In the past decade, the prevalence of obesity in the United States has reached epidemic proportions.1–3 In 2000, the prevalence of obesity (as defined by a body mass index [BMI] greater than or equal to 30 kg/m2) was 19.8%.1–3 Almost 40 million U.S. citizens are obese, with approximately half of these being women.1 The adverse effects of obesity on morbidity and quality of life are well established.4–8 Physicians in the United States, particularly those in surgical subspecialties, are frequently faced with the unique clinical and technical challenges of caring for obese patients. The gynecologic surgeon is no exception.
The advent and rapid evolution of modern laparoscopic surgery have furnished the surgeon with a powerful tool, making possible more complex procedures using minimally invasive techniques. Although some authors have regarded obesity as a relative contraindication to operative laparoscopy,9 laparoscopic techniques may be particularly well suited to the treatment of obese patients because surgical complications are often related to the poor healing of surgical wounds and infection when diabetes is present.10 These techniques may also afford more rapid recovery and shorter period of hospitalization than open procedures.11 Reich introduced his technique for laparoscopic hysterectomy in 1989.12 This technique has been modified by various operators and further perfected to expand the breadth of its application. The purpose of this study was to estimate the risk of complications and adverse outcomes associated with total laparoscopic hysterectomy among women who are obese versus those who are not.
MATERIALS AND METHODS
This study was approved by the Institutional Review Board of Ochsner Clinic Foundation. A retrospective cohort study of short-term clinical outcomes was performed for all patients who underwent total laparoscopic hysterectomy at Ochsner Clinic Foundation in New Orleans from February of 1998 through June of 2002. The data were extracted from a database of patients undergoing total laparoscopic hysterectomy that was created longitudinally for the purpose of study. This database compiled biologic information, indications for surgery, surgical procedure, and operative parameters, as well as operative and postoperative complications, readmissions to the hospital, and reoperation at any time for a condition related to the hysterectomy. The data were systematically checked for accuracy by cross-referencing records with information found in our comprehensive departmental database of gynecologic patients. A detailed review of the medical record was performed for every patient who experienced a major complication, was readmitted, or underwent reoperation.
Patients were classified as obese according to the criteria of the National Heart, Lung, and Blood Institute.13 Accordingly, those patients with a BMI of 30.0 kg/m2 or greater were classified as obese. Although National Heart, Lung, and Blood Institute criteria classify individuals having a BMI of 40.0 kg/m2 or greater as extremely obese, we did not make this distinction in analyzing our data. Outcome variables for all patients having a BMI of 30.0 kg/m2 or greater were compared with those outcome variables for patients with a BMI less than 30 kg/m2. All patients included in the study had a well established indication for hysterectomy. Patients were selected for total laparoscopic hysterectomy when they were not optimal candidates for vaginal hysterectomy (because of pelvic anatomy or uterine size) and when there were no absolute contraindications to laparoscopic approach.
Introduced at our institution in 1998, total laparoscopic hysterectomy is practiced as described by Koh14 that same year. This technique makes use of an articulated uterine manipulator (RUMI System; Cooper Surgical, Trumbull, CT), an occluding vaginal balloon (KOH Colpopneumo Occluder; Cooper Surgical), and a hard ring of polymeric resin (KOH Colpotomizer System; Cooper Surgical), which is fitted to the patient's cervix. This system allows for laparoscopic colpotomy, as well as electrodesiccation and division of the uterine vessels.
We use a 10-mm port (10 mm/15 cm trocar; Ethicon Surgery, Cincinnati, OH), placed at the umbilicus for accommodation of a 10-mm 0° or 45° laparoscope, and two 5-mm ports (5 mm/10 cm trocar, Ethicon Surgery), placed approximately 4–5 cm below the umbilicus in the right and left paramedian positions, for the operative instruments. A reusable unipolar electrosurgical scissor, reusable unipolar electrosurgical spatula (Encision, Inc, Boulder, CO), disposable bipolar electrosurgical desiccating and cutting forceps (Everest BiCOAG Bipolar Cutting Forceps; Vital/Med Systems Corp, Colorado Springs, CO), and various reusable tissue forceps are used to perform the hysterectomy and, if indicated, adnexectomy.
