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Case report

Extreme obesity and total laparoscopic hysterectomy – case report

Milan Dokić1,2, Dragiša Šljivančanin1,2, Sandra Babić1, Branislav Milošević1,2

ABSTRACT

Introduction: Previously, the laparoscopic approach was not considered for obese people, because of the increased risk of operative and postoperative complications. In recent years, however, the approach has changed in favor of minimally invasive procedures that avoid laparotomy, which, in obese people, is the most common cause of complications, in the form of slower and aggravated wound healing, bleeding, and infections at the laparotomy site. In emergency situations, extreme obesity accompanied by multiple comorbidities still remains a real challenge for endoscopic surgery, the surgeon and the entire surgical and anesthesiology team.

Case report: We present a case of a 61-year-old, extremely obese patient, who was admitted to hospital as an emergency case, due to prolonged vaginal bleeding and anemia. After preoperative preparation, the patient underwent surgery – laparoscopic total hysterectomy with bilateral salpingo-oophorectomy.

Conclusion: Obesity is a major problem in modern society. In addition to directly affecting health, excessive body weight in a patient makes it very difficult to perform surgical procedures. The thickness of the abdominal wall and accompanying health problems are a contraindication for laparoscopic operations. In such cases, performing surgery, especially laparoscopic procedures, requires a trained team of professionals and appropriate equipment. Laparoscopic surgery is more and more present, even in the most difficult cases. In presenting this case, we aimed to demonstrate that it is possible to successfully perform total laparoscopic hysterectomy in extremely obese patients with associated health problems, even in emergency situations.


INTRODUCTION

Obesity is a serious health problem of modern society. Obese women are at higher risk of developing certain gynecological diseases including endometrial hyperplasia and endometrial carcinoma [1]. In addition, excessive body weight makes it difficult to perform surgical procedures in such patients and represents an immediate source of increased risk of complications during surgery and later, during postoperative recovery [2]. Normal body mass index (BMI) values range from 25 - 29.9 kg/m2 . A BMI over 30 kg/m2 is an indication of excess body weight. Obesity is a chronic disease, which is also strongly associated with an increase in mortality and morbidity, including diabetes mellitus, hypertension, cardiovascular disease, disability, stroke, and other chronic diseases [3]. All these conditions, especially insulin dependent diabetes mellitus (IDDM), are also associated with a higher risk of intraoperative and postoperative complications [4],[5].

Until recently, the laparoscopic approach was considered only for slender people, precisely because of the increased safety risk [6]. In recent years, however, the approach has changed in favor of minimally invasive procedures that avoid laparotomy, which, in obese people, is the most common cause of complications, in the form of slower and aggravated wound healing, bleeding, and infections at the laparotomy site [7].

Nevertheless, extreme obesity accompanied by multiple comorbidities remains a real challenge for endoscopic surgery, the endoscopic surgeon and the entire surgical and anesthesiology team, especially in emergency situations.

CASE REPORT

A 61-year-old patient was admitted to hospital, as an emergency case, due to prolonged vaginal bleeding and severe anemia. Endometrial polypectomy and fractional curettage procedures had successfully been performed two months previously. The histopathological finding indicated endometrial hyperplasia with atypia.   This was a cardiovascular patient with insulin-dependent diabetes mellitus and hypothyroidism.

On admission, the patient’s body weight was 132 kg, while her height was 172 cm (BMI = 44.62 kg/m2); her blood pressure was 170/90 mmHg; her glycemia was 4.2 mmol/l. Laboratory blood test results confirmed severe anemia: red blood cell count = 2.4 x 106; hemoglobin = 61.0 g/l; HCT =18.7.

The patient’s anemia was corrected with blood transfusions (3 doses). Preparations were made for surgical treatment. Before the operation, after spending three days in our hospital, the patient’s overall status was improved – her blood pressure was 140/80 mmHg, while the blood test results were significantly better: red blood cell count = 4.06 x 106; HCT = 32.5; hemoglobin = 104.0 g/l. However, the vaginal bleeding remained constant, with varying intensity.

