4 How we do it: laparoscopic cholecystectomy in patients with severe obesity
Thomas Russell, Somaiah Aroori- Surgery
Abstract
Aims
The number of patients with obesity is set to rise, as is the proportion with severe obesity. These patients are a high-risk subgroup who present additional challenges to the surgeon when performing laparoscopic cholecystectomy (LC). It is important that all surgeons who perform this procedure have a safe strategy they can revert to so that morbidity is minimised. Here we outline our approach.
Methods/Results
After obtaining a pneumoperitoneum via a supra-umbilical incision, we advise placing a fascial suture before proceeding with the operation. This allows for high-quality closure, reduces the incidence of incisional hernia, and reduces the risk of an inadvertent bowel injury. We also advise the repositioning of the patient on the operating table prior to port placement such that an ergonomic set-up can be achieved. In addition to the standard ports, we use an additional twelve millimetre port in the left upper quadrant (LUQ). A fan retractor can then be inserted via this port and used to gently retract the duodenum inferiorly. This provides adequate exposure for Calot’s dissection and arguably reduces the risk of injury to a fatty liver. This technique can also be used in non-obese patients in whom Calot’s dissection is particularly challenging e.g., those who undergo delayed LC.
Conclusions
When performing LC in obese patients, one can consider placing an additional twelve millimetre port in the LUQ. A fan retractor can then be used to gently retract the duodenum inferiorly to improve access and reduce the risk of injury to a fatty liver.