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INTRODUCTION

Surgery in the morbidly obese patient poses unique challenges for the surgeon, compared to those with a normal BMI. Meticulous preoperative planning is imperative in these patients to prevent postoperative complications and allow smooth progression intraoperatively. In this chapter, we will discuss certain technical aspects of minimally invasive colorectal surgery applicable to the obese patient population—a large number of the Western patient population tend to be overweight and, therefore, being able to safely operate on obese patients is essential.

ACCESS

We used the open Hasson technique to access the abdomen in all our cases. However, in the morbidly obese patient, this can be uniquely challenging and time-consuming and so it is reasonable to use a different approach such as the Veress needle or an Optiview. The standard approach with the Veress needle at the Palmer’s point may be used followed by an Optiview trocar insertion. In our approach, we still use the open Hasson technique; however, we do so at the point of extraction of the specimen, which allows us to use a larger skin incision to gain access, while keeping the fascial incision small in order to avoid a CO2 leak during the surgery.

PERIOPERATIVE CHALLENGES

The morbidly obese patient tends to have comorbidities such as hypertension, diabetes, coronary artery disease, and malnutrition that need to be managed proactively to avoid postoperative surgical morbidities. In patients undergoing surgery for benign conditions or in whom the surgery can be safely deferred for a few weeks to months, it is very beneficial to ask the patient to lose weight, perform prehabilitation in the form of an aerobic exercises, incentive spirometry, physical therapy, smoking cessation if applicable, dietary modification, and weight reduction. Good glucose control and blood pressure control in the perioperative period for those patients with concomitant hypertension and diabetes leads to better outcomes and reduction in surgical morbidity. Postoperative mobilization and ambulation can be a challenge in in the morbidly obese patient and it helps to have early involvement of physical therapist and occupational therapist. Preoperative education about expectations and the need for early mobilization is very helpful in these patients. Lastly, in patients in whom it is deemed appropriate, it may be beneficial to refer the patient to a bariatric surgeon for a bariatric procedure prior to their colorectal surgery or a concomitant bariatric/colorectal operation.

PATIENT POSITION AND SAFETY DURING SURGERY

In morbidly obese patients, it is very important to make sure that the patient is properly secured, and the pressure points are padded in order to avoid nerve injuries. This may require use of specialized equipment such as foam or bean bags and the need for additional measures to secure the patient on to the operating room table in the form of additional belts and securing the patient with the help of silk tapes. ...

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