The patient underwent emergency surgery – laparoscopic total hysterectomy with bilateral salpingo-oophorectomy. The procedure was without complications, lasting 110 minutes, with a blood loss of 152.7 ml.

Postoperatively, the patient continued to receive the necessary therapy, including antibiotics. The final histopathological finding was – atypical endometrial hyperplasia. The patient recovered without experiencing any complications and was dismissed on the third postoperative day.

DISCUSSION

Obesity is a major and increasing problem that affects people’s health worldwide. The number of women with a BMI over 40 has increased to nearly 7.5% in the United States [8]. In addition to directly affecting health, excessive body weight in the patient makes it very difficult to perform surgical procedures. The thickness of the abdominal wall and accompanying health problems are a contraindication for laparoscopic operations [6]. Also, morbid obesity is a significant challenge with respect to ventilation, as it decreases respiratory compliance, increases airway pressure, and impairs cardiac function [9].

At present, surgeons are still unfamiliar with laparoscopic operations on patients with a BMI > 40, possibly due to initial trocar entry, port placement, management of hypercarbia or a higher rate of laparotomy conversions. Nevertheless, laparoscopic surgery is more and more present even in the most severe cases [10]. It goes without saying that surgery, especially laparoscopic procedures, requires a trained team of professionals and appropriate equipment. Our operation time and blood loss were comparable with literature data for obese as well as for normal weight patients [10]. The patient was discharged on the third postoperative day, which is a day or two longer than the standard protocol for normal weight patients undergoing total laparoscopic hysterectomy. However, the patient’s numerous comorbidities and significant anemia before the operation also need to be taken into consideration. Ultimately, the discharge was four days earlier than it would have been if open surgery had been performed, and the procedure was performed without any postoperative complications.

In presenting this case, we aimed to demonstrate that it is possible to successfully perform laparoscopic procedures in extremely obese patients with multiple comorbidities, even in emergency situations.

  • Conflict of interest:
    None declared.

Informations

Volume 3 No 2

June 2022

Pages 224-227
  • Keywords:
    extreme obesity, hysterectomy, endoscopic surgery
  • Received:
    10 May 2022
  • Revised:
    17 May 2022
  • Accepted:
    19 May 2022
  • Online first:
    25 June 2022
  • DOI:
Corresponding author

Branislav Milošević
Clinic for Gynecology and Obstetrics, Clinical Center of Serbia
26 Koste Todorovića Street, 11000 Belgrade, Serbia
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.


  • 1. Dottino JA, Zhang Q, Loose DS, Fellman B, Melendez BD, Borthwick MS, et al. Endometrial biomarkers in premenopausal women with obesity: an at-risk cohort. Am J Obstet Gynecol. 2021 Mar;224(3):278.e1-278.e14. doi: 10.1016/j.ajog.2020.08.053.[CROSSREF]

    2. Çinar M, Tokmak A, Güzel AI, Aksoy RT, Özer İ, Yilmaz N, et al. Association of clinical outcomes and complications with obesity in patients who have undergone abdominal myomectomy. J Chin Med Assoc. 2016 Aug;79(8):435-9. doi: 10.1016/j.jcma.2016.02.008.[CROSSREF]

    3. Smith KB, Smith MS. Obesity Statistics. Prim Care. 2016 Mar;43(1):121-35, ix. doi: 10.1016/j.pop.2015.10.001.[CROSSREF]

    4. Tan DJH, Yaow CYL, Mok HT, Ng CH, Tai CH, Tham HY, et al. The influence of diabetes on postoperative complications following colorectal surgery. Tech Coloproctol. 2021 Mar;25(3):267-78. doi: 10.1007/s10151-020-02373-9.[CROSSREF]

