Can Body Mass Index Influence the Outcome of a Laparoscopic Hysterectomy?

Abstract

Objective: The purpose of this study was to evaluate differences in outcomes on the basis of body mass index (BMI) in patients undergoing laparoscopic hysterectomy. Design: The study was a retrospective analysis. Methods: All cases of laparoscopic hysterectomy performed from May 2008 to May 2012 for benign, microinvasive cervical, early endometrial, and occult ovarian carcinoma were reviewed. There were 347 patients analyzed by BMI. As proposed by the World Health Organization classification system of obesity, patients were categorized by BMI. Ideal BMI was defined as being between 18.5 and 24.9 kg/m², overweight was defined as having a BMI between 25 and 29.9 mg/m², and obesity was defined as having a BMI ≥30 kg/m². Laparoscopic surgery was completed successfully in 338 patients, and 9 patients had their surgery converted to laparotomy for findings at the surgery, not for complications relating to the surgery, and, therefore, were excluded from the analysis. Results: Mean age was 51.1 years in the ideal group, 50.45 in the overweight group, and 55.49 in the obese group. The patients' ages ranged in all the samples between 31 and 94 years (p<0.003). Mean operating time was 105.5 minutes, mean blood loss was 252 mL, and mean length of hospital stay was 2.4 days. There was not a significant difference among the three groups. Total major complication rate was 3.7% and early postoperative complication rate was 5. There was not a significant difference among the three groups. Urologic injury was present in 0.6% of all patients. Conclusions: Laparoscopic hysterectomy is feasible and safe, resulting in short hospital stay, minimal blood loss, and minimal operating time for patients in all BMI groups. The laparoscopic approach may extend the benefits of minimally invasive hysterectomy to the very obese, for whom abdominal surgery poses serious risk. (J GYNECOL SURG 30:74)

Introduction

In the United Kingdom, ∼60,000 hysterectomies are performed each year.¹ High body mass index (BMI) is a known risk factor for benign gynecologic pathologies, and for endometrial hyperplasia and endometrial cancer. For this reason, many women with high BMI will require a hysterectomy.²

Currently, standard gynecologic practice dictates that, when feasible, vaginal hysterectomy (VH) is the surgical route of choice for benign hysterectomy.¹ This is based on numerous studies, including a Cochrane review, which have shown VH to be associated with reduced infective morbidity and earlier return to normal activities than abdominal hysterectomy (AH).^3,4 Moreover, a recent meta-analysis comparing total laparoscopic hysterectomy (TLH) to VH showed no differences in perioperative complications, but did show reduced postoperative pain scores and reduced hospital stay with TLH.⁵

There are situations in which vaginal surgery is not the ideal route for hysterectomy, such as: if women have had previous pelvic surgery, in the presence of severe endometriosis, if the uterus is large, if there is suspected adnexal pathology, and if there is limited uterine motility and/or descent. With advances in laparoscopic surgical techniques and instrumentation, a combined approach is now possible, and it offers a better view of the surgical anatomy, allows performance of concomitant surgery, and is suitable for larger uteri and those with little or no descent, which may be difficult to remove vaginally.

Laparoscopic-assisted vaginal hysterectomy (LAVH) and the advent of TLH now offer a means of converting an otherwise abdominal approach to a vaginal procedure, theoretically maintaining the advantages of the vaginal and of the laparoscopic approach.⁶

Higher BMI is known to add morbidity to open surgery, and was historically seen as a relative contraindication for advanced laparoscopic procedures. After recent reviews, however,^7–9 it has been shown that compared with open surgery, the laparoscopic approach may actually be beneficial to women with higher BMI, other than that there is a longer operating time. In a series of surgeries performed with total laparoscopic approach in 11 morbidly obese patients, there were no complications reported.¹⁰

LH and lymphadenectomy for the treatment of endometrial cancer have been reported in obese women.^11,12 The safety of laparoscopic surgery in women with early endometrial cancer has been recently confirmed in a multicenter randomized clinical trial. In this study, patients treated with laparoscopic surgery had a 74% decreased risk of serious complications when compared with women allocated to an abdominal approach.¹³

Moreover, laparoscopic subtotal hysterectomy has been shown to be an alternative for large uteri even in women with high BMI. However, relatively longer operating times and more blood loss can be expected in morbidly obese women.^14,15

The purpose of this retrospective study is to evaluate and describe the experience of LH in a district general hospital, and compare the differences in techniques (TLH and LAVH) and in outcomes in relation to patients' BMI.

Materials and Methods

This retrospective comparative study was conducted in the advanced laparoscopic surgery unit of the Princess Alexandra Hospital (United Kingdom) from May 2008 until May 2012 after approval from the hospital research and development committee.

