Obesity in Gynaecology (587)

BMI should be available before counselling and written consent is obtained as surgical and anaesthetic risks rise with increasing BMI. Many gynaecological conditions will respond favourably to weight loss e.g. menstrual disorders, PCOS, subfertility, prolapse and stress incontinence. Non-surgical management of the obese patient with benign disease is often most clinically appropriate. There should be clear discussion and documentation of which medical treatment options have been offered and whether they were accepted or declined.

In situations where surgery is deemed necessary for benign disease, weight loss is desirable and should be advised. The increased risks of common intra- and post-operative complications such as bleeding, visceral damage, wound infection, thromboembolism and respiratory tract infection should also be discussed and documented.

Pre-operative planning should take place in order to reduce the risk.

• Requirement for in-patient management will depend on local day surgery BMI limit
• Obese patients will require longer list time (surgical and anaesthetic)
• Theatre tables generally support a weight of 300Kg and extenders are available to increase bed width. Local specifications should be ascertained prior to operating on a morbidly obese patient
• Appropriate measures for moving and handling must be taken eg. appropriate staffing, hover mattresses etc
• Surgical Equipment – special equipment requirements such as Alexis retractors, long ports/instruments, ligasure / ligasure atlas short etc should be communicated to the theatre team in advance
• Surgical assistance – the appropriate skill-mix and number of assistants should be arranged
• HDU/ITU bed should be booked in advance of surgery if likely to be required

Obese women have an increased risk of anaesthetic difficulty and complications, related to their obesity, as well as the presence of medical co-morbidities. Specialist expertise is required to address:

• difficult venous access
• difficult airway access
• co-morbidities (altered cardio-respiratory function/disease, hypertension/IHD, diabetes and obstructive sleep apnoea)
• altered drug metabolism

Laparoscopic surgery has significantly lower morbidity than open surgery for obese patients however this will depend on the surgical expertise available. Surgery may be more complicated due to:

• Altered surface landmarks
• Difficult access – especially with pannus (Risk of collateral damage, complications may be difficult to access and repair)
• Bowel falls in to view
• Difficult positioning/slippage with Trendelenberg tilt
• Higher risk of conversion from laparoscopic to open surgery

Clinical evidence increasingly suggests that alternative laparotomy entry sites ( high transverse avoiding the pannus) may lead to lower SSI (surgical site infection) rates.

Obesity is NOT a contraindication to Enhanced Recovery After Surgery guidance.

Obese patients may require HDU care post-operatively to cater for additional needs in the immediate post-operative period. Forward planning may be required if specialist beds/hoists/commodes/chairs are required in order to aid mobility and reduce risk of post-operative ileus and pressure sores.

The risk of thrombo-embolic disease is increased in the obese patient. Early mobilisation, leg exercises, adequate hydration and correctly fitted anti-embolism stockings (either above or below the knee) as recommended by SIGN 122 should be instituted to reduce risk (2). Weight adjusted dosage of low molecular weight heparin should be given subcutaneously as per the relevant guideline.

Obesity also contributes to a greater risk of post-operative sepsis, in particular surgical site infection. There are no specific recommendations for routine administration of additional prophylactic antibiotics. Early intervention and treatment should be initiated however, should post operative sepsis becomes evident.