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.

Disclosures Olympus Corporation Applied Medical Gore Corporation Atrium Corporation Ethicon Endosurgery

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

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

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

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

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)

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)

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

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

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

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

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

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

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

Port Placement Scheme for Sigmoid or Anterior Resection

Obese or Lengthy Body Habitus: Transverse Colectomy 5 12 12 5

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

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

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

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

Retraction of Uterus to Abdominal Wall

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

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

Right Hemicolectomy, Standard Incision Extracorporeal Anastomosis Extraction incision

Right Hemi Port Placement Extracorporeal Anastomosis

Obesity Skin incision Fascial incision Peritoneal incision

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):818-26.

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

Relationship Between Rate of Utilization of Hand-Laparoscopic Methods & BMI BMI Category % of Cases Done with Hand*+ < 33 23 % >33 44 % >40 50 % * Greater than 90 percent of hand cases were sigmoid or LAR resections + Length of say similar in hand and laparoscopic-assisted cases

Columbia Presbyterian Conversion* Rates As Per Method & BMI BMI Laparoscopic Hand/Hybrid < 25 7.2% (4.9cm) 13.9% (10.2cm) 30 24% (7.0cm) 26.1% (10.6cm) 35 40% (8.5cm) 19 % (10.4cm) 40 66.7% (11.5cm) 28.6% (11.4cm) * Strict incision length criteria was used to define conversion (lap= >7 cm, hand= >12 cm)

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

Conversion to Hand-Assisted Sigmoid Resection

Planned Hand-assisted Sigmoid/LAR

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

Right Colectomy Hand Port Placement: What I Did

Right Hemi Hand Port Placement: Should Of Done

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

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

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

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

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

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

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):818-26.

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

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

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):818-26.

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