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JOGC

Guideline No. 386-Gynaecologic Surgery for Patients with Obesity

      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

      • 1
        One in 5 Canadians is obese, with an increasing prevalence over time and with implications for multiple body systems (high).
      • 2
        Obesity is associated with widespread physiological changes and comorbid conditions that can impact the conduct of gynaecologic surgery (high).
      • 3
        Minimally invasive hysterectomy (vaginal, laparoscopic, robotic) is associated with fewer wound complications and shorter hospital stays compared with open hysterectomy in patients with obesity (moderate).
      • 4
        In 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).
      • 5
        There is no evidence for continuing thromboprophylaxis after hospital discharge based solely on body mass index or obesity (very low).
      • 6
        Patients with obesity are prone to nerve injuries and pressure sores, particularly during long cases (strong).
      • 7
        Management of the panniculus depends on the patient's weight distribution, mobility of the panniculus, and surgeon preference (moderate).
      • 8
        In 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

      • 1
        Surgical teams should measure body mass index as part of the preoperative evaluation (strong, high).
      • 2
        Surgical 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).
      • 3
        Surgical 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).
      • 4
        Surgical 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).
      • 5
        Surgical teams should counsel all patients with obesity to stop or wean smoking prior to gynaecologic surgery (strong, very low).
      • 6
        Surgical teams should identify patients with potential airway concerns (e.g. enlarged neck circumference) and consider referral to Anaesthesia for preoperative assessment (strong, very low).
      • 7
        Surgical 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).
      • 8
        Wherever possible, surgeons should choose a minimally invasive approach to hysterectomy in patients with obesity, rather than laparotomy (strong, high).
      • 9
        Surgeons 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).
      • 10
        In 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).
      • 11
        For 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).
      • 12
        Initial 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).
      • 13
        Surgeons should have a low threshold to use the left upper quadrant for abdominal entry at laparoscopy in patients with obesity (weak, low).
      • 14
        The 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).
      • 15
        In 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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