{"paper_id":"3d266892-8744-4c7d-abf2-f75cfa67ecb8","body_text":"Submit Manuscript | http://medcraveonline.com\nBackground\nThe benefits of minimally invasive techniques in gynecologic \nsurgery are well-known and include faster recovery times, decreased \npostoperative pain, and faster return of bowel function. 1 Barring \ncontraindications, most physicians and patients elect to perform and \nundergo, minimally invasive surgery if available. \nObesity is one factor that complicates the decision to proceed \nwith laparoscopic or robotic surgery. A minimally invasive procedure \nbecomes more technically challenging for the surgeon in an obese \npatient.1 Concerns about patient positioning and optimal visualization \nduring surgery lead to laparotomy in many obese patients.2 However, \ndespite the adverse associated effects of obesity on the cardiovascular \nand respiratory systems, minimally invasive techniques may still be \npreferable over laparotomy to minimize postoperative complications \nin patients with compromised health status.\nWe discuss a case report and review the current literature comparing \npostoperative complications in minimally invasive gynecologic \nsurgery versus laparotomy to advocate for the use of laparoscopic \nand robotic techniques in gynecologic surgery. We aim to highlight \nthe important benefits of laparoscopic surgical techniques in patients \nregardless of Body Mass Index (BMI).\nPresentation of the case\nAt the time of her surgery, the patient was a 37-year-old G1P1 \nwoman with a BMI of 80.72kg/m2 and a past medical history significant \nfor menorrhagia, bilateral adnexal masses, hypertriglyceridemia, and \nlymphedema in the legs bilaterally. \nShe originally presented to the emergency room, complaining of \nmenorrhagia for a few weeks and was given a norethindrone-ethinyl \nestradiol taper. She followed up with her PCP and reported the OCP \ntaper slowed her bleeding somewhat. She was however referred to \nOBGYN at La Nueva Casa Clinic and was seen there on 6/12/14 \ncomplaining of continued heavy periods. She reported passing golf \nball-sized clots and changing feminine hygiene products every two \nhours. Since menarche at the age of 10, her periods had been 3-7 days \nwith regular flow except for one episode of heavy bleeding years prior \nwhich was treated with OCP taper. She reported missed periods in Feb-\nApril of the year of her presentation. The patient had associated hot \nflashes and constipation. She reported no vaginal discharge, itching, \nObstet Gynecol Int J. 2019;10(2):164‒167. 164\n©2019 Rezai et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which \npermits unrestricted use, distribution, and build upon your work non-commercially.\nObesity and gynecologic surgery via minimally \ninvasive surgery with comparison to open \nlaparotomy; a case report and review of the \nliterature \nVolume 10 Issue 2 - 2019\nShadi Rezai,1 Richard Giovane,2 Allison J \nLazenby,3 Celestine S T ung,5 Cassandra E \nHenderson,4 Xiaoming Guan1\n1Division of Minimally Invasive Gynecologic Surgery, \nDepartment of Obstetrics and Gynecology, Baylor College of \nMedicine, USA\n2Department of Family Medicine, University of Alabama, USA\n3The University of Alabama (UAB) School of Medicine, 1670 \nUniversity Boulevard, USA\n4Maternal and Fetal Medicine, Department of Obstetrics and \nGynecology, Lincoln Medical and Mental Health Center, USA\n5Division of Gynecologic Oncology, Department of Obstetrics \nand Gynecology, Baylor College of Medicine, USA\nCorrespondence: Xiaoming Guan MD PhD, Section Chief and \nFellowship Director, Division of Minimally Invasive Gynecologic \nSurgery, Department of Obstetrics and Gynecology, Baylor \nCollege of Medicine, 6651 Main Street, 10th Floor, Houston, \nT exas, 77030, USA, T el (832) 826-7464, Fax (832) 825-9349, \nEmail \nReceived: March 03, 2019 | Published: April 25, 2019\nAbstract\nBackground:  Minimally invasive gynecological surgery (MIGS), has many benefits \nfor patients, such as shorter recovery times and a decrease in postoperative pain. \nMIGS can prove challenging in obese patients as well. Obesity complicates MIGS due \nto the technical challenge for the surgeon as well as patient positioning. Often open \nlaparotomy is done due to the aforementioned issues. However, MIGS provides better \noutcomes for patients.