Specimens are typically recovered vaginally and the vaginal cuff closed with a laparoscopic suturing device (Endostitch; AutoSuture, Norwalk, CT) to place interrupted sutures of 0 braided polyglycolic acid. Sutures are tied by using extracorporeal technique. Power morcellation (Gynecare X-TRACT Tissue Morcellator; Ethicon, Somerville, NJ) is performed as necessary to facilitate recovery of a large uterine specimen.
Total laparoscopic hysterectomy was performed with the same technique on all study subjects at Ochsner Clinic Foundation by an attending gynecologist with senior house staff assisting in most cases. All procedures were performed with the patient in the modified low lithotomy position using adjustable leg supports. Surgical antibiotic prophylaxis, consisting of either cefazolin or cefotetan, was administered to all nonallergic patients 30–60 minutes before the initiation of surgery. Patients allergic to penicillin or cephalosporins received clindamycin as surgical prophylaxis.
Major operative complications were defined as unintended injury to vital structures of the abdomen or pelvis or operative blood loss sufficient to require intraoperative or postoperative blood transfusion. The primary attending surgeon and the anesthesiologist together arrived at an appropriate estimate of operative blood loss. Information on blood loss and operative time were extracted directly from the anesthesia records. Major postoperative complications were considered those that directly or indirectly prolonged the postoperative hospital stay, resulted in readmission to the hospital, or resulted in reoperation. Minor complications were those that did not prolong postoperative hospital stay or require hospital readmission or reoperation. Febrile morbidity was defined as an oral temperature of 38°C, present on 2 separate occasions at least 6 hours apart, or a single oral temperature of 38.5°C.
We performed univariate and bivariate analyses to compare the obese and nonobese groups with respect to their patient characteristics and operative and postoperative parameters. Differences between the 2 groups were evaluated by using the Pearson χ2 and Fisher exact tests for categorical variables. The Student t test and Wilcoxon rank sum test were used to detect differences in continuous variables. A P value of ≤ .05 was considered statistically significant. Operative time and estimated operative blood loss were not normally distributed, as determined graphically, as well as by using the Shapiro-Wilk test for normal data. We analyzed the association between BMI and the risk of conversion to abdominal hysterectomy and laparoscopically assisted vaginal hysterectomy (LAVH) using a multinomial logistic regression model. Risk of major and minor complications and postoperative parameters associated with obesity were evaluated by computing relative risks (RR) and 95% confidence intervals (CIs). Analyses were performed by using Stata 8.0 (Stata Corporation, College Station, TX).
During the study period, 273 patients underwent attempted total laparoscopic hysterectomy; 3 were excluded because of incomplete data. The mean BMI of the entire study population was 29.3 kg/m2 (range 18.2–56.8 kg/m2). Of the 270 patients, 106 (39.3%) were classified as obese (range 30.11–56.8 kg/m2). Seventeen of these patients had BMIs exceeding 40 kg/m2. The groups were similar with respect to age (mean 43.5 years) and parity (mean 2.0). The overall mean preoperative American Society of Anesthesiologists health status score was 1.8. A significantly larger proportion of obese patients had an American Society of Anesthesiologists score of 3 (12.3%) than did the nonobese patients (7.0%, P = .01). Table 1 lists indications for surgery. The most common reason for hysterectomy was abnormal uterine bleeding (80.0%), followed by uterine fibroids (50.4%). Pelvic pain was a factor in 35.0% of cases. Obese patients were more likely than nonobese patients to have a diagnosis of abnormal uterine bleeding as their indication for surgery (88% versus 75%, P = .01).