Included were all the women who underwent LH for benign gynecologic indications, microinvasive cervical cancer, occult borderline ovarian cancer, and early stage endometrial cancer. Patients with advanced endometrial, ovarian, and cervical cancers or with a history of severe cardiac failure, myocardial infarction, unstable angina, or moderate pulmonary obstructive disease that was poorly controlled and made them unable to tolerate being in a prolonged steep Trendelenburg position were excluded from the study. No obese patients were refused a laparoscopic approach because of cardiopulmonary comorbidities, diabetes, older age, or illness. In addition, no patients were denied the laparoscopic approach on the basis of their BMI.

BMI was calculated by dividing a person's weight in kilograms by the square of her height in meters. Ideal BMI was defined being between 18.5 and 24.9 kg/m², overweight was defined as a BMI between 25 and 29.9 kg/m², and obesity was defined as having a BMI of ≥30 kg/m², as proposed by the World health Organization classification system of obesity.

Preoperative clinical evaluation included assessment of uterine size and mobility, pelvic ultrasonography or magnetic resonance imaging (MRI) if required, and endometrial sampling, which was performed with or without hysteroscopy if clinically indicated. Patients were fully counseled regarding the proposed procedure and available alternatives, written information was provided, and an informed consent was taken.

LH were divided in four surgical categories. Category 1 was the laparoscopic subtotal hysterectomy with a dissection to the level of the uterine body including the uterine vessels. Category 2 was the LAVH with a dissection to the level of the uterine vessels, with the procedure being completed vaginally. Category 3 was the LH with a laparoscopic dissection of the cardinal and uterosacral ligaments, without opening the vagina laparoscopically. Category 4 was the TLH with dissection of the uterosacral ligament, and opening of the vagina laparoscopically.

A three-port laparoscopic technique was performed for all the categories of hysterectomy. A 12 mm umbilical port was used with one 5 mm port on the operator side and a 5 mm port on the side opposite to the operating surgeon, both slightly lower than the umbilical port. The CO₂ pneumoperitoneum was created through direct entry, by the umbilical trocar as reported by Dingfelder.¹⁶ In cases where there had been previous surgery, a Palmer point direct entry was used.

In some cases in which dense adhesions or bleeding were present, an extra 5 mm port was used on the same side as the operator. The patient was in a modified lithotomy position, with the hips at ∼180 degree extension and the knees flexed at nearly 90 degrees, with the table tilted nearly 45 degrees Trendelenburg. All the patients had general anesthesia and received standard prophylactic cephalosporin antibiotics, and all had an upper body warmed-air circulating body warmer. The cytologic washing, if indicated, was always obtained before manipulating the tissues for abdominal inspection. All adhesions were lysed when present before the hysterectomy. The ureters were identified at the pelvic brim, and when a bilateral salpingo-oophorectomy was needed, the infundibulopelvic or utero-ovarian ligaments were cauterized with bipolar diathermy, and cut using the 5 mm LCS Harmonic scalpel (Ethicon Endo-Surgery). Subsequently, broad and round ligaments were sealed and cut by using the Harmonic scalpel. The uterus was then placed under tense axial elevation by pushing the uterine manipulator, to allow a bladder flap to be incised with the Harmonic scalpel and to expose the anterior cervical fascia. The uterine arteries were skeletonized and cauterized at the junction of the lower and middle third of the cervical body by using the bipolar cautery, and incised with the Harmonic scalpel directly to the cervical fascia beneath. The arterial pedicles were pushed inferiorly, exposing the cardinal ligament fibers. These were incised in three bundles: first anteriorly, then posteriorly to include the uterosacral ligament, and, finally, medially and inferiorly, staying on the cervical fascial surface. This last incision usually identifies the exact edge of the cervicovaginal margin. The anatomy was repeatedly confirmed by using instrument palpation of the firmer cervix stroma, which moves together as a solid mass, compared with the more pliant upper lateral vagina, which dimples easily.

Entry into the vagina and the incision of the entire cervix was performed with the Harmonic scalpel in the category 4 LH. The specimen was then retrieved vaginally. In the patients in whom a subtotal supra cervical hysterectomy was performed, the specimen was removed using a morcellator.

The catheter inserted during surgery was retained until the next day. Patients were reviewed daily and, subject to satisfactory recovery, were discharged from the hospital the next day or the day after.

Data were collected on a standardized pro forma, and entered into a computerized database. The database included patient demographics, operative indications, operating time, blood loss, operative and early postoperative complications, uterine weight, duration of hospital stay, and histology details. Measuring the volume of fluid in the suction system and subtracting the amount of irrigation used during the procedure calculated the intraoperative blood loss. The operating time was calculated from the insertion of the first port to skin closure of the last port site.

