Obesity

Obesity poses a major challenge to the laparoscopic surgeon, both from the surgical (technical) and the medical aspect. Obesity has been recognized as an independent cardiovascular risk factor, and is associated with serious medical comorbidity including the metabolic syndrome, which is characterized by impaired glucose tolerance, dyslipi-demia, and hypertension. Other medical conditions caused or aggravated by obesity include sleep apnea, daytime sleepiness, asthma, and gastroesophageal reflux. Physical disability, body image, and depressive illness can also be present. All these issues need to be factored in the treatment of such patients.

For adults, overweight has been defined by a body mass index (the weight in kilograms divided by the square of the height in meters) of 25 or higher, obesity by an index of 30 or higher, and extreme or "morbid" obesity by an index of 40 or higher.

A body mass index of 40 or higher represents at least 100 lb of overweight status for men and 80 lb for women. In the United States, the age-adjusted prevalence of overweight in adults increased from 55.9% to 64.5% between the period 1988 and 1994 and the period 1999 and 2000. The prevalence of obesity increased from 22.9% to 30.5%; the prevalence of extreme obesity increased from 2.9% to 4.7% (24).

The epidemic of obesity in the United States has spawned a second epidemic of bariatric surgery. The number of gastrointestinal surgeries performed annually for severe obesity increased from about 16,000 in the early 1990s to about 103,000 in 2003. This increase has been fueled by the increase in the number of people who are extremely obese; the failure of diets, exercise, and medical therapy; and the advent of laparoscopic procedures (25). Minimally invasive techniques have been used in bariatric surgery since 1993. Laparoscopic bariatric procedures have proven to be safe and conserve known benefits of laparoscopic surgery, including but not limited to a shorter recovery with an earlier return to normal activity (26,27).

Experience gained form laparoscopic bariatric surgery paved the way for laparo-scopic surgery for almost all abdominal and retroperitoneal pathologies. Obesity was once considered a relative contraindication for urologic laparoscopic surgery; however, nowadays obese patients are probably better served with minimally invasive approaches that harbor fewer complications and offer faster recovery.

The acute major complications of open or laparoscopic surgery in the obese patient include pulmonary embolism, respiratory failure, cardiovascular events, wound infection, and bleeding. The most common late complication is incisional hernia. The level of risk is related to the specific procedure and the patient's age, degree of obesity, and other medical conditions. There is no comprehensive registry of such complications. Thus, it is difficult to obtain accurate data about the specific rates of serious complications and death that can be anticipated and that may occur even with excellent care.

Owing to the smaller access incision, wound infections and incisional hernias after laparoscopic surgery are expected to be less common than after open surgery. The extent of incisional hernia is related to the size of the initial incision. Incisional hernias after open surgery tend to be larger and require a more extensive repair with mesh, whereas incisional hernias that develop after laparoscopic surgery tend to be small and can be repaired with primary closure. Another easily recognized benefit of laparoscopic surgery in the obese patient is the reduced risk for retained instruments and laparotomy pads. Morbidly obese patients undergoing open surgery are at high risk for retained foreign objects. Another possible benefit of laparoscopy is the reduction in bowel obstruction because of the theoretical reduction in adhesion formation and the early return to normal bowel function.

In a comprehensive review of complications of laparoscopic bypass surgery in over 3400 patients as compared to open surgery, Podnos et al. reported that laparoscopic surgery in this morbidly obese population was associated with a decrease in wound

The presence of ascites (irrespective of type) has been previously recognized as a significant and independent risk factor for early port site recurrences in the general surgery and gynecology literature.

A body mass index of 40 or higher represents at least 100 lb of overweight status for men and 80 lb for women. In the United States, the age-adjusted prevalence of overweight in adults increased from 55.9% to 64.5% between the period 1988 and 1994 and the period 1999 and 2000.

Experience gained form laparoscopic bariatric surgery paved the way for laparoscopic surgery for almost all abdominal and retroperitoneal pathologies. Obesity was once considered a relative contraindication for urologic laparoscopic surgery; however, nowadays obese patients are probably better served with minimally invasive approaches that harbor fewer complications and offer faster recovery.

infection, incisional hernia, and mortality. However, there were no significant differences in the frequency of pulmonary embolism or pneumonia (28).

There are fewer reports in the urologic literature on laparoscopic surgery in the obese patient. However, contemporary series of laparoscopic nephrectomy, donor nephrectomy, adrenalectomy, and prostatectomy have been published and demonstrated safety and success of these complex procedures in obese patients.