Two hundred fifty-three (93.7%) cases were completed successfully by using purely endoscopic technique, whereas 7 (2.6%) were completed with a combined vaginal approach (LAVH) (Table 2). Only 10 (3.7%) cases were converted to laparotomy, 7 occurring in the obese group and 3 in the nonobese group. Indications for conversion to laparotomy included extensive adhesive disease (4 cases), hemorrhage (2 cases), cystotomy (2 cases), bowel injury (1 case), and inadequate visualization secondary to large myomas (1 case). The rate of successful completion of total laparoscopic hysterectomy was 89.6% in the obese group compared with 96.3% in the nonobese group. Estimated relative risks for conversion from total laparoscopic hysterectomy to either LAVH or total abdominal hysterectomy (TAH) were not statistically significant.
Mean operative time for the entire study group was 121 minutes. Mean operative time among obese patients was 133 minutes compared with 114 minutes for the nonobese group (Table 3). Procedure completion for obese patients was 60% more likely to require at least 2 hours compared with nonobese patients (RR 1.6; 95% CI 1.2, 2.0). Mean estimated blood loss for the entire study group was 202 mL. Mean estimated blood loss was 240 mL for obese patients compared with 178 mL for nonobese patients (Table 3). Obesity conveyed a 3-fold increased risk of operative blood loss exceeding 500 mL when compared with nonobese patients (RR 2.9; 95% CI 1.2, 7.0). Mean uterine weight for the entire study group was 194 g. The mean uterine weight for the obese group was 218 g versus 178 g for the nonobese group (difference 40 g, P = .04).
Seventeen (6.3%) patients experienced major intraoperative complications (Table 4). Nine (8.5%) of these occurred among obese patients and 8 (4.9%) among nonobese patients. This difference did not represent a statistically significant increased risk. Intraoperative complications included 2 inferior epigastric artery injuries, 1 injury of the small bowel mesentery, 2 serosal injuries of the large bowel, and 3 cystotomies. Only 6 patients in the study group required blood transfusion: 4 obese patients (3.8%) and 2 nonobese patients (1.2%).
Twenty-two (8.1%) patients experienced major postoperative complications (Table 5). Five (4.7%) of these occurred in the obese group and 17 (10.4%) in the nonobese group. This difference did not represent a statistically significant increased risk. Major postoperative complications included 5 vaginal cuff dehiscences, 4 of which occurred in the nonobese group. The first of these patients experienced vaginal bleeding on postoperative day 2, necessitating a return to the operating room. Two other cuff dehiscences followed sexual intercourse in the early postoperative period. One cuff failure occurred spontaneously 5 months after surgery, and another occurred when a suspicious vaginal lesion was biopsied 11 months after surgery in a patient later found to have metastatic adenocarcinoma of the colon. There were also 2 pelvic abscesses, and 1 patient developed a suspected vesicovaginal fistula that resolved spontaneously within 1 week of being detected.
The mean length of postoperative hospital stay for all subjects was 1.2 days (Table 6). The mean length of stay among obese patients was 1 day compared with 1.3 days for nonobese patients. Obesity conveyed no apparent increased risk of prolonging length of postoperative hospital stay beyond 1 day. Only 11 (4.1%) study women were readmitted for postoperative complications, of whom 3 (2.8%) were obese. Ten (3.7%) patients required reoperation. Three (2.8%) of these patients were obese. Neither the risk of readmission nor the risk of reoperation was significantly different between the 2 groups. Twelve (4.4%) patients experienced minor complications, 3 (2.8%) of which occurred in the obese group. The difference in risk of minor complication did not differ significantly between groups. There were no deaths in the study population.
The prevalence of obesity in this country and throughout the industrialized world is such that the practicing surgeon cannot reasonably expect to avert its many implications for patient care. Hysterectomy is performed on approximately 600,000 women each year in the United States, making it second only to cesarean delivery as the most common major operation.15 Despite this and the ever-increasing rate of obesity in this country, the gynecologic literature remains limited in its treatment of laparoscopic hysterectomy for the obese patient.