    5. Atalay F, Uygur F, Cömert M, Özkoçak I. Postoperative complications after abdominal surgery in patients with chronic obstructive pulmonary disease. Turk J Gastroenterol. 2011 Oct;22(5):523-8. doi: 10.4318/tjg.2011.0389.[CROSSREF]

    6. Thomas D, Ikeda M, Deepika K, Medina C, Takacs P. Laparoscopic management of benign adnexal mass in obese women. J Minim Invasive Gynecol. 2006 Jul-Aug;13(4):311-4. doi: 10.1016/j.jmig.2006.03.017.[CROSSREF]

    7. Siedhoff MT, Carey ET, Findley AD, Riggins LE, Garrett JM, Steege JF. Effect of extreme obesity on outcomes in laparoscopic hysterectomy. J Minim Invasive Gynecol. 2012 Nov-Dec;19(6):701-7. doi: 10.1016/j.jmig.2012.07.005.[CROSSREF]

    8. Sturm R, Hattori A. Morbid obesity rates continue to rise rapidly in the United States. Int J Obes (Lond). 2013 Jun;37(6):889-91. doi: 10.1038/ijo.2012.159.[CROSSREF]

    9. Nguyen NT, Wolfe BM. The physiologic effects of pneumoperitoneum in the morbidly obese. Ann Surg. 2005 Feb;241(2):219-26. doi: 10.1097/01.sla.0000151791.93571.70.[CROSSREF]

    10. O’Hanlan KA, Emeney PL, Frank MI, Milanfar LC, Sten MS, Uthman KF. Total Laparoscopic Hysterectomy: Making It Safe and Successful for Obese Patients. JSLS. 2021 Apr-Jun;25(2):e2020.00087. doi: 10.4293/JSLS.2020.00087[CROSSREF]


REFERENCES

1. Dottino JA, Zhang Q, Loose DS, Fellman B, Melendez BD, Borthwick MS, et al. Endometrial biomarkers in premenopausal women with obesity: an at-risk cohort. Am J Obstet Gynecol. 2021 Mar;224(3):278.e1-278.e14. doi: 10.1016/j.ajog.2020.08.053.[CROSSREF]

2. Çinar M, Tokmak A, Güzel AI, Aksoy RT, Özer İ, Yilmaz N, et al. Association of clinical outcomes and complications with obesity in patients who have undergone abdominal myomectomy. J Chin Med Assoc. 2016 Aug;79(8):435-9. doi: 10.1016/j.jcma.2016.02.008.[CROSSREF]

3. Smith KB, Smith MS. Obesity Statistics. Prim Care. 2016 Mar;43(1):121-35, ix. doi: 10.1016/j.pop.2015.10.001.[CROSSREF]

4. Tan DJH, Yaow CYL, Mok HT, Ng CH, Tai CH, Tham HY, et al. The influence of diabetes on postoperative complications following colorectal surgery. Tech Coloproctol. 2021 Mar;25(3):267-78. doi: 10.1007/s10151-020-02373-9.[CROSSREF]

5. Atalay F, Uygur F, Cömert M, Özkoçak I. Postoperative complications after abdominal surgery in patients with chronic obstructive pulmonary disease. Turk J Gastroenterol. 2011 Oct;22(5):523-8. doi: 10.4318/tjg.2011.0389.[CROSSREF]

6. Thomas D, Ikeda M, Deepika K, Medina C, Takacs P. Laparoscopic management of benign adnexal mass in obese women. J Minim Invasive Gynecol. 2006 Jul-Aug;13(4):311-4. doi: 10.1016/j.jmig.2006.03.017.[CROSSREF]

7. Siedhoff MT, Carey ET, Findley AD, Riggins LE, Garrett JM, Steege JF. Effect of extreme obesity on outcomes in laparoscopic hysterectomy. J Minim Invasive Gynecol. 2012 Nov-Dec;19(6):701-7. doi: 10.1016/j.jmig.2012.07.005.[CROSSREF]

