Minimally Invasive Surgery in the Obese Patient Ginger J. Gardner, MD Associate Professor, Weill...

Minimally Invasive Surgery in Minimally Invasive Surgery in the Obese Patientthe Obese Patient

Ginger J. Gardner, MDGinger J. Gardner, MDAssociate Professor, Weill Cornell Medical CollegeAssociate Professor, Weill Cornell Medical College

Associate Member, Gynecology ServiceAssociate Member, Gynecology ServiceDirector, Survivorship ProgramDirector, Survivorship Program

Department of SurgeryDepartment of SurgeryMemorial Sloan-Kettering Cancer CenterMemorial Sloan-Kettering Cancer Center

Minimally Invasive SurgeryMinimally Invasive SurgeryBenign hysterectomy in the US 2003Benign hysterectomy in the US 2003

Wu JF. Et al. Obstet Gynecol 2007;110:1091-1095.

Mean LOS=1.7 days*

Mean LOS=2.0 days*

Mean LOS=3.0 days*

*P-value<0.001

Kornblith AB, et al. J Clin Oncol 2009;27:5337-5342.

GOG LAP-2GOG LAP-2Quality of lifeQuality of life

GOG LAP-2GOG LAP-2Conversion rateConversion rate

Walker JL, et al. J Clin Oncol 2009;27:5331-5336

ObesityObesityScope of the problem in USScope of the problem in US

Source: Behavioral Risk Factor Surveillance System, CDC.

Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%




No Data <10% 10%–14%




No Data <10% 10%–14%




No Data <10% 10%–14%




No Data <10% 10%–14%




No Data <10% 10%–14%




No Data <10% 10%–14% 15%–19%




No Data <10% 10%–14% 15%–19%




No Data <10% 10%–14% 15%–19%




No Data <10% 10%–14% 15%–19%




No Data <10% 10%–14% 15%–19%




No Data <10% 10%–14% 15%–19%




No Data <10% 10%–14% 15%–19% ≥20%




No Data <10% 10%–14% 15%–19% ≥20%




No Data <10% 10%–14% 15%–19% ≥20%




No Data <10% 10%–14% 15%–19% ≥20%




No Data <10% 10%–14% 15%–19% 20%–24% ≥25%




No Data <10% 10%–14% 15%–19% 20%–24% ≥25%




No Data <10% 10%–14% 15%–19% 20%–24% ≥25%




No Data <10% 10%–14% 15%–19% 20%–24% ≥25%




No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%




No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%




No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%




No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%




No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Robotic Surgery in the Robotic Surgery in the ObeseObese

Case Selection?Case Selection?

ObesityObesityNot all about the BMINot all about the BMI

Brandon JacobsRB – NY Giants

BMI = 32

OBESE!!

Obesity and SurgeryObesity and SurgeryAdipose distributionAdipose distribution

House MG, et al. J Gastrointest Surgery 2008;12:270-278

Preop imaging measurements

#1: abd wall fat thickness (AW)#2: hip girdle fat thckness (HG)#3: pancreatic duct diameter (PD)#4: retrorenal visceral fat (VF)


House MG, et al. J Gastrointest Surgery 2008;12:270-278

356 pancreaticoduodenectomies


Morris K, et al. Arch Surg 2010;145:1069-1073

349 major hepatectomies

ObesityObesityBMI not best predictor for fat distributionBMI not best predictor for fat distribution

Morris K, et al. Arch Surg 2010;145:1069-1073

Correlation coefficients: 0.33 (IAF vs BMI), 0.47 (OAF vs BMI), -0.02 (IAF vs OAF – not shown)BMI poorly correlated with IAF or OAF

Laparoscopy in Obese PatientsLaparoscopy in Obese PatientsAssessing risk of conversionAssessing risk of conversion

• Endometrial cancer• All BMI >30 kg/m2• Measured weight, height, BMI,

waist circumference (WC), waist-hip ratio (WHR) as well as:

• Transabdominal US (at umbilicus – 1 cm lateral)

– SF-USG: subcut fat distance– IVF-USG: intrabdominal visceral fat

distance

• CT scan (level just before aortic bifurcation)

– IVF-CT: intraabdominal visceral fat area

Palomba S, et al. JMIG 2007;14:195-201

Laparoscopy in ObeseLaparoscopy in ObeseAssessing risk of conversionAssessing risk of conversion

