Hand Assisted Laparoscopic Surgery In The Morbidly Obese Patient: Does It Have An Advantage Over ‘Pure’ Laparoscopy?

1. Hand Assisted Laparoscopic Surgery In The Morbidly Obese Patient: Does It Have An Advantage Over ‘Pure’ Laparoscopy? M. Albert, S. Atallah, S. Larach, and E. Parra-Davila Center For Colon & Rectal Surgery Florida Hospital, Orlando, Florida Background: Morbid obesity presents a significant challenge for surgeons, particularly in patients undergoing laparoscopic colon surgery. Careful review of recent literature demonstrates morbid obesity to be one of the most common causes of conversion to an open operation in patients undergoing a ‘pure’ laparoscopic colectomy. Ironically, the morbidly obese represent a subset of patients who can benefit the most from minimally invasive, laparoscopic surgery. Findings: Four hundred thirty-one patients underwent laparoscopic sigmoid resection, anterior resection, total colectomy, or restorative proctocolectomy at our center between 2004-20008. Of this group, fourty (9.2%) were classified as being morbidly obese (BMI > 40), with a mean BMI of 42.5 and average age of 57.2 (26-79). In all 40 morbidly obese patients, the hand-assisted laparoscopic approach was used via a 7.5 cm pfannensteil incision with a mean operative time of 96 minutes. There were no (0/40) conversions to open operation, and with the hand-assist approach, it was not necessary to extend the pfannesteil incision. Postoperatively, the average length of stay was 4.1 days. There were no anastomotic leaks. Wound dehiscence was not observed. In one patient, a pulmonary embolism developed post-op day four despite prophylaxis with compression hose, fractionated heparin, and an IVC filter that had been placed preoperatively. No patients required ICU admission, or temporary post-operative mechanical ventilation. However, the 30-day readmission rate was 7.5%. In our series, there were no patients who developed systemic complications such as sepsis or pneumonia. Wound infections was the only significant postoperative complication and this occurred in 5% (2/40) of the patients. At two year follow up, none of the morbidly obese patients in our series had incisional hernias. One patient developed an anastamotic stricture. In the subset of morbidly obese patients who underwent an oncologic resection, an average of 24 lymphnodes were harvested; there was no evidence of colorectal cancer recurrence at two year follow up. Objective: To determine whether or not morbidly obese patients would maintain the advantages seen in ‘pure’ laparoscopic cases with fewer conversion rates when a hand-assist laparoscopic technique is used. Methods: A retrospective review from our center was done over a four year period. All laparoscopic colectomies performed on morbidly obese patients – defined as a body mass index (BMI) of greater than 40 – were reviewed. All 40 patients in the study underwent resection using the hand-assist laparoscopic technique with a pfannensteil incision, Applied Gel Port, and three 5mm Applied trocars to facilitate laparoscopy. Measurable outcomes were recorded for the perioperative period as well as at twenty-four month follow-up. Indications for Surgery in The Morbidly Obese Conclusion: Hand assisted laparoscopic colectomy in morbidly obese patients maintains the advantages of minimal access surgery and the outcomes compare favorably with those seen after ‘pure’ laparoscopy. We recommend the hand-assist technique as the preferred modality for morbidly obese patients who are candidates for laparoscopic colon resection. The ability to complete a laparoscopic operation without converting to an open procedure is an important advantage of the hand-assist approach. Furthermore, the hand assist technique – particularly with left-sided resections – may provide an excellent, first alternative to conversion to an open operation. Type of Hand Assist Laparoscopic Surgery Performed Laparoscopy and Outcomes in Morbidly Obese Patients Pts (n) Conversion O.R. Time Morbidity Rate (min) Author