\nCase:  We report a case of a 37 year old G1P1 with a BMI of 80.72 kg/m2 who \ncomplained of menorrhagia for 4 months. The patient was given a trial of OCP therapy \nfor conservative treatment which did ameliorate the complaint. The patient continued \nto have heavy vaginal bleeding passage of large clots. Along with blood work, a pelvic \nultra sound was done which showed bilateral multicystic and septated adnexal masses \non the ovaries. A CT scan was also done which confirmed the mass, without a concern \nfor malignancy. The patient was then scheduled for a total laparoscopic hysterectomy \nand bilateral salpingo-oophorectomy, via laparoscopic technique. The patient tolerated \nthe procedure well. The adnexal masses were sent to pathology which revealed serous \nborderline tumors of the ovaries.\nConclusion:  Gynecological surgery in the obese patient provides a challenge during \nthe patient’s pre, intra and postoperative management. Using MIGS, obese patients \ncan have shorter hospital stay, with fewer complications as well as have less post-\noperative pain.\nKeywords: complications, gynecologic surgery, minimally invasive surgery, \nobesity, MIGS, trendelenburg, BMI\nObstetrics & Gynecology International Journal \nCase Report\n Open Access\n\n\nObesity and gynecologic surgery via minimally invasive surgery with comparison to open laparotomy; a \ncase report and review of the literature \n165\nCopyright:\n©2019 Rezai et al.\nCitation: Rezai S, Giovane R, Lazenby AJ, et al. Obesity and gynecologic surgery via minimally invasive surgery with comparison to open laparotomy; a case \nreport and review of the literature. Obstet Gynecol Int J. 2019;10(2):164‒167. DOI: 10.15406/ogij.2019.10.00438\nor swelling of labia. She exhibited no hirsutism or acne, had no nipple \ndischarge, headaches or visual changes. She was going through a \ndivorce and was not sexually active at the time. She had no history of \nabnormal pap smears, mammograms, or STIs; she had one caesarean \nsection in 2001. The patient worked as a caregiver for elderly. Family \nhistory was unobtainable as she was adopted. She reported no used \nof tobacco, alcohol, or drugs. Review of systems was significant for \nweight loss, fatigue, shortness of breath and night sweats. She had a \npast history of an ovarian cyst noted in 2011. \nHer medication list included furosemide, amitriptyline, \nlevothyroxine, gabapentin, terbinafine, ibuprofen, phenazopyridine \nHCl, nystatin, Norco, ferrous sulfate, cetirizine, naproxen, omega \nfatty acid supplement, and biotin. \nAt the time of her evaluation, her blood pressure was elevated at \n141/83; pulse was 82, respiratory rate was 20, and temperature was \n98.3F. Physical exam showed a morbidly obese white female in no \nacute distress. Grape-sized blood clots were visualized in the vaginal \nvault; cervix was unable to be visualized and uterus and adnexa \nwere unable to be palpated due to patient’s habitus. Hemoglobin and \nhematocrit were low, at 7.3g/dL and 25.9%, respectively. MCV was \nmildly elevated at 94fL. TSH was also elevated at 3.87uIU/mL. Urine \npregnancy test was negative. \nThe patient was scheduled for an ultrasound and FSH, estradiol, \nPL, DHEA-S, free testosterone, and 17-hydroxyprogesterone levels \nwere ordered. The patient was advised to follow up with her primary \ncare physician regarding her elevated TSH.