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26 The Morbidly Obese Patient
Fig. 26.3 OR positioning for
laparoscopic colectomy showing
steep Trendelenburg, a maneuver
that helps with retraction and
exposure. Red line indicates the
patient’s orientation in steep
Trendelenberg
409
everyone in the operating room can see the patient does not
fall and provides confi dence during the case when the drapes
are on and the operating room is dark and you ask for steeper
positioning.
We recommend insertion of ureteral stents for patients
with prior pelvic surgery, radiation, and other situations
where ureteral anatomy may be altered. We also fi nd stents
helpful when fi stulizing disease is present—either to the
bladder or the vagina—or if large abscesses or phlegmons
(either retroperitoneal or pelvic) complicate the intestinal
disease. In our opinion, obesity in and of itself is not an indication for ureteral stent insertion. Identifi cation of the ureter
in a very large patient with excessive mesenteric and retroperitoneal fat can be daunting and cause a lot of heartache
and prolonged operating room time. Stents may be one
means by which critical steps of the operation can be
facilitated.
We recommend using more ports than you are normally
accustomed for additional graspers to provide retraction and
aid in the dissection. Have them available ahead of time.
Since these are “bariatric patients,” you need to have bariatric length equipment—cameras, graspers, and staplers.
Traditional ports that you are accustomed to using may not
adequately reach through the body wall and longer trocars
may be required. Regarding port placement, the principles of
maximizing exposure to all parts of the abdomen by maintaining good ergonomics and triangulation still apply in the
obese individual. Again, as you need to elevate the heavy
colon and bulky mesentery, moving your ports a little more
medially than normal will allow you to maintain the optimal
fulcrum. When the ports are placed too lateral, you will often
hit the bed with your grasper and not be able to manipulate
the instruments freely. Remember, this is further exacerbated
by the lack of working space in between the bowel and anterior abdominal wall with a standard pneumoperitoneum at
15 mmHg.
Exposure to the central mesentery is diffi cult as a result of
bulky visceral fat. A medial-to-lateral approach may thus be
diffi cult, or even not possible. Therefore, you should be
skilled and prepared to employ the spectrum of colonic
mobilization techniques: lateral to medial, superior or “topdown” starting at the transverse colon, and inferior to superior. Be fl exible and be willing to switch to a different
approach during the various steps of the operation to accommodate the patient’s habitus and pathologic condition. In
addition to placing additional ports, one way to handle the
bulky omentum is to take down the falciform ligament. This
will provide a broad space over the top of the liver and the
anterior stomach to fl ip the omentum back up on itself. A
small sponge pad placed through a 10 mm trocar or hand port
can “stick” to the omentum and anterior abdominal wall,
retracting the omentum away from the operative fi eld.
Opening the sponge (or rolling it) and using it as a barrier to
hold back the creeping small bowel is often helpful as well.
Dissection Techniques
Key concept : Gaining access to the correct plane and using
precise sharp dissection will be helpful . Take care of all
410
J.E. Efron and H.D. Vargas
bleeding early as even small amounts will distort tissue
planes and make dissection more problematic .
Standard dissection and identifying the correct planes is
similar regardless of body habitus—it is the degree of diffi culty that varies. In general, I (HDV) favor energy devices
for mobilizing the bowel and, in particular, fi nd ultrasonic
dissectors to have fi ner tips that facilitate sharp dissection.
The key, ultimately, is to ensure adequate hemostasis. Tissue
planes are distorted and the visual effect of “yellow out”
(similar to “white out” during a snow storm) can lead to
imprecise dissection, violating embryologic planes, and lead
to small (or large) amounts of meddlesome bleeding. Avoid
grasping on the fatty mesentery and attempting to elevate its
bulk—it will likely tear and bleed. Atraumatic graspers on
the bowel or epiploica utilizing a larger bite (i.e., similar to
grasping a vein), while avoiding tearing, will avoid serosal
or even full-thickness bowel injuries. Increased blood loss—
another surrogate marker for technical diffi culty—may not
be measurably different, but it is our impression that obese
patients have greater bleeding during mobilization and blood
staining of tissues can further obfuscate dissection planes.
Furthermore, due to differences in hemoglobin-related light
absorption, this will result in decreased laparoscopic illumination and visualization.
The extent of mobilization should be considered. You
should anticipate mesenteric shortening and the resulting
possibility of encountering increased tension at your
intended anastomosis site. This mandates a disciplined
attention to ensuring complete mobilization of the colon to
avoid this scenario. We have found several keys to help in
this aspect. First, mobilize back to the root of the mesentery—while this is often a bit worrisome for the novice surgeon in a heavy patient with thick mesentery and ill-defi ned
planes, it is needed to gain length. Next, completely mobilize the mesentery cranially and caudally, and always
mobilize the fl exures. Many surgeons selectively take down
the fl exures—in obese patients, this is the norm. The omentum can either be dissected off the colon or taken with
specimen, the lesser sac needs to be entered, and you have
to divide the retroperitoneal attachments to ensure a full
fl exure mobilization. Additionally, vessels are divided high
to achieve full mobilization and to avoid ischemia at the
distal end of the bowel. This proximal division reduces the
number of vessels and volume of tissue to be divided, but
requires precise, disciplined dissection with skeletonization of the named vessels to ensure adequate primary and
collateral vascularization. I (HDV) prefer staplers for vessel division, due to the volume of tissue divided, though
many surgeons successfully used energy devices alone. All
these maneuvers typically provide enough mobility to the
remaining bowel to effect a tension- free anastomosis. This
is also crucial when bringing up a colostomy. Without
Fig. 26.4 Stenotic stoma as a result of ischemia created when devascularizing the bowel to allow reach through thick abdominal wall
(Courtesy of Philip Y. Pearson, MD)
Fig. 26.5 Intraoperative photo of large sigmoid colon enveloped by
massive visceral adipose tissue fi lling a relatively large incision
adequate mobilization and preservation of blood supply,
your patient may be left with a sunken or stenotic stoma
(Fig.
26.4 ), an extremely diffi cult problem to deal with in
this population.
Regardless of the technique used, extracorporeal division
of mesenteric vessels should be avoided. This will prove
very diffi cult through a small laparoscopic incision, with
limited ability to visualize and manipulate a large foreshortened colon and bulky mesentery that fi lls the small wound
(Fig.
26.5 ). The mesentery will be placed on tension and
risks avulsion and bleeding. Your best visualization will be
laparoscopically, and you will have the best opportunity to
do something should any problems arise. Avoid the temptation—divide the major vessels intracorporeally.
26 The Morbidly Obese Patient
411
Specimen Extraction and Ideal Wound Placement
Key concept : Specimen extraