ABSTRACT
Objective
To provide gynaecologic surgeons with a contemporary review of pre-, intra-, and postoperative
issues associated with obesity and to provide guidance for optimization and strategies
for safer surgical care.
Intended Users
Physicians, including gynaecologists, family physicians, general surgeons; nurses,
including registered nurses and nurse practitioners; medical trainees, including medical
students, residents, and fellows; and all other health care providers.
Target Population
Adult women (18 years and older) meeting criteria for obesity (body mass index ≥30)
and undergoing gynaecologic surgery.
Outcomes
Physiologic changes and comorbid conditions associated with obesity; the evidence
for the impact of obesity on gynaecologic surgery; and preoperative, intraoperative,
and postoperative interventions to reduce risk.
Evidence
For this guideline, relevant studies were searched in the PubMed, EMBASE, Medline,
and Cochrane databases. MeSH search terms included Gynecology, Obesity, Obesity/morbid,
Overweight, Body mass index, Surgery, Laparoscopy, Laparotomy, Anesthesia, Intraoperative
complications, Postoperative complications, Morbidity, and Mortality.
Validation methods
The content and recommendations were drafted and agreed upon by the principal authors
and members of the Gynaecology Committee. The Board of the Society of Obstetricians
and Gynaecologists of Canada (SOGC) approved the final draft for publication. The
quality of evidence was rated using the criteria described in the Grading of Recommendations
Assessment, Development and Evaluation (GRADE) methodology framework.
Benefits, Harms, and Costs
Obesity affects 1 in 5 Canadian adults. This guideline outlines strategies to improve
outcomes in women with obesity undergoing gynaecologic surgery.
Guideline Update
This SOGC clinical practice guideline will be automatically reviewed 5 years after
publication. However, authors can propose another review date if they feel that 5
years is too short/long based on their expert knowledge of the subject matter.
Sponsors
This guideline was developed with resources funded by the SOGC.
SUMMARY STATEMENTS
- 1One in 5 Canadians is obese, with an increasing prevalence over time and with implications for multiple body systems (high).
- 2Obesity is associated with widespread physiological changes and comorbid conditions that can impact the conduct of gynaecologic surgery (high).
- 3Minimally invasive hysterectomy (vaginal, laparoscopic, robotic) is associated with fewer wound complications and shorter hospital stays compared with open hysterectomy in patients with obesity (moderate).
- 4In women with benign conditions, increasing body mass index and obesity are associated with increased complications primarily with open hysterectomy, but less so with minimally invasive hysterectomy (high).
- 5There is no evidence for continuing thromboprophylaxis after hospital discharge based solely on body mass index or obesity (very low).
- 6Patients with obesity are prone to nerve injuries and pressure sores, particularly during long cases (strong).
- 7Management of the panniculus depends on the patient's weight distribution, mobility of the panniculus, and surgeon preference (moderate).
- 8In patients with elevated body mass index and central obesity, the umbilicus lies more caudally in relation to the aortic bifurcation when compared with lean counterparts (strong).
RECOMMENDATIONS
- 1Surgical teams should measure body mass index as part of the preoperative evaluation (strong, high).
- 2Surgical teams should recommend weight loss in patients with obesity, with consideration of referral to a dietitian or weight loss program; bariatric surgery may be an option with Class III obesity or Class II obesity with comorbidity (weak, very low).
- 3Surgical teams should tailor preoperative investigations, such as pulmonary and cardiac testing, in patients with obesity depending on current symptoms, comorbidities, and the type of surgery (weak, very low).
- 4Surgical teams may consider screening for diabetes in patients with obesity based on symptoms, risk factors, and/or age; preoperative treatment of skin infections should be done in all patients with obesity, regardless of diabetic status (weak, low).
- 5Surgical teams should counsel all patients with obesity to stop or wean smoking prior to gynaecologic surgery (strong, very low).
- 6Surgical teams should identify patients with potential airway concerns (e.g. enlarged neck circumference) and consider referral to Anaesthesia for preoperative assessment (strong, very low).
- 7Surgical teams should consider screening patients with obesity for obstructive sleep apnea (e.g., the STOP-BANG questionnaire) and make appropriate preoperative referral for those who screen positive (e.g., ≥5) (strong, very low).
- 8Wherever possible, surgeons should choose a minimally invasive approach to hysterectomy in patients with obesity, rather than laparotomy (strong, high).
- 9Surgeons can consider using published weight-based dosing of cefazolin, gentamicin, and vancomycin; however, there is insufficient evidence to support re-dosing antibiotics intraoperatively or continuing postoperatively based on obesity alone (strong, low).
- 10In patients with obesity undergoing gynaecologic surgery, surgical teams can use the Caprini score to estimate venous thromboembolism risk and thus whether to prescribe mechanical, pharmacological, or both types of thromboprophylaxis (strong, low).
- 11For laparoscopy, patients should be positioned on a bed fitted to prevent slippage in Trendelenburg position, with the arms tucked at the sides and legs in low lithotomy position, using extra padding as necessary (strong, low).
- 12Initial abdominal entry for laparoscopic cases should be based on several factors, including expertise of the surgeon, size and mobility of the panniculus, and selection of port placement to optimize triangulation and surgical visualization (strong, moderate).
- 13Surgeons should have a low threshold to use the left upper quadrant for abdominal entry at laparoscopy in patients with obesity (weak, low).
- 14The abdomen can be insufflated initially to a high intraperitoneal pressure (25–30 mm Hg) for port placement and then should be maintained at or below 12–15 mm Hg, maintaining the lowest pressure possible that does not compromise visualization (strong, low).
- 15In the admitted patient with obesity after gynaecologic surgery, surgical teams should optimize respiratory function including early ambulation, proper positioning, general respiratory care, opioid-sparing analgesics, and continuous positive airway pressure in selected cases (strong, very low).
Key Words
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Article Info
Publication History
No. 386, September 2019
Footnotes
This document reflects clinical and scientific consensus on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well-documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the publisher.
All people have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to facilitate informed choice, patients should be provided with information and support that is evidence-based, culturally appropriate, and tailored to their needs.
This guideline was written using language that places women at the centre of care. The SOGC is committed to respecting the rights of all people—including transgender, gender non-binary, and intersex people—for whom the guideline may apply. We encourage health care providers to engage in respectful conversation with patients regarding their gender identity and their preferred gender pronouns to be used as a critical part of providing safe and appropriate care. The values, beliefs, and individual needs of each patient and their family should be sought and the final decision about the care and treatment options chosen by the patient should be respected.
Identification
Copyright
© 2018 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