The study was powered adequately from a statistical perspective, and three groups included continuous data. The Kruskal–Wallis test for nonparametric data was used to detect medium to large effects, which would be of clinical relevance. A probability value of <0.05 was considered to be statistically significant.

Results

Of 347 patients identified, laparoscopic surgery was completed successfully in 338 patients, and 9 patients had their surgery converted to open laparotomy for findings at the surgery and not for complications relating to the surgery, and, therefore, were excluded from the analysis. Of the final 338 women included in the analysis, 87 had an ideal BMI, 101 were overweight, and 150 were obese. Of the 9 excluded from the final analysis, 1 patient with ideal BMI had surgery converted to open laparotomy because of a large uterus that weighed >1500 g. Four of the excluded women were in the overweight group and among those, 3 were excluded because of a large uterus that weighed >2 kg at the final histology, and 1 was excluded because of a large cervical retroperitoneal myoma. Four were in the obese group, and among those, 1 had surgery converted for a 12-cm vascular, solid, and cystic ovarian mass, which could not fit into the available morcellation bag for intact removal, 2 had surgery converted because of extensive and dense adhesions in addition to a large uterus, and 1 had surgery converted because of an isthimic myoma, which precluded hemostatic access to the uterine arteries.

There were significant differences in height and weight among the three BMI groups (p<0.001) (Table 1). Although the mean age was 51.1 years in the ideal group, 50.45 in the overweight group, and 55.49 in the obese group, the patients' ages ranged in all the samples between 31 and 94 years (p<0.003).

Table 1.

Patients' Characteristics

Characteristic	Ideal BMI (18.5–24.9) n=87	Overweight (25–29.9) n=101	Obese (≥30) n=150	p-Value
Age (mean)	51.11	50.45	55.49	<0.003
BMI (kg/m²) (mean)	22.11	27.12	36.09	<0.001
Premenopausal	51/87	69/101	65/150
Postmenopausal	36/87	32/101	85/150

BMI, body mass index.

Clinical parameters including the clinical indications for the surgeries and the final pathologic diagnosis can be found in (Table 2). The more common clinical indications were heavy periods in all three groups, followed by postmenopausal bleeding, especially in obese women, an endometrial ablation that had failed, persistent cervical dysplasia, incidental finding of pelvic mass, severe endometriosis, history of breast cancer, positive estrogen and progesterone receptors, and family history of ovarian cancer. Oncologic indications for hysterectomy included endometrial hyperplasia, early-stage endometrial carcinoma, and occult or apparent stage I ovarian carcinoma.

Table 2.

Patients' Symptoms by BMI

Symptoms	Ideal BMI	Overweight	Obese
Pelvic discomfort	5/87	7/101	7/150
Postmenopausal bleeding	12/87	22/101	68/150
Continuous bleeding per vaginum	7/87	4/101	3/150
Severe dysmenorrhea	2/87	3/101	4/150
Heavy periods with large uterus; not suitable for endometrial ablation and/or patient's choice	14/87	34/101	25/150
Failed endometrial ablation	18/87	11/101	13/150
Dyspareunia	1/87	0/101	0/150
Complication after a procedure	0/87	0/101	1/150
Persistent cervical dysplasia	7/87	7/101	11/150
Incidental finding of pelvic mass	11/87	7/101	9/150
Severe endometriosis	5/87	4/101	4/150
Prophylactic surgery (previous breast cancer and/or family history of ovarian cancer)	4/87	2/101	4/150
Severe premenstrual tension	1/87	0/101	1/150

BMI, body mass index.

In the majority of the patients in the three groups, the histologic findings of the specimens were leiomyoma with or without adenomyosis, or with endometriosis or endometrial hyperplasia (Table 3).

Table 3.

Postoperative Histologic Diagnoses According to BMI

Diagnosis	Ideal BMI n=87	Overweight n=101	Obese n=150
No pathologic diagnosis	21	13	19
Benign ovarian lesions	5	9	9
Cervical and/or vaginal dysplasia	3	3	7
Leiomyoma+/− adenomyosis	39	50	46
Endometrial hyperplasia	7	8	27
Endometrial cancer/sarcoma	5	11	37
Ovarian cancer	0	0	0
Tubal cancer	1	0	2
Cervical cancer	0	0	0
Borderline ovarian tumor	0	1	0
Endometriosis	6	5	3
Metastatic cancers	0	1	0

BMI, body mass index.

