1. Laparoscopic Colon Surgery in Obese Patients
2011 MISS Meeting, Salt Lake City
Laparoscopic Colon Surgery in Obese Patients
Richard L. Whelan, MD
St. Luke’s Roosevelt Hospital
Columbia University
New York, N.Y.

2. Disclosures Olympus Corporation Applied Medical Gore Corporation
Atrium Corporation
Ethicon Endosurgery

3. In the Beginning …
During the first decade of laparoscopic colorectal resection, high BMI was an exclusion criteria
It was thought not possible or advisable to use MIS methods in obese patients
As experience was gained surgeons began doing higher BMI patients and it became clear that is was feasible in many patients

4. Potential Benefit of MIS Methods is Greater in Obese Population
Incision required for open surgery is usually very long
Full pubis to xyphoid incision is often needed
Wound associated morbidity is high
Increased pain med requirement
Atelectasis & pulmonary complications
Poor ambulation, > LOS
Wound infection / seroma
Dehiscence is a real concern
Hernia formation

5. Realistic Expectations
Extra ports may be needed
Extraction incision will be longer
Greater chance that hand-assisted method may be used (Whelan practice)
Case will take more time
Case likely to be difficult
Conversion rate will be notably higher
Morbidity in this group likely to be higher

6. Potential Problems in Obese Population
Anesthesia respiratory concerns relating to pneumo & positioning
Positioning before & during the case
Establishing pneumo & 1st port placement
Port arrangement and position
Central abdominal & pelvic exposure
Reach
Devascularization
Anastomosis

7. Anesthesia & General Concerns
Need 2 large bore IV lines at a minimum
Arterial line advised
CO2 pneumoperitoneum issues:
Respiratory concerns (poor toleration of pneumo)
Hypercarbia
The need for high inspiratory pressures
Trendelenberg position
Impact on renal function (oliguria)
Potential hemodynamic impact (pt must be kept euvolemic)

8. Strategies for Pneumo-related Respiratory Problems
Use of lower insufflation pressures (10-12mmHg)
Pneumo “breaks”
5-10 minutes long
Allows CO2 to be blown off
Come out of Trendelenberg and work in different area (leave pelvis & work on flexure instead)

9. Other General Concerns
Anti-DVT prophylaxis a must
Heparin
Venodynes
Adjust antibiotic dose for patients weight
Redosing of antibiotics on schedule is critical
Use high FIO2 throughout the case and in PACU is strongly advised

10. Anchoring of Patient to Table
Chest taping (at manubrium)
Giant bean bag or gel pad
Stirrups
May not be safe
If used, must be fully secured to table
Spit straight leg table preferable
Far safer (must still secure legs)
Legs lay flat
Tucking of arms at sides can be a challenge:
Add another draw sheet to each side (1/2 body tuck)
This gives more length to tuck / secure each arm

11. Equipment and Instruments
Extra long equipment should be available:
Laparoscopes
Ports
Graspers
Suction devices
Tissue cutting devices can be a problem
OR staff must be informed that patient is obese so that preparations can be made
Obesity table (split leg if possible)
Extra long equipment gathered
Hand port in room

12. Establishing Pneumoperitoneum & Placement of 1st Port
Cutdown method very difficult due to abdominal wall girth
Veress needle method preferred
Must avoid old incisions
Periumbilical location in virgin abdomen VS
LUQ
Often unclear when in peritoneal cavity
Standard ports may be too short
First port placement can be frightening
If cutdown needed, do it in upper abdomen
Final option, start with placement hand port

13. Laparoscopic Port Placement & Choice of Laparoscope
Minimize (or avoid) use of 10 and 12 mm ports
Fascial closure can be a challenge
Hernia formation is a concern (rarely seen with 5 mm ports)
Use 5 mm laparoscope
Look & avoid epigastric vessels when placing lateral ports
Should have extra long ports in room

