was undertaken, with the objective to identify published evidence on pulmonary complications in laparoscopic surgery in the obese. Outcome measures included pulmonary morbidity, pulmonary infection and mortality. The random effects model was used to calculate combined overall effect sizes of pooled data. Data are presented as the odds ratio (OR) with 95% confidence interval (CI). A total of 6 randomized and 14 observational studies were included, which reported data on 185,328 patients. Pulmonary complications occurred in 1.6% of laparoscopic and in 3.6% of open procedures (OR 0.45, 95% CI 0.34-0.60). Pneumonia was reported in 0.5% and in 1.1%, respectively (OR 0.45, 95% CI 0.40-0.51). Available evidence suggests lower pulmonary morbidity for laparoscopic surgery in obese patients; further quality studies are however necessary to consolidate these findings.

Consideration for safe and effective gynaecological laparoscopy in the obese patient

The number of obese and morbidly obese patients within the developed world is dramatically increasing within the last 20 years. Apart from demographical changes, obese patients are especially prone to have oestrogen-dependent morbidities and neoplasias, of which laparoscopic treatment should be the standard of care. The increasing number of patients with BMI >40 is concerning, making it necessary to summarise considerations for safe and effective Gynaecological Laparoscopic Surgery. The sequel to successful laparoscopic surgery in obese patients comprises an interdisciplinary appreciation of laparoscopy. Preoperatively, anaesthetics and medical review are suggested to optimise treatment of comorbidities (i.e. infections and blood sugar levels). Positioning of the patient should consider anti-slip options and pannus fixation to ease laparoscopic access and decrease pressure to the chest. There is no standard port placement in obese patients and landmarks have to be the bony structures of the pelvis and ribs. Retraction of the bowel is essential and mobilisation of the sigmoid with fan retractors or endoloops can accomplish adequate vision. 30° scopes can be considered for vision "around the obstacle". An experienced assistant with anticipation of surgical steps is favourable for successful surgery completion. Intra-operatively, good surgical techniques are essential. Vessel sealing systems reduce the need for instrument changes and may be helpful in following visualised tissue planes. A transvaginal vault closure may be advantageous compared to laparoscopic closure and Endostiches may be preferred to close the fascia of large trocar sites under vision.

Safety of Left Upper Quadrant Entry during Laparoscopic Surgery in Obese Patients with a History of Prior Abdominal Surgery

Safety of Left Upper Quadrant Entry during Laparoscopic Surgery in Obese Patients with a History of Prior Abdominal Surgery

Titration morphinique intraveineuse en salle de surveillance post-interventionnelle (SSPI) après chirurgie bariatrique sous cœlioscopie

ObjectiveThere is limited information available regarding intravenous (IV) morphine admistration in obese patients in PACU. The aim of this study was to compare two IV morphine titration (IMT) regimen in two surgical centers. Study designObservational study. PatientsLaparoscopic bariatric surgery in one private (Saint-Grégoire Clinic) and one public (University Hospital of Amiens) surgical center. MethodsA strict and common protocol of IMT was implemented if PACU of both centers according to the recommendations of the French Society of Anaesthesia and Intensive Care. When pain score increased to>30, IMT was titrated every 5min in 3mg increments until pain relief (VAS≤30mm). Pain level, dose of morphine (per total and ideal body weight), effectiveness, and side events were recorded. ResultsData were recorded for 159 adult patients (129 women). Mean age and BMI were 42±12 yrs and 43.8±6.9kg/m2. Ninety-eight patients were eligible for IMT regimen but only 76 patients received IV morphine (47.8 %). Mean dose was 7.3mg±3.5mg [1–19mg], (60.4μg/kg and 115.8μg/kg). IMT was less frequent, mean dose was greater (8.6±4.2 vs 6.2±2.9mg) and number of patients with pain relief was higher (73.7 vs 35.6 %) in the public hospital. No severe adverse events have been recorded and there was no difference in both centers regarding these events. ConclusionImplementation of a IMT regimen in PACU was not associated with effective pain relief after laparoscopic surgery in obese patients.

Single-Incision Laparoscopic Adnexectomy in an Obese Patient with Previous Laparotomies

No case of single-incision laparoscopic surgery in obese patients who had previously undergone multiple midline vertical laparotomies has been described in the literature to date. Hence we report the first case of single-port laparoscopic salpingo-oophorectomy in an obese patient who was affected by a left adnexal mass and who had previously undergone 3 midline vertical laparotomies. A postmenopausal 57-year-old woman with a body mass index of 31.2 kg/m(2) and a history of 3 midline vertical cesarean deliveries and a right salpingooophorectomy was diagnosed with a left adnexal mass and underwent a single-incision laparoscopic salpingo-oophorectomy. The patient was treated successfully. The operative blood loss was minimal. The postoperative hospital stay lasted 18 hours, and postoperative pain was short-lasting. No early or long-term postoperative complications were registered. On histopathologic examination, a diagnosis of ovarian serous cystadenoma was made. Even though this unique case is the first to be reported in the literature, its encouraging results suggest the use of this new surgical technique in similar clinical situations to verify whether the feasibility and safety reported in this article are confirmed.