Category 1 LH was performed in 28/87 (32%) of the patients in the ideal group, in 23/101 (22%) of the overweight patients, and in 28/87 (18%) of the obese patients. Subtotal hysterectomy (category 2) was chosen in 6/87 (6%) of the ideal BMI group, in 7/101 (6%) of the overweight group, and in 5/150 (3%) of the obese group. Category 3 LH was used in 5/87 (5%) of the patients with ideal BMI, in 9/101 (8%) of the patients in the overweight group, and in 11/150 (7%) of the obese patients. Category 4 LH was performed in 48/87 (55%) of the patients in the ideal BMI group, in 62/101 (61%) of the overweight patients, and in 106/150 (70%) of the obese patients.

There were no statistically differences in duration of surgery, volume of blood loss, and duration of hospital stay among the three BMI groups (Table 4).

Table 4.

Surgical Outcome According to BMI

Outcome	Ideal BMI (mean)	Overweight (mean)	Obese (mean)	p-Value
Duration of surgery (minutes)	105.91	104.27	106.42	0.839
EBL (mL)	244.02	233.86	279.0	0.069
Length of hospital stay (days)	2.44	2.40	2.52	0.918

BMI, body mass index; EBL, estimated blood loss.

The specimen weights and dimensions were not statistically significantly different according to BMI category (p=0.057); 2 patients had a specimen weighing 800 g and, in 1 patient, the specimen weighed 1300 g.

The overall complication rate for the series was 3.7% (Table 5), with no statistically significant difference among the three groups (p=0.005). There were no complications in any of the subtotal hysterectomies performed. In the ideal BMI group, there was one stomach injury that required a conversion to laparotomy in order to be repaired, and one bladder injury repaired by laparoscopy. Among the overweight patients, there was a patient with a ureter injury, which was sutured laparoscopically. In the obese group, 1 patient had bowel damage during the port entry, and the damage was identified laparoscopically and repaired.

Table 5.

Intraoperative Complications According to BMI

Complication	Ideal BMI n=87	Overweight n=101	Obese n=150	Total N=338
Bowel injury	0	0	1	1
Stomach injury	1	0	0	1
Bladder injury	1	1	0	2
Ureter injury	0	1	0
Conversion to laparotomy because of complications	1	0	0	1
Anesthetic complications	0	0	0	0
Bleeding requiring intraoperative blood transfusion	0	0	0	0
Overall percentage of complications	2/87(2%)	2/101(0.9%)	1/150 (0.6%)	3.70%

BMI, body mass index.

Early postoperative complications were 6% in the patients with ideal BMI, compared with 3% among the patients who were overweight, and 5% in the obese group (Table 6). The overall early complications rate did not show significant difference among the three groups (p=0.015). There were no early postoperative complications in the patients who underwent subtotal hysterectomies.

Table 6.

Early Postoperative Complications According to BMI (<7 Days Postoperation)

Complication	Ideal BMI n=87	Overweight n=101	Obese n=150	Total N=338
Paralytic ileus	1	0	1	2
Diarrhea	2	0	1	3
Urinary infection	0	0	0	0
Severe postoperative pain	2	2	5	9
Deep vein thrombosis/pulmonary embolism	1	1	1	3
Return to theater	0	0	0	0
Trochar site hernia	0	0	0	0
Pelvic hematoma	0	0	0	0
Myocardial infarction	0	1	0	1
Vaginal bleeding	0	0	0	0
Overall percentage of complications	6/87(7%)	4/101(4%)	8/150 (5%)	18/338 (5%)

BMI, body mass index.

Discussion

Laparoscopic surgery in the obese gynecologic patient can be technically challenging. Establishment and maintenance of the pneumoperitoneum pose significant difficulty, given the thickness of the abdominal wall and the amount of preperitoneal fat. A direct trochar entry technique with elevation of the umbilicus by towel clips proved efficient even in the patients with high BMI.¹⁷

Although large women tolerate increased intraperitoneal pressure well with regard to cardiac function,¹⁸ respiratory mechanics can be adversely affected for the duration of the pneumoperitoneum and from the position during the operation. Moreover, large women in the Trendelenburg position, because the weight of the abdominal wall, bowel, and omentum, have reduced ventilatory compliance during the surgery.¹⁹

None of the surgeries in the present series were prematurely terminated because of excessive ventilatory pressures, hypercarbia, and/or for cardiac reasons. One patient in the overweight group developed myocardial infarction 1 day after the operation, but no relation to the intraoperative events was found. Few patients in the obese group required two to three interruptions of the pneumoperitoneum to allow the partial pressure of carbon dioxide to reduce with ventilation.