VariableGroup A

Success LRSGroup B1

“Early” convertGroup B2

“Late” convert

N 122 (80%) 19 (13%) 10 (7%)

Reasons for convertAdhesions (2)

“Anesthesia” (17)Bleeding or Technical

Mean BMI (+/-SD) 34.5 (1.6) 34.4 (1.5) 34.4 (1.8)

Complications Intraoperative Postoperative

10 (8%)30 (25%)*

2 (10.5%)11 (58%)

1 (10%)6 (60%)

Median measurements (IQR) WC WHR IVF-USG SF-USG IVF/SF-USG IVF-CT

96.8 (4)0.97 (0.05)

5.3 (2)3 (2.1)

1.5 (0.6)121.2 (42.1)

96 (6)0.97 (0.05)

7.4 (3)**3.2 (2)

2.2 (0.7)**150.1 (20.7)**

96.5 (4)0.97 (0.04)

5.1 (2)3.2 (1.4)106 (0.2)

120.5 (31.8)

*P<0.05 for Group A vs B1 and B2**P<0.05 for Group B1 vs A and B2

Palomba S, et al. JMIG 2007;14:195-201

Robotics in Obese PatientsRobotics in Obese PatientsCase selection?Case selection?

• Can we appropriately select preoperatively?• BMI alone is not sufficient• Location of adipose important• Height important (taller = more room in abdomen?)• What’s the downside to trying and assessing intraoperatively?

Robotic Surgery Positioning and setup

RoboticsRoom setup

RoboticsPatient positioning



RoboticsPatient positioning – morbidly obese

BMI=47

MIS in Obese PatientsMIS in Obese PatientsSet-up Take Home PointsSet-up Take Home Points

• Careful patient positioning and discussion with anesthesia is important– Arm sleighs, Wide leg spreader bars, A-line

• Abdominal entry is deep– Consider open scope or LUQ insufflation

• High robotic trocar sites, well above the pannus can be beneficial

• Request extra long trocars

• Can use temporary stitch for colon retraction is needed

Robotic Surgery Robotic Surgery Anesthesia in the obeseAnesthesia in the obese

Laparoscopy in Obese PatientsLaparoscopy in Obese PatientsRespiratory Mechanics and OxygenationRespiratory Mechanics and Oxygenation

• Supine obese anesthetized without pneumo– 30% lower static lung compliance– 68% higher inspiratory resistance

• Position (head up or head down)– No additional large alterations in respiratory mechanics

• Pneumoperitoneum– Further decrease in static lung compliance– Further increase in inspiratory resistance

• Oygenation– PaO2 adversely affected by patient weight but not by

pneumo or positioning– Require only a 15% higher ventilation requirement to

maintain normcapnia– ETCO2 less accurate measurement in obese

Sprung J, et al. Anesth Analg 2002;94:1345-1350

Laparoscopy in Obese PatientsLaparoscopy in Obese PatientsRespiratory Mechanics and OxygenationRespiratory Mechanics and Oxygenation

“Despite less favorable mechanical and ventilatory requirements…it appears that…alterations in the mechanics of breathing are of little clinical significance.”

Sprung J, et al. Anesth Analg 2002;94:1345-1350

Robotics in Obese PatientsRobotics in Obese PatientsPractical Anesthesia IssuesPractical Anesthesia Issues

• Loss of diaphragmatic tone induced by anesthetic agents makes movement of the diaphragm passively dependent

• Gravity and increasing abdominal contents result in less movement of the dependent portion of diaphragm

• Lung bases are underventilated because of airway closure and atelectasis

• Increased physiologic dead space• Intubation can be a challenge

– Increased upper airway soft tissue– Increased tongue size– Larger breasts– Increased neck circumference

Courtesy of Dr. Luis Tollinche (MSKCC Dept of Anesthesia and Critical Care)

Robotics in Obese PatientsRobotics in Obese PatientsMethods for Successful AnesthesiaMethods for Successful Anesthesia

• Extra precaution during intubation– Judicious use of Rapid Sequence Intubation– Propping patient in “ramp” position