14. Port Placement Pattern: Umbilical Position in the Obese
Midway between xyphoid & pubis in most low & normal BMI patients
Notably lower than the midpoint in obese patients
Cannot place ports based on umbilical position
Determine mid-point between xyphoid & pubis and work from there

15. Shift Port Placement Pattern Toward Most Critical Quadrant
Abdominal surface area & girth in the morbidly obese can be very large
A “central” port pattern placed around mid-point of abdomen often not ideal due to reach issues
Shifting entire pattern north or south is helpful
Caudad for sigmoid, LAR, and APR
Cephalad for Right, transverse, descending colectomy

16. Port Placement Scheme for Sigmoid or Anterior Resection

17. Obese or Lengthy Body Habitus: Transverse Colectomy5 12 12 5

18. May Need Additional 5 mm Ports
For flexure takedown
For retraction of the small bowel
For the laparoscope, on occasion
Threshold for placement of extra 5 mm ports should be low
Flexure takedown from a mile away is difficult and potentially dangerous
Trauma associated with added 5 mm port is small

19. Exposure in Central Abdomen
Harder to retract the small bowel
Omentum can be > 1 inch thick & difficult to reflect over stomach
Working in mid abdomen is very difficult
Altering patient’s position to shift viscera is useful
Head up or down, airplaning of table
Must work with anesthesia
Helps but often doesn’t solve the problem

20. Lateral to Medial Mobilization Methods May Be Only Option
Medial to lateral methods for Right, transverse, and proximal left colectomy are very difficult
Risk of small bowel injury from tissue cutting devices higher if small bowel is close by
The intact right and descending colon keep the small bowel in central abdomen
By lifting the colon & retracting medially as the lateral attachments are cut, the small bowel is kept out of the operative field

21. Ileocolic, Middle Colic, Left Colic, and IMA Division
More difficult in obese patients due to difficulty retracting the small bowel
Vessels often divided later in case than usual
Options if having problems:
Patient positioning
Place extra port(s)
Use hand-assisted method
As last resort, can divide vessels extracorporeally

22. Retraction of Uterus to Abdominal Wall

23. Anastomosis
May be difficult to get mobilized & devascularized colon to reach skin level
Need only to place anvil for sigmoid/LAR
For Right, transverse, and descending colectomy:
extracorporeal anastomosis may require longer incision
Alternative is intracorporeal anastomosis
Carefully choose extraction incision site

24. Extraction Incision for Extracorporeal Anastomosis
What limits reach of the mobilized colon is the mesentery
Must place incision directly above the critical mesenteric vessel
Wound protector (or specimen bag) a must
Make incision large enough to safely remove the specimen & bowel ends
Must accept need for larger incision

25. Right Hemicolectomy, Standard Incision Extracorporeal Anastomosis
Extraction incision

26. Right Hemi Port Placement Extracorporeal Anastomosis

27. Obesity Skin incision Fascial incision Peritoneal incision

28. What About Using Hand-Assisted Method?
When extraction incision likely to be 8 cm or >
Very obese patients
Bulky pathology (cancer or phlegmon)
Saves time*
Final incision between 8-11 cm
Allows manual palpation & retraction
Can use lap pad in abdomen
Can overcome many obesity-related problems
* Marcello et al. Dis Colon Rectum 2008 Jun;51(6):

29. Case volume x 2 years, 498 elective cases 87 % were MIS resections
Use of Straight Laparoscopic & Hand/Hybrid Methods at New York Presbyterian Hospital, Columbia Campus
Case volume x 2 years, 498 elective cases
87 % were MIS resections
71% laparoscopic assisted
29% hand-assisted / hybrid
13 % were open cases
MIS methods are preferred, “default” method

30. Relationship Between Rate of Utilization of Hand-Laparoscopic Methods & BMI
BMI Category % of Cases Done with Hand*+
< %
> %
> %
* Greater than 90 percent of hand cases were sigmoid or LAR resections
+ Length of say similar in hand and laparoscopic-assisted cases