In one surgical series, an association with conversion to open laparotomy was observed with increasing BMI >30 kg/m².²⁰

In this series, 9 patients had their surgery converted to laparotomy before starting the procedure, as a result of unfavorable surgical anatomy or newly recognized inapplicability of the procedures. Perhaps this could have been avoided if preoperative assessment with an MRI had been advocated. No patients had their surgery converted to laparotomy because of difficulties attributed to high BMI.

This case series included procedures performed by 3 different surgeons, who were all accredited laparoscopic surgeons. Two of them advocated category 1 or 2 LH for all women needing hysterectomy, reserving subtotal hysterectomy for women with large uteri. The third surgeon performed the entire category 4 LH in the series and operated on a few of the patients needing subtotal hysterectomy in cases of large fibroid growths.

Some researchers^21–23 have shown that VH are associated with higher risk of urinary incontinence and vault prolapse. This is likely because the women who qualify for a VH or LAVH are usually parous, and the closure from below may not offer VH patients the greatest support, specifically because it is undertaken from below.

There is disagreement with some authors^24,25 who stated that LAVH is a longer procedure than TLH, as in the data from this study, there were not significant differences in the length of the operating time between the two procedures on the basis of the BMI of the patient (∼2.45 hours on average, with the inclusion of some additional procedures for some patients).

Moreover, previous studies have not shown LH to confer benefits compared with VH.^4,26 However, many of these studies are older, and as the experience of LH among gynecologists has grown, the superiority of VH over LH has begun to be challenged.^27,28

Moreover, our laparoscopic blood loss, surgical duration, and number of days in the hospital have all decreased over time when comparing the data from 2008 with those from 2010 onwards, with the most recent laparoscopic cases in the series losing no more than 50 mL of blood, and the majority of patients going home on postoperative day 1.

A real learning-curve effect in LH has been demonstrated, which has not always received sufficient attention in studies on surgical approach to hysterectomy. Wattiez et al. reported significantly higher complications in surgeons with 30 or fewer procedures performed.²⁹ Recently, Tunitsky et al. demonstrated reduced febrile morbidity, conversion to laparotomy, and operating time for surgeons who have performed >30 LH compared with the first 29 procedures by the same surgeons, although the rate of serious complications was unchanged.³⁰

The overall complication rate in this study was 3.7%, which compares favorably with open laparotomy data, which has been reported to be as high as 15.2% by some authors.³⁰ With open laparotomy, obese patients have been shown to have a higher incidence of wound infection and other complications, resulting in extended hospitalizations and additional procedures, directly proportional to their BMI.³¹ This study also has similar complications rates when compared with other LH series.^32,33 One of the specific concerns regarding the laparoscopic approach to hysterectomy has been a purported higher incidence of urinary tract injuries, specifically ureteric injury and the development of pelvic organ fistula.³⁴ The overall risk of urinary tract injury in the present study was 0.8%. A recent meta-analysis comparing VH versus LH for benign conditions has shown no difference in ureteric injury between surgical approaches.⁵

Furthermore, LH is more costly than conventional hysterectomy, although additional costs are lower in comparison with AH than with VH. In addition, the cost effectiveness in LH compared with AH is more finely balanced, mainly because of the shorter mean inpatient stay associated with laparoscopy, which results in lower additional costs.³⁵

There are a number of potential limitations to this analysis. The principal limitation was that it was a retrospective study and, therefore, many variables existing among patients (e.g., cancer status, nutritional status, medical comorbidities) were not taken into account in this observational comparison. In addition, different surgeons performed the procedures and trainees did some of the surgery, and this may have increased the length of the operating times and, perhaps, the complication rates.

Some studies comparing LH and VH, such as the eVALuate (for Vaginal, Abdominal, and Laparoscopic hysterectomy) trial have been criticized in the past, because many of the LH procedures were performed by inexperienced laparoscopic surgeons.²⁶

Any future randomized clinical study looking at BMI as a possible factor, which could affect outcome of laparoscopic surgery, should control for patients' baseline health and for additional procedures, and should address the experience of the surgeon.

In the United Kingdom, 40% of the population is obese, and the number has increased significantly from 2009 to 2012. As laparoscopy is rapidly becoming the standard of care, it becomes important to focus on the feasibility and safety of performing laparoscopic surgery on larger women.

Conclusions

The data from the current study offer further support for policies that advocate the use of minimally invasive approaches, as LH is as feasible and safe for patients with high BMI as it is for patients with overweight or with ideal BMI. Complications are minimized with training, experience, and a meticulous approach.

Footnotes

Disclosure Statement

None of the authors have conflicts of interest to declare.

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