Outcomes in Laparoscopic Colectomy for Colorectal Cancer in the Obese

Background: Although laparoscopic resection is widely accepted for the surgical treatment of colorectal cancer (CRC), the impact of obesity on the potential short-term benefits of laparoscopy seems unclear since oncological outcomes must be preserved. Objectives: This review aimed to examine the published data supporting laparoscopic surgery in obese patients with localized CRC. Methods: We reviewed the relevant literature (PUBMED, EMBASE and the Cochrane databases) from 2005 to 2013 for obese patients with CRC who underwent laparoscopic surgery. Results: A total of 18 studies were included. Conversion to open surgery was higher in the obese population, without affecting oncologic long-term outcome. The harvested lymph nodes, specimen length, or resection margins were not affected by obesity. One study reported no differences in disease-free (p=0.6) and overall survival (p=0.5) between obese and non-obese patients. The anastomotic leak was similar in both groups; only one study reported a higher incidence of anastomotic leak in obese patients, but only in the mid to lower rectum. No studies reported any statistically significant differences between obese and nonobese patients in terms of mortality and time to resumption of intestinal function or oral intake. The incidence of wound infection had variable results among the studies. Conclusion: Laparoscopic surgery for localized CRC can be safe in obese patients, including preservation of oncological outcome.

Robotic Surgery in the Obese Gynecologic Patient

Despite robust interest in minimally invasive surgery for obese gynecologic patients, widespread use by gynecologic surgeons has been hindered by the technical difficulty of completing these procedures. The use of robotic assistance to overcome these challenges continues to increase. This study discusses the problem of obesity in the United States, provides basic definitions and calculations related to the disease, reviews some of the literature supporting laparoscopic surgery in obese patients, explores the emergence of robotics in this patient population, and offers "surgical pearls" to aid in the successful completion of minimally invasive robotic gynecologic procedures in heavier patients.

Technique of open laparoscopy for supramesocolic surgery in obese patients

Incidence of obesity and related diseases are increasing in the world. Visceral surgeons are more often confronted with laparoscopic surgery in obese patients. Besides validated surgery procedures, such as cholecystectomy and gastroesophageal reflux surgery, bariatric procedures are increasingly performed. In obese patients, the thickness of adipose panicle makes open laparoscopy hazardous. In our department, we use systematically a technique of open laparoscopy in obese patients for supramesocolic surgery, which is safe, reproducible, and permits good closure of the abdominal wall. The surgical technique consists of opening the abdominal wall through the rectus abdominis. Helped by specific retractors called Descottes (Medtronic Laboratory), both fascias are charged by sutures separately. Incision in the fascias is made safely by pooling on sutures. Introduction of port-site is made under view control. At the end of laparoscopy, closure of both fascias is easily done. We present a technique of open laparoscopy in obese patients, systematically used, for supramesocolic surgery. This technique is safe, reproducible, and permits an efficient closure of the abdominal wall.

Re-expansion Pulmonary Edema after Laparoscopic Bariatric Surgery: A case report

Laparoscopic procedures are accompanied by an increased intra-abdominal pressure and diaphragmatic elevation, which may interfere with adequate ventilation in obese patients. Re-expansion of a collapsed lung could be followed by pulmonary edema. Here, we describe a case of re-expansion pulmonary edema after laparoscopic bariatric surgery. A 23-year-old-female with morbid obesity received general anesthesia for laparoscopic adjustable gastric banding surgery. Unintentional one lung ventilation occurred for a short period during the operation and was promptly corrected. At the end of the operation, as spontaneous respiration recovered, profuse pinkish frothy sputum emerged from the endotracheal tube. Diffuse patchy increased opacity on the left lung field was observed by chest X-ray. With aspiration of bronchial secretion and oxygen supplementation, the patient was recovered uneventfully. We presume that inadequate lung expansion during pneumoperitoneum and unintentional right endobronchial intubation caused atelectasis of the left lung, and induced re-expansion pulmonary edema at the end of the operation. This case emphasizes the importance of constant vigilance with respect to endotracheal tube position and ventilation during laparoscopic surgery in obese patients.

Obesity: physiologic changes and challenges during laparoscopy

The purpose of this report was to describe the evidence for the benefits of laparoscopic surgery in obese patients, to review the physiologic abnormalities that are associated with obesity, and to explore surgical techniques that will enable surgeons to perform laparoscopy successfully in obese patients. This article is a review of the available literature on obesity, the physiologic changes that occur in obese patients, and the impact of these changes on laparoscopy outcomes. Obesity is associated with sudden death and a wide range of morbid conditions such as hypertension, atherosclerosis, angina, chronic obstructive disease, and diabetes mellitus. Recent studies have demonstrated that obese patients who undergo laparoscopy have shorter hospital stays, less postoperative pain, and fewer wound infections when compared with obese patients who undergo laparotomy. Laparoscopy patients also have fewer postoperative ileus and fevers. With thorough preparation and careful preoperative evaluation, laparoscopy can be performed safely and is the preferred surgical method in obese patients.

A simple laparoscopic method to provide access to the gastroesophageal junction in obese patients.

By now, the feasibility of laparoscopic surgery in obese patients is well established; a conversion rate of 1.4-4.3% has been reported [1, 2]. The main reason for conversion in these cases is the difficulty encountered in exposing the gastroesophageal junction due to a huge fatty liver that covers the entire upper abdomen ("the invisible stomach" [1]). We report here a simple method that allows easy access to the upper stomach in such cases. This technique involves the exposure of the gastroesophageal junction using a laparoscopic suprahepatic route.