31. Columbia Presbyterian Conversion* Rates As Per Method & BMI
BMI Laparoscopic Hand/Hybrid
< % (4.9cm) % (10.2cm)
% (7.0cm) % (10.6cm)
% (8.5cm) % (10.4cm)
% (11.5cm) % (11.4cm)
* Strict incision length criteria was used to define conversion (lap= >7 cm, hand= >12 cm)

32. Minimally Invasive Strategies
Laparoscopic-assisted
Full Open Incision
Hand-assisted / Hybrid
Laparoscopic-assisted
Hand-assisted / Hybrid
Full Open Incision

33. Conversion to Hand-Assisted
Sigmoid Resection

34. Planned Hand-assisted
Sigmoid/LAR

35. Case Presentation: Op Date2/14/11
38 year old man
Large bulky right colon cancer, invading lateral abdominal wall
350 lbs, 6’0”
Pannus 4 ½” thick in upper abdomen
Completed case with hand-assisted approach
Incision extended to permit anastomosis
Final incision length 12 cm

36. Right Colectomy Hand Port Placement: What I Did

37. Right Hemi Hand Port Placement: Should Of Done

38. Summary MIS resections can be done in obese patients
Challenging cases but patient benefits are great
Prepare for obese cases
OR staff
Table
Extra-long equipment
Patient (expectations)
Anesthesiologist
Anchor patient carefully to table

39. Summary Adjust port placement arrangement toward target quadrant
Long graspers and suction device
Add 5 mm ports if needed
Lateral to medial mobilization
Alter patient’s position (carefully)
Careful use of tissue division devices in central abdomen
Place extraction incision over critical mesenteric vessel

40. Summary Utilize hand-assisted methods when needed
From the start in pts with bulky path or BMI > 40
As conversion strategy
Place hand port at anticipated site of extraction
Convert to fully open method if needed
Allow for more time for these cases

47. Retraction of the Giant Uterus
#2 nylon suture on straightened retention needle passed through lower abdominal wall
Once inside, needle passed through uterus near round ligament
Passed back outside
Tied over small gauze
Identical suture on opposite side

48. Other Methods of Uterine & Vaginal Retraction
Uterine manipulator
Retractor placed transvaginally into cervix
Fixed in position either with cervical balloon or a clamp
Downard traction on external end of device retracts the uterus upwards
Vaginal identification & retraction
Can use EEA sizers OR clean proctoscope

49. Obese Pelvis Long instruments Expert 1st assistant
Well anchored patient, Trendelenberg
Identify key landmarks
Ureters
Bladder and G/U structures in male
Anterior reflection in woman
Ureteral stents good idea for some patients

50. Hand-Assisted Methods: Faster Than Straight Laparoscopic*
Multi-center randomized trial
Hand-assist vs straight lap method
Left segmental and subtotal colectomy
95 patients total
For Left colectomy: 33 minute time savings
For subtotal colectomy: 57 min. savings
Incision length: Hand 8.2 cm vs Lap 6.1 cm
No difference in LOS, morbidity
* Marcello et al. Dis Colon Rectum 2008 Jun;51(6):

51. Specimen Extraction
Despite completion of intracorporeal operation laparoscopically may still need big incision:
Bulky specimen
Obese patient

52. Different segmental Colectomy (R,L,sigmoid, etc)
Must really tackle the hand issue
Give CPMC MIS and hand data
Hand port location for sigmoid, LAR
Hand port location for R and proximal L colectomy
Logic of hand port use in super obese
Use of hand port allows greater % of MIS cases

53. Hand-assisted Laparoscopic Methods
When ?
Obese
Bulky pathology (large cancer, phlegmon)
Where extraction incision likely > 8cm
Why ?
Because final incision likely to be large anyway
Operation is shorter*
Allows use of one hand intracorporeally
* Marcello et al. Dis Colon Rectum 2008 Jun;51(6):

54. New York Presbyterian Series: Other Data
> 90 percent of hand cases were sigmoid/LAR resections
Length of say statistically similar in hand and laparoscopic-assisted cases