8. Sturm R, Hattori A. Morbid obesity rates continue to rise rapidly in the United States. Int J Obes (Lond). 2013 Jun;37(6):889-91. doi: 10.1038/ijo.2012.159.[CROSSREF]

9. Nguyen NT, Wolfe BM. The physiologic effects of pneumoperitoneum in the morbidly obese. Ann Surg. 2005 Feb;241(2):219-26. doi: 10.1097/01.sla.0000151791.93571.70.[CROSSREF]

10. O’Hanlan KA, Emeney PL, Frank MI, Milanfar LC, Sten MS, Uthman KF. Total Laparoscopic Hysterectomy: Making It Safe and Successful for Obese Patients. JSLS. 2021 Apr-Jun;25(2):e2020.00087. doi: 10.4293/JSLS.2020.00087[CROSSREF]

1. Dottino JA, Zhang Q, Loose DS, Fellman B, Melendez BD, Borthwick MS, et al. Endometrial biomarkers in premenopausal women with obesity: an at-risk cohort. Am J Obstet Gynecol. 2021 Mar;224(3):278.e1-278.e14. doi: 10.1016/j.ajog.2020.08.053.[CROSSREF]

2. Çinar M, Tokmak A, Güzel AI, Aksoy RT, Özer İ, Yilmaz N, et al. Association of clinical outcomes and complications with obesity in patients who have undergone abdominal myomectomy. J Chin Med Assoc. 2016 Aug;79(8):435-9. doi: 10.1016/j.jcma.2016.02.008.[CROSSREF]

3. Smith KB, Smith MS. Obesity Statistics. Prim Care. 2016 Mar;43(1):121-35, ix. doi: 10.1016/j.pop.2015.10.001.[CROSSREF]

4. Tan DJH, Yaow CYL, Mok HT, Ng CH, Tai CH, Tham HY, et al. The influence of diabetes on postoperative complications following colorectal surgery. Tech Coloproctol. 2021 Mar;25(3):267-78. doi: 10.1007/s10151-020-02373-9.[CROSSREF]

5. Atalay F, Uygur F, Cömert M, Özkoçak I. Postoperative complications after abdominal surgery in patients with chronic obstructive pulmonary disease. Turk J Gastroenterol. 2011 Oct;22(5):523-8. doi: 10.4318/tjg.2011.0389.[CROSSREF]

6. Thomas D, Ikeda M, Deepika K, Medina C, Takacs P. Laparoscopic management of benign adnexal mass in obese women. J Minim Invasive Gynecol. 2006 Jul-Aug;13(4):311-4. doi: 10.1016/j.jmig.2006.03.017.[CROSSREF]

7. Siedhoff MT, Carey ET, Findley AD, Riggins LE, Garrett JM, Steege JF. Effect of extreme obesity on outcomes in laparoscopic hysterectomy. J Minim Invasive Gynecol. 2012 Nov-Dec;19(6):701-7. doi: 10.1016/j.jmig.2012.07.005.[CROSSREF]

8. Sturm R, Hattori A. Morbid obesity rates continue to rise rapidly in the United States. Int J Obes (Lond). 2013 Jun;37(6):889-91. doi: 10.1038/ijo.2012.159.[CROSSREF]

9. Nguyen NT, Wolfe BM. The physiologic effects of pneumoperitoneum in the morbidly obese. Ann Surg. 2005 Feb;241(2):219-26. doi: 10.1097/01.sla.0000151791.93571.70.[CROSSREF]

10. O’Hanlan KA, Emeney PL, Frank MI, Milanfar LC, Sten MS, Uthman KF. Total Laparoscopic Hysterectomy: Making It Safe and Successful for Obese Patients. JSLS. 2021 Apr-Jun;25(2):e2020.00087. doi: 10.4293/JSLS.2020.00087[CROSSREF]


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