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
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Journal of Obstetrics and Gynaecology CanadaAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
REFERENCES
- Overweight and Obese Adults (Self-Reported), 2014.Statistics Canada, Ottawa2014 (Available at:) (Accessed on February 15, 2019)
- The burden of adult obesity in Canada.Chronic Dis Can. 2007; 27: 135-144
- Inclusion of body mass index in the history of present illness.Obstet Gynecol. 2013; 121: 59-64
- Hysterectomy in obese patients: special considerations.Clin Obstet Gynecol. 2014; 57: 106-114
- Laparoscopy in the morbidly obese: physiologic considerations and surgical techniques to optimize success.J Minim Invasive Gynecol. 2014; 21: 182-195
- Considerations for minimally invasive gynecologic surgery in obese patients.Curr Opin Obstet Gynecol. 2016; 28: 283-289
- Body mass index trumps age in decision for endometrial biopsy: cohort study of symptomatic premenopausal women.Am J Obstet Gynecol. 2016; 215: 598.e1-598.e8
- Hysterectomy in very obese and morbidly obese patients: a systematic review with cumulative analysis of comparative studies.Arch Gynecol Obstet. 2015; 292: 723-738
- Laparoscopic and vaginal approaches to hysterectomy in the obese.Eur J Obstet Gynecol Reprod Biol. 2015; 189: 85-90
- Association between body mass index, uterine size, and operative morbidity in women undergoing minimally invasive hysterectomy.J Minim Invasive Gynecol. 2016; 23: 1113-1122
- Laparoscopic-assisted vaginal hysterectomy versus total laparoscopic hysterectomy for the management of endometrial cancer: a randomized clinical trial.J Minim Invasive Gynecol. 2006; 13: 114-120
- Case-mix variables and predictors for outcomes of laparoscopic hysterectomy: a systematic review.J Minim Invasive Gynecol. 2016; 23: 317-330
- Influence of the modifiable life-style factors body mass index and smoking on the outcome of hysterectomy.Acta Obstet Gynecol Scand. 2016; 95: 65-73
- The effect of obesity on total abdominal hysterectomy.J Womens Health (Larchmt). 2010; 19: 1915-1918
- Does obesity complicate perioperative course in patients undergoing abdominal hysterectomy?.Arch Gynecol Obstet. 2012; 286: 385-388
- Effect of body mass index on maternal morbidity following peripartum hysterectomy.Clin Obes. 2015; 5: 72-78
- The impact of BMI on surgical complications and outcomes in endometrial cancer surgery–an institutional study and systematic review of the literature.Gynecol Oncol. 2015; 139: 369-376
- Impact of body mass index and operative approach on surgical morbidity and costs in women with endometrial carcinoma and hyperplasia.Gynecol Oncol. 2017; 145: 55-60
- A population-based registry study evaluating surgery in newly diagnosed uterine cancer.Acta Obstet Gynecol Scand. 2016; 95: 901-911
- Predictors of complications in gynaecological oncological surgery: a prospective multicentre study (UKGOSOC-UK gynaecological oncology surgical outcomes and complications).Br J Cancer. 2015; 112: 475-484
- Robotic surgery in supermorbidly obese patients with endometrial cancer.Am J Obstet Gynecol. 2015; 213 (49.e1–8)
- Robotic hysterectomy in severely obese patients with endometrial cancer: a multicenter study.J Minim Invasive Gynecol. 2016; 23: 94-100
- Laparoscopic surgery for early endometrial cancer.Acta Obstet Gynecol Scand. 2016; 95: 894-900
- Outcomes and feasibility of laparoscopic sacrocolpopexy among obese versus non-obese women.Int J Gynaecol Obstet. 2013; 120: 49-52
- The incidence of transfusion and associated risk factors in pelvic reconstructive surgery.Am J Obstet Gynecol. 2017; 217 (612.e1–8)
- No. 360-induced abortion: surgical abortion and second trimester medical methods.J Obstet Gynaecol Can. 2018; 40: 750-783
- Laparoscopic management of tubal ectopic pregnancy in obese women.Fertil Steril. 2004; 81: 198-202
- Endometrial ablation for the treatment of heavy menstrual bleeding in obese women.Int J Gynaecol Obstet. 2013; 121: 20-23
- Association of clinical outcomes and complications with obesity in patients who have undergone abdominal myomectomy.J Chin Med Assoc. 2016; 79: 435-439
- Clinical practice guidelines for antimicrobial prophylaxis in surgery.Am J Health Syst Pharm. 2013; 70: 195-283
- Centers for Disease Control and Prevention guideline for the prevention of surgical site infection, 2017.JAMA Surg. 2017; 152: 784-791
- Effects of maternal obesity on tissue concentrations of prophylactic cefazolin during cesarean delivery.Obstet Gynecol. 2011; 117: 877-882
- Antibiotic prophylaxis in gynaecologic procedures.J Obstet Gynaecol Can. 2012; 34: 382-391
- Global guidelines for the prevention of surgical site infection.WHO, Geneva2016
- Venous thromboembolism prophylaxis in gynecologic surgery: a systematic review.Obstet Gynecol. 2011; 118: 1111-1125
- Efficacy of intermittent pneumatic compression for venous thromboembolism prophylaxis in patients undergoing gynecologic surgery: a systematic review and meta-analysis.Oncotarget. 2017; 8: 20371-20379
- Prevention of VTE in nonorthopedic surgical patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines.Chest. 2012; 141: e227S-e277S
- Effect of obesity on patients undergoing vaginal hysterectomy.J Minim Invasive Gynecol. 2014; 21: 168-175
- Perioperative rates of deep vein thrombosis and pulmonary embolism in normal weight vs obese and morbidly obese surgical patients in the era post venous thromboembolism prophylaxis guidelines.Am J Surg. 2015; 210: 859-863
- Obesity: physiologic changes and challenges during laparoscopy.Am J Obstet Gynecol. 2004; 191: 669-674
- Obesity in laparoscopic surgery.Best Pract Res Clin Obstet Gynaecol. 2015; 29: 554-564
- Consideration for safe and effective gynaecological laparoscopy in the obese patient.Arch Gynecol Obstet. 2015; 292: 135-141
- Alignment of the umbilical axis: an effective maneuver for laparoscopic entry in the obese patient.Obstet Gynecol. 1998; 92: 869-872
- Laparoscopic entry techniques.Cochrane Database Syst Rev. 2015; CD006583
- No. 193-laparoscopic entry: a review of techniques, technologies, and complications.J Obstet Gynaecol Can. 2017; 39: e69-e84
- Laparoscopy in morbidly obese patients.J Am Assoc Gynecol Laparosc. 1999; 6: 307-312
- The relationship of the umbilicus to the aortic bifurcation: implications for laparoscopic technique.Obstet Gynecol. 1992; 80: 48-51
- Abdominal wall characterization with magnetic resonance imaging and computed tomography. The effect of obesity on the laparoscopic approach.J Reprod Med. 1991; 36: 473-476
- Anatomy of the left upper quadrant for cannula insertion.J Am Assoc Gynecol Laparosc. 2000; 7: 211-214
- Safety in laparoscopy.J Reprod Med. 1974; 13: 1-5
- Safe laparoscopic entry guided by Veress needle CO2 insufflation pressure.J Am Assoc Gynecol Laparosc. 2003; 10: 415-420
- Effect of body habitus and parity on the initial Veres intraperitoneal CO2 insufflation pressure during laparoscopic access in women.J Minim Invasive Gynecol. 2006; 13: 108-113
- How much gas is required for initial insufflation at laparoscopy?.Gynaecol Endosc. 1999; 8: 369-374
- The impact of morbid obesity, pneumoperitoneum, and posture on respiratory system mechanics and oxygenation during laparoscopy.Anesth Analg. 2002; 94: 1345-1350
- Laparoscopic exposure in obese high-risk patients with mechanical displacement of the abdominal wall.Obstet Gynecol. 2004; 103: 383-386
- Robotic hysterectomy strategies in the morbidly obese patient.JSLS. 2013; 17: 418-422
- Vaginal hysterectomy: 6 challenges, an arsenal of solutions.OBG Management. 2006; 18: 96-103
- Vacuum assisted wound closures in gynaecologic surgery.J Obstet Gynaecol Can. 2011; 33: 1031-1037
- Cost of care using prophylactic negative pressure wound vacuum on closed laparotomy incisions.Gynecol Oncol. 2014; 132: 684-689
- Prophylactic negative pressure wound therapy for obese women after cesarean delivery: a systematic review and meta-analysis.Obstet Gynecol. 2017; 130: 969-978
- Evaluation of indicated non-cosmetic panniculectomy at time of gynecologic surgery.Int J Gynaecol Obstet. 2017; 138: 207-211
- Extended antibiotic prophylaxis for prevention of surgical-site infections in morbidly obese women who undergo combined hysterectomy and medically indicated panniculectomy: a cohort study.Am J Obstet Gynecol. 2010; 202 (306.e1–9)
- Hysterectomy with concurrent panniculectomy: a propensity-matched analysis of 30-day outcomes.Plast Reconstr Surg. 2015; 136: 582-590
- Outcomes and safety of the combined abdominoplasty-hysterectomy: a preliminary study.Aesthetic Plast Surg. 2015; 39: 667-673
- Assessing the safety and efficacy of combined abdominoplasty and gynecologic surgery.Ann Plast Surg. 2011; 67: 272-274
- A technique for laparoscopic peritoneal entry after abdominoplasty.J Laparoendosc Adv Surg Tech A. 2013; 23: 990-991
- Laparoscopic surgery following abdominal wall reconstruction: description of a novel method for safe entry.BJOG. 2004; 111: 1452-1453
- Laparoscopy in patients following transverse rectus abdominis myocutaneous flap reconstruction.Obstet Gynecol. 2000; 96: 132-135
- Difficulties of bariatric surgery after abdominoplasty.Case Rep Surg. 2014; 2014620175
- The utility of diagnostic laparoscopy in post-bariatric surgery patients with chronic abdominal pain of unknown etiology.Obes Surg. 2017; 27: 1924-1928
- Laparoscopic revolution in bariatric surgery.World J Gastroenterol. 2014; 20: 15135-15143
- American Society for Metabolic and Bariatric Surgery integrated health nutritional guidelines for the surgical weight loss patient 2016 update: micronutrients.Surg Obes Relat Dis. 2017; 13: 727-741
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.