\nOn 6/19/14, pelvic ultrasound showed large, bilateral \nmulticystic and septated adnexal masses. The right mass (Figure 1) \nmeasured 13.7×14×8.8cm, while the left mass (Figure 2) measured \n15.4×12.2×21.1cm. An enlarged uterus was also noted, but imaging \nwas overall limited due to the patient’s habitus.\nFigure 1 Pelvic ultrasound showing Multicystic and a septated right adnexal \nmass measuring 13.7×14.0×8.8cm.\nThe patient had a follow-up office visit for abnormal pelvic US \nresults on 7/1/14. Previous lab-work showed decreased levels of \nFSH, LH, and estradiol, at 2.63IU/L, 1.84IU/L, and <11.8 pg/mL, \nrespectively. Results and need for surgery were discussed with patient. \nCEA, CA-125, and CA 19-9 levels were ordered and the patient was \nreferred to gynecologic oncology.\nFigure 2 Pelvic ultrasound showing Multicystic and septated left adnexal mass \nmeasuring 15.4×12.2×21.1 cm.\nThe patient subsequently had a CT scan on 7/23/14 which \nconfirmed the presence of large bilateral ovarian masses, which \nwere noted to be mostly solid and concerning for malignancy. No \nlymphadenopathy was noted. The also was found to have hepatic \nsteatosis, diverticulosis, and a large cystic lesion of the right kidney.\nTotal laparoscopic hysterectomy and bilateral salpingo-\noophorectomy were scheduled for 9/4/14; the potential need for \nexploratory laparotomy due to her size was discussed with the patient. \nOn 9/1/14, the patient was admitted to hospital for a pre-op evaluation. \nHer CA-125 was noted to be elevated at 132.2U/mL. Physical exam \nwas unremarkable. A type and cross as well as a CBC was ordered \nfor the day of her surgery. It was also noted that the patient had a \nsubclavian vessel pressing on her trachea and needed fiberoptic \nintubation, per anesthesiology.\nOn 9/4/14, the patient was taken to OR for TLH and BSO as \nplanned. She was appropriately positioned (Figure 3); the decision \nwas made for a LUQ entry due to the patient’s habitus and large \nsize of ovarian masses. A trochar was placed at Palmer’s point, the \nabdomen was insufflated with CO 2, and ports were subsequently \nplaced. There was some concern about laceration to liver during \nplacement of the trochar, but the surgery continued with no signs \nof active bleeding. Visualization was difficult; both adnexal masses \nwere found to be torsed. The LigaSure was used to suture ligate both \novarian masses, as well as the uterus and cervix. The uterus was \nplaced in an EndoCatch bag and removed through the vagina. The \nadnexal masses were too large to be removed through the vagina; the \ndecision was made to convert the supraumbilical port to a 7cm hand-\nassisted port, with subsequent drainage and removal of each ovarian \nmass in a sterile X-ray cover bag. Both masses, uterus, and cervix \nwere sent to pathology for frozen section. The vaginal cuff was closed \nand the bladder was inspected with a 30-degree cystoscope. The upper \nabdomen was again inspected due to initial concern of liver injury; \ngeneral surgery was consulted for evaluation. A 1-cm through-and-\nthrough injury to the left lobe of the liver, as well as injury to the \nanterior body of the stomach measuring approximately 5-10 mm, was \nfound. The decision was made to convert to an exploratory laparotomy \ndue to poor visualization of the injuries. The injury to the stomach was \nrepaired by general surgery; the injury to the liver was hemostatic \nwith no need for repair. The total estimated blood loss during the \nprocedure was 2500 cc and the patient was given two units of pRBCs. \nThe abdomen was closed; the patient tolerated the procedure well. \nShe remained intubated and was transferred to the SICU.\nThe patient was extubated on post-operative day 1 and remained \n\n\nObesity and gynecologic surgery via minimally invasive surgery with comparison to open laparotomy; a \ncase report and review of the literature \n166\nCopyright:\n©2019 Rezai et al.