• Preoxygenation– Goal of expired FiO2 > 85%

• High inspiratory oxygen fractions• Tidal volumes as great as 10 ml/kg IBW• Inclusion of large, manually or automatically

performed lung inflations (recruitment maneuver)• Use of PEEP after recruitment maneuver• Adequate prehydration to optimize preload • Goal during entire cycle of ventilation is to “keep

lung open”• Keep intraabdominal pressures <15 mmHg

Courtesy of Dr. Luis Tollinche (MSKCC Dept of Anesthesia and Critical Care)

MIS in Obese PatientsMIS in Obese PatientsKey points - AnesthesiaKey points - Anesthesia

• Clinical judgment and comfort should not be ignored

• Avoid quick “giving up”

• Requires a skilled and dedicated TEAM in OR

• Intraop ventilatory alterations and demands do not necessarily translate to meaningful clinical concerns

• Much worse to convert!

Robotic Surgery in ObeseRobotic Surgery in ObeseOutcomesOutcomes

Endometrial Cancer in ObeseEndometrial Cancer in ObeseRobotic vs OpenRobotic vs Open

Variable ROBOT OPEN P-value

N 109 191

“Adequate” staging 85% 91% NS

PLN&PALND done 73% 72% NS

Mean total LN counts 25 24 NS

Mean OP time (min) 228 143 <0.001

Mean EBL (ml) 109 394 <0.001

Mean LOS 1 3 <0.001

Seamon LG, et al. Obstet Gynecol 2009;114:16-21 (all BMI ≥ 30)

Endometrial Cancer in ObeseEndometrial Cancer in ObeseRobotic vs OpenRobotic vs Open

Seamon LG, et al. Obstet Gynecol 2009;114:16-21 (all BMI ≥ 30)

OR=0.22 (95%CI:0.13-0.65)

OR=0.10 (95%CI:0.02-0.43)

OR=0.29 (95%CI:0.13-0.65)

Endometrial Cancer in ObeseEndometrial Cancer in ObeseRobotic vs LaparoscopicRobotic vs Laparoscopic

Variable ROBOT LRS P-value

N 49* 32**

PLN&PALND done 92% 84% NS

Mean total LN counts 31 24 0.004

Mean OP time (min) 189 215 0.0004

Conversions 0 3 (9%) NS

Mean EBL (ml) 50 150 <0.0001

Mean LOS 1.02 1.27 0.01

Total complications 6 (12%) 4 (13%) NS

Gehrig PA, et al. Gynecol Oncol 2008;111:41-45 (all BMI ≥ 30)

*Over a 2+ year period**Over a 4+ year period

*Chi DS, et al. Am J Obstet Gynecol 2004;191:1138-1145 (1/1/91-12/31/00)**Gardner GJ, et al. SGO 2010 (5/1/07-9/1/09)

RoboticsRoboticsImpact on PracticeImpact on Practice

All cases7%

17%

Robotics in ObeseRobotics in ObeseObese vs non-obeseObese vs non-obese

VariableNon-obese(BMI<30)

Obese(BMI≥30)

P-value

N 238 113

Median BMI (range) 24.4 (16.4-29.9) 35.2 (30-60.6) <0.001

Converted 19 (8%) 17 (15%) 0.04

Median OP time (min) 192 205 NS

Median docking time (min) 29 34 0.004

Median console time (min) 130 141 NS

Median hyst time (min) 51 60 0.05

Median cuff time (min) 18 22 0.02

Median EBL (ml) 50 50 NS

Median LOS (d) 1 1 NS

Total complications 33 (15%) 11 (12%) NS

Gardner GJ, et al. SGO 2010

All indications (5/1/07-9/1/09)

RoboticsRoboticsBMI=60.6BMI=60.6

MIS in Obese PatientsMIS in Obese PatientsFinal thoughtsFinal thoughts

• Preoperative Case Selection– Difficult to say “how big is too big”– perhaps based on

surgeon comfort?– Its worth trying – worst case you have to convert

• Positioning & Trocars– High port sites, Extra long trocars, Arm sleighs

• Anesthesia & Surgical Outcomes– Challenging issues but worth the effort– Conversion to laparotomy results in a much greater risk

of complications– Success dependent on skilled TEAM working together

THANK YOU!THANK YOU!1884

2010

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Minimally Invasive Surgery in the Obese Patient Ginger J. Gardner, MD Associate Professor, Weill...

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