Safety of Laparoscopy in Obese Infertile Women

Abstract:

• Design: A prospective comparative study.
• Settings: Al Husien University Hospital, between June 2002 and April 2003.
• Aim of the Work: For evaluation of difficulties and complications of laparoscopy operation in obese women versus non obese women.
  Patients and Methods: 60 obese infertile women (BMI >30) and 60 non-obese infertile women (BMI <25) were subjected to laparoscopy operation. The difficulties and complications of the procedure were compared in both groups.
• Results: There was no statistically significant differences between both groups as regard to the pathological findings and diagnosis of infertility causes through diagnostic laparoscopy, and the operative procedures done for treatment of pathological lesions found in both groups. There was no statistically significant differences as regard to intra-operative and postoperative complications found in both groups.
  The mean duration of diagnostic and operative laparoscopy was statistically significant longer in obese women group (p<0.05). The mean time needed for Veress needle insertion and creation of pneumoperitoneum was statistically significant more in obese women group (p<0.05). A second site for Veress needle insertion was used in 11 obese women (18.3%) vs. one case(1.7%) in non obese women (p<0.05).
• Conclusions: No statistically significant differences were found between obese women and non obese women as regard to intra-operative and postoperative complications of diagnostic and operative laparoscopy.
  Minor technical difficulties are more common among obese women during diagnostic and operative laparoscopy.
  Laparoscopy operation can be considered as safe in obese women as in non obese women.

Introduction:

• Obesity alters the physiological and biochemical functions of the body and shortens life expectancy⁽¹⁴⁾.
• Postoperative morbidity and mortality are higher in obese than in non obese patients. Wound infection is twice common among obese patients. DVT and pulmonary embolism are higher specially after abdominal surgery due to postoperative pain and lack of ambulation⁽²²⁾.
• Laparascopic surgery may be of particular benefit to obese patients for prevention of post-laparotomy complications⁽³⁾.
• Significant obesity is a relative contraindication to laparoscopy operation, as regard to technical difficulties and complications⁽⁸⁾.
• The aim of this work was to evaluate the intra-operative and postoperative complications of laparoscopy operation in obese infertile women in comparison to non obese infertile women.

Patients and Methods:

This study included 120 infertile women for whom laparoscopy operation was indicated for evaluation of the cause of infertility. They were selected according to their body mass index (BMI) and divided into 2 equal groups. Group A included 60 obese women with BMI >30 and group B included 60 normal weight women with BMI <25. Women with BMI between > 25 and <30 were excluded to avoid overlapping of results in this group of overweight women with lower risk than in obese women. Cases with associated medical disorders were excluded. All cases were subjected to full history taking, complete general and gynecological examination. The BMI was calculated for selection of cases in each group: 

General anaesthesia was used for all cases with recording of difficulties encountered during and after anaesthesia. Laparoscopy operations were done as usual using triple punctures technique. Open laparoscopy⁽⁹⁾ was done for cases of previous mid line abdominal scars with possible intraperitoneal adhesions. Long Veress needle was used for obese women. CO₂  gas was used for insufflation with recording of time, CO₂  volume used and difficulties during creation of pneumoperitoneum in all cases. Diagnostic laparoscopy was done with methyline blue hydrotubation test for all cases. Operative laparoscopy was done whenever indicated for treatment of pelvic pathological lesions. The diagnosis of the case, the operative procedures done, the time needed, and the intra-operative difficulties and complications were recorded and compared for both groups. The postoperative complications and hospital stay were compared for both groups.
All data were tabulated and statistically analyzed using computer E.P.I. information program.

Results:

Open laparoscopy was done for 6 obese women due to bad midline abdominal scars in 2 cases, and to overcome extraperitoneal insufflation in 3 cases and surgical emphysema in one case. While it was done in one case in non obese group due to bad scar.

Discussion:

Obesity is associated with several health risks and decreases life expectancy. Morbidly obese individuals may develop one or more complications. These are mainly cardiovascular, metabolic, respiratory, gastrointestinal, renal, genitourinary and gynecological complications^{(23, 15, 10)}. Obese patients are at significant risk of complications when undergoing anaesthesia and laparotomy⁽²⁾.

While obesity was considered a relative contraindication to laparoscopy⁽⁸⁾, it should no longer be considered a contraindication to laparoscopic surgery^{(20, 5)}.
In the present study 2 equal groups of obese women and non obese women, had nearly equal numbers of diagnostic and operative laparoscopy operations in both groups. No statistically significant differences were found in the demographic data of both groups. It was found that the mean duration of diagnostic and operative laparoscopies was statistically significant longer in obese women group (<0.05). These results go in agreement with that reported by⁽⁶⁾, who found significantly longer mean times for diagnostic and operative laparoscopies in obese patients and significantly longer mean times for Veress needle insertion and trocar and canula insertion in obese group. Similarly in the present study the mean times for Veress needle insertion, CO₂ insufflation and mean volume of CO₂  used for creation of pneumoperitoneum, in obese group were significantly longer than in non obese group. 

These findings can be explained by difficulty in introduction of Veress needle due to thick subcutaneous fat, downward displacement of the umbilicus and big peritoneal cavity in obese women. A second site for Veress needle insertion was needed in 11 cases of obese women, VS.1 (p<0.05). It was inserted through the base of the umbilicus after correction of it’s downward shift, or at the left mammilary line at the margin of the left costal arch. These findings are going in agreement with that reported by^{(11,13,18,16)}.

The overall intra-operative complication rate was 11.8% in obese women vs. 1.7% (p>0.05) and laparotomy was needed in 1.7% VS., 0% (p>0.05). This is going in agreement with results reported by^(1,12,6), found no significant difference in the rate of intra-operative complications between obese and non obese women except the high laparotomy conversion rate of 14.9% in obese women, VS., 5.6% (p=0.04). While⁽²¹⁾ found that intra-operative complication rate was lower in obese patients than in non obese patients.

In a multicentral study of 29965 cases of diagnostic and operative laparoscopies, they found that the mortality rate was 3.33 per hundred thousand laparoscopies, overall intra-operative complications rate of 4.64 per thousand laparoscopies and laparotomy conversion rate of 3.2 per thousand laparoscopies (4).
As regard to anaesthesia related complications in the present study. No significant difference had been found between both groups, this is go in agree with study done by⁽⁷⁾ who found no difference between healthy obese and non obese women in the cariovascular changes during laparoscopy.

It was reported that obese women are more liable to unpredictable difficulties during endotracheal intubation⁽²⁴⁾. In the present study difficult endotracheal intubation was found in 4 cases of obese women vs. 1 (p>0.05) case in non-obese group.

As regard to postoperative complications and hospital stay no significant differences were found between both groups. This is going with findings reported by:^{(17, 6, 1, 12, 19)}.

Conclusions:

• Laparoscopy, whether diagnostic or operative, needs more time in obese women.
• Technical difficulties must be expected during laparoscopy for obese women.
• Laparoscopy is as safe in obese women as in non-obese women.
• The postoperative complications and hospital stay after laparoscopy for obese women are as minimal as in non-obese women.

References:

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