\nCitation: Rezai S, Giovane R, Lazenby AJ, et al. Obesity and gynecologic surgery via minimally invasive surgery with comparison to open laparotomy; a case \nreport and review of the literature. Obstet Gynecol Int J. 2019;10(2):164‒167. DOI: 10.15406/ogij.2019.10.00438\nin the SICU for two days. She had several episodes of desaturation \nduring sleep which required use of a BiPAP machine and/or nasal \ncannula. She was discharged on post-operative day 9 on home oxygen. \nFigure 3 Positioning obese patients for minimally invasive gynecologic surgery.\nPathologic examination of the adnexal masses revealed serous \nborderline tumors of the ovaries, with involvement of the surface of \neach ovary. Stage was reported as 1C2. \nThe patient’s postoperative course was otherwise unremarkable \nwith normal wound healing. Follow-up visits were conducted at 3-4 \nmonth intervals.\nDiscussion\nObesity as a diagnosis is defined by three classes. Class 1 \nencompasses those with a BMI of 30-34.9, Class II of 35-39.9 and \nclass III of a BMI greater than 40.3 \nGynecological surgery in obese patients, defined as a BMI \nof greater than 30, can pose a health risk to the patient during the \noperation and well as post-operatively. Intraoperatively, patients who \nare obese have an increase in oxygen consumption which can lead \nto a decrease in oxygenation during apnea. Moreover, patients with \nobesity are more prone to developing left and heart failure. 4 Poster \noperatively, obese patient are at an increased risk of infection and \nvenous thromboembolisms.5 \nDoing minimally invasive gynecology surgery [MIGS] versus \na laparotomy approach in obese patients has advantages and \ndisadvantages. MIGS has been shown to have a lower post-operative \ncomplication rate, lower hospital stays and less post-operative pain \nwhen compared to laparotomy (Table 1).6–9\nIt was found that MIGS in obese patients provided a safe \napproach for gynecological surgery. 2,10,11 These studies showed \nthat the complication was low and as reported by Wysham et al., 2 \ncomplications can be as low as 3%. 2 Although robotic surgery has \nits benefits of having fewer complications; there is the risk that the \nsurgery might be converted to laparotomy. As reported by Cosin et \nal.12 the likelihood of converting a robotic surgery to laparotomy has \na positive correlation with a patient’s BMI.12 However, although there \nis a great chance to convert to laparotomy, if successful, hospital stay \nand morbidity of doing MIGS is the same as that of a patient with \na normal BMI. 13 When comparing MIGS versus laparotomy, Yu et \nal.6 reported that, patients who had laparotomy for gynecological \noncology cases, had a longer hospital stay of 7 days as well as had an \nincreased risk for developing infections at the surgical site.14,15 \nProper positioning techniques for obese patients for gynecological \nsurgery are important to minimize post-operative complications such \nas nerve damage. The most common nerve injuries are from ulnar \nand sciatic compressions due to excessive weight compressing these \nnerves as well as the patient being in a deep Trendelenburg position.6,16 \nCommon techniques to avoid nerve injury are to have the patient in \nthe military position with their legs in the lithotomy position. 17 This \nwill minimize any excessive compression to nerves. Entry to the \nabdominal cavity also poses a challenge as the patient as an increased \nin fascia to abdominal wall. In a patient with a normal BMI, the \ntrocar entry is usually at the umbilicus as it is the thinnest point of \nentry; however, in obese patients, the umbilicus moves more caudally \nand can prevent the surgeon from getting optimal viewing. 