Laparoscopic Colon Surgery in Obese Patients

1. 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 Colectomy 5 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 intracorporealanastomosis • 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 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):818-26.

29. 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*+ < 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

31. 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)

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

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. RightColectomy 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):818-26.