Fugita et al. reviewed the Johns Hopkins series of intraperitoneal laparoscopic radical nephrectomy in the obese patient population. A body mass index greater than 30 was used to define obesity. Technical modifications included slightly greater insufflation pressures and a lateral shift in trocar sites. Of 101 patients, 32 were obese and 69 were not. The authors did not find significant differences in any of the analyzed parameters between the obese and nonobese patients, including operative time, time to ambulation, length of hospital stay, conversion rate to an open procedure, and complication rate. One conversion to an open procedure was required in both the obese and the nonobese laparoscopic groups (29). These authors concluded that obesity should not be considered a contraindication to laparoscopic nephrectomy. Similarly, Doublet et al. reported that retroperitoneal laparoscopic simple nephrectomy in obese patients was not associated with higher morbidity or longer hospitalization than in nonobese patients. In this series, eight patients had a body mass index 30 or greater and were compared to 40 nonobese patients. Of note, 22 patients were renal transplant recipients and underwent nephrectomy of native kidney (30). Fazeli-Matin et al. compared retrospectively the outcome of laparoscopic versus open renal and adrenal surgery in the obese patient (body mass index 30 or greater) at the Cleveland Clinic. The majority of laparo-scopic procedures were performed using a retroperitoneoscopic approach. To insure adequate case matching, open group patients with factors precluding laparoscopic surgery were excluded from the study. There were 21 obese patients in each group and baseline parameters were comparable between groups. Surgical time between the laparoscopic and open groups was comparable; however, the laparoscopic group had decreased blood loss, quicker resumption of oral intake and ambulation, decreased narcotic analgesic requirements, shorter hospital stay, and quicker convalescence. The complication rate was similar (31).

The applicability of laparoscopic donor nephrectomy has also been reported in the obese donor. In a small series of 40 patients at the Georgetown Transplant Institute, the outcome of obese patients (body mass index >31) did not differ from nonobese donors (32). In a larger report, Jacobs et al. assessed 431 laparoscopic living donor nephrectomies. The markedly obese group consisted of 41 patients with a body mass index greater than 35. Forty-one controls with a body mass index less than 30 were matched to the obese donors. Donor operations in the markedly obese were significantly longer by an average of 40 minutes. Obese donors were more likely to require open conversion. More and larger laparoscopic ports were used in the markedly obese. The postoperative recovery of the gastrointestinal tract, hospitaliza-tion time, analgesic requirements, and total complications were equal in the two groups, although the obese donors' complications tended to be cardiopulmonary problems. But most importantly, the recipient graft function was equivalent between

Markedly obese patients have an the two groups (33).

increased risk of complications from Markedly obese patients have an increased risk of complications from surgery, surgery, regardless of the approach. regardless of the approach.

The current literature suggests that laparoscopic renal and adrenal surgery is technically feasible in the obese patient and results in decreased blood loss, quicker return of bowel function, less analgesic requirement, shorter convalescence, and reduced hospital stay as compared to open surgery. Upper tract laparoscopic surgery in this subset of patients does not seem to negatively impact the long-term functional and oncologic outcomes.

Less is known about lower tract laparoscopic surgery in obese patients. In a multi-institutional review of the incidence and factors contributing to conversion from laparoscopic radical prostatectomy to open prostatectomy among eight U.S. surgeons, obesity was found to be a major player. Of 670 operations, 13 (1.9%) were converted to open. Comorbidities associated with conversion were prior pelvic surgery and obesity (body mass index greater than 30). Six of the 13 conversions occurred in the surgeons' first five cases. Despite open conversion, the functional outcomes did not appear to be adversely affected (34). In another review of 100 consecutive cases of transperitoneal laparoscopic radical prostatectomy, prostate weight, androgen deprivation, and prior abdominal surgery did not significantly affect the operative time. However, obesity and the level of surgeon's experience increased the operative time by an average of 38 minutes (35).

In general, obese patients should initially be considered as relative contraindication to laparoscopic surgery until the learning curve has been overcome. In experienced hands, obese patients do benefit from the minimal invasiveness of laparoscopy. Regardless of approaches, obese patients remain at higher risks of medical and surgical complications due to associated comorbidities and technical difficulty. Appropriate patient selection, optimization of medical condition, and informed consent are paramount in this process.

Surgical planning and medical optimization of the patient condition are emphasized in the obese. The patient should be cleared for surgery by the medical team. Deep venous thrombosis prophylaxis is achieved with subcutaneous heparin or low molecular weight heparin, compressive lower extremity stockings or pneumatic sleeves, and early ambulation. Prophylactic antibiotics (first- or second-generation cephalosporins) are also administered perioperatively. Minor intraoperative modifications can facilitate the procedure in obese patients and these include proper trocar site selection, which is usually more lateral in upper tract surgery. We do not recommend routine use of higher insufflation pressure because it compromises ventilation; however, occasional increased pressure may achieve a larger working space.

In general, obese patients should initially be considered as relative contraindication to laparoscopic surgery until the learning curve has been overcome. In experienced hands, obese patients do benefit from the minimal invasiveness of laparoscopy. Regardless of approaches, obese patients remain at higher risks of medical and surgical complications due to associated comorbidities and technical difficulty. Appropriate patient selection, optimization of medical condition, and informed consent are paramount in this process.

The minimally invasive nature of laparoscopic surgery in general offers several advantages over open surgery in the elderly patient population.

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