18 In this \nregard, initial entry is usually done via the left upper quadrant or via \nsupraumbilical region. This mitigates the risk of poor triangulation \nas well as obstructing proper view. 6,19 Although obesity poses an \nincreased risk that laparoscopy will be converted to laparotomy, \ncertain techniques can be done peri-operatively to decrease this risk \nUsing a steep Trendelenburg position sparingly can minimized the \nrisk as it would prevent a decrease in minute ventilation of the patient; \nsimilarly, proper retraction within the abdominal wall has the same \nbenefits. Lastly, a tilt test, while in Trendelenburg position should \nbe done before an incision is made to assess the patient’s ability to \nmaintain adequate perfusion.19 \nT able 1 Postoperative Recovery and Complications for Minimally Invasive Gynecologic Surgery (MIGS) versus Open Surgical T echnique (Laparotomy)\nT able 1: Study Laparotomy \ncases\nMIGS \ncases\nHospital stay for \nlaparotomy cases\nHospital stay for MIGS \ncases\nComplications for \nlaparotomy cases\nComplications for \nMIGS cases\nYu et al.6 4 4 11.5 4 4 0\nEisenhauer et al.7 154 57 N/A N/A Incidence:35% Incidence: 8%\nWalker et al.8 246 1248 94% [Greater than \n2 days] 52% [Greater than 2 days] 21% 14%\nGeppert et al.9 64 25 3.8 1.6 23/64=36% 2/25= 8%\n\nObesity and gynecologic surgery via minimally invasive surgery with comparison to open laparotomy; a \ncase report and review of the literature \n167\nCopyright:\n©2019 Rezai et al.\nCitation: Rezai S, Giovane R, Lazenby AJ, et al. Obesity and gynecologic surgery via minimally invasive surgery with comparison to open laparotomy; a case \nreport and review of the literature. Obstet Gynecol Int J. 2019;10(2):164‒167. DOI: 10.15406/ogij.2019.10.00438\nConclusion\nGynecological surgery in the obese patient provides a challenge \nduring the patient’s pre, intra and postoperative management. Using \nMIGS, obese patients can have shorter hospital stay, with fewer \ncomplications as well as have less post-operative pain. MIGS is a good \nalternative for gynecological surgery; however, care must be taken on \nproper positioning of the patient as well as the surgical approach to \nthe abdominal cavity.\nAcknowledgments\nDr. Xiaoming Guan is a speaker for Applied Medical, Rancho \nSanta Margarita, California. \nConflicts of interest\nOther authors did not report any potential conflicts of interests.\nReferences\n1. Cooper K, Falcone T. Gynecologic surgery in the obese patient. J Minim \nInvasive Gynecol. 2014;21(2):155–156. \n2. Wysham WZ, Kim KH, Roberts JM, et al. Obesity and perioperative \npulmonary complications in robotic gynecologic surgery. Am J Obstet \nGynecol. 2015;213(1):33.e1–33.e7.\n3. Kabon B, Nagele A, Reddy D, et al. Obesity decreases perioperative tissue \noxygenation. Anesthesiology. 2004;100(2):274–280.\n4. Executive summary of the clinical guidelines on the identification, \nevaluation, and treatment of overweight and obesity in adults. Arch Intern \nMed. 1998;158(17):1855–1867.\n5. Committee opinion no. 619: Gynecologic surgery in the obese woman. \nObstet Gynecol. 2015;125(1):274–278.\n6. Yu CK, Cutner A, Mould T, et al. Total laparoscopic hysterectomy as a \nprimary surgical treatment for endometrial cancer in morbidly obese \nwomen. BJOG. 2005;112(1):115–117.\n7. Eisenhauer EL, Wypych KA, Mehrara BJ, et al. 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Am J Obstet Gynecol.  2004;191(2):669–\n674.\n17. Hurd WW, Bude RO, Delancey JO, et al. The relationship of the umbilicus \nto the aortic bifurcation: implications for laparoscopic technique. Obstet \nGynecol. 1992;80(1):48–51.\n18. Afors K, Centini G, Murtada R, et al. Obesity in laparoscopic surgery. Best \nPract Res Clin Obstet Gynaecol. 2015;29(4):554–564.\n19. Stany MP, Winter WE, Dainty L, et al. Laparoscopic exposure in obese \nhigh-risk patients with mechanical displacement of the abdominal wall. \nObstet Gynecol. 2004;103(2):383–386.","source_license":"CC0","license_restricted":false}