Laparoscopic cholecystectomy has been shown by several authors to be safe and well suited to the obese patient.16–18 A multicenter review of urologic laparoscopic surgery in 125 obese patients was less favorable, showing an increased rate of operative and postoperative complications in obese patients.19 A prospective study by Holub et al20 showed a nonsignificant trend toward an increased rate of major operative complications in a group of 54 obese patients undergoing laparoscopic hysterectomy. Only half of the patients in that study underwent attempts at total laparoscopic hysterectomy, whereas the remaining half were attempted as laparoscopically assisted vaginal hysterectomies, a procedure shown by Milad et al21 to be associated with greater morbidity than supracervical laparoscopic hysterectomy. Ostrzenski22 showed no increased rate of complications in his series of total laparoscopic hysterectomies in 11 obese women. His was a pilot phase report in which obesity was defined as a function of ideal body weight, rather than BMI. More recently, O'Hanlan et al23 reported on 330 patients, stratified according to BMI groups, who underwent total laparoscopic hysterectomy. That retrospective study included 78 obese women and found similar mean operating time, mean operative blood loss, mean length of hospital stay, and complication rates across all BMI groups.
Technical obstacles associated with open pelvic surgery in the obese are primarily those related to exposure of the operative field and access to deep pelvic structures. These obstacles present similar challenges when laparoscopy is attempted, as have been previously described.24,25 Loffer and Pent26 discussed at length the additional, unique difficulty of establishing pneumoperitoneum in obese patients. Together, all of these limitations place the obese patient undergoing laparoscopy at an inherently increased risk of conversion to laparotomy, as confirmed by several authors.17–19 In a recent review of 2,530 attempted gynecologic laparoscopic surgeries, Sokol et al27 determined that a BMI greater than 30 kg/m2 placed patients at a more than 2-fold risk of unintended laparotomy. Eltabbakh et al28 noted similar findings in a review of 47 obese patients who underwent operative gynecologic laparoscopies.
Despite these challenges, a laparoscopic approach is well suited to the obese patient, who is inherently less mobile and, therefore, more susceptible to thromboembolic events and suboptimal wound healing following laparotomy.29 One randomized, prospective trial comparing outcomes of laparoscopic with abdominal hysterectomy found less operative blood loss, less postoperative pain, and shorter hospital and convalescence times for patients undergoing laparoscopic hysterectomy.30 These same authors concluded that total laparoscopic hysterectomy may afford significant benefit to society in the form of indirect costs related to recovery time, when compared with abdominal hysterectomy.31
Of those studies addressing the technique of total laparoscopic hysterectomy for obese women, ours comprises the largest cohort of obese patients to date. Total laparoscopic hysterectomy was successfully completed without excessive operative or postoperative complications in almost 90% of our obese patients compared with 96% of our nonobese patients. The 6.6% rate of conversion to laparotomy associated with obese patients in our study is similar to rates reported by others.27,28,32 Moreover, no conversion to laparotomy in our study occurred after December 2000, supporting the notion that this risk decreases as operator experience is accrued.27,32
In practice, the number of patients in our study is relatively large. However, the observational nature of a retrospective study precludes absolute conclusions. We have insufficient statistical power to detect modest differences, such as a 2-fold increase in the risk for major complications, between the 2 studied groups. Gynecologic surgeons having less operative exposure to obese patients or less experience with laparoscopy may experience higher rates of complications and conversion to laparotomy when attempting laparoscopic hysterectomy for obese women. These limitations should be considered when attempting to apply our findings to one's individual clinical practice.
Despite these limitations, our study adds to the growing body of literature suggesting that total laparoscopic hysterectomy can be performed safely for obese patients, with complication rates similar to those for nonobese patients. Large, prospective studies to determine the safest, most appropriate approach to hysterectomy in obese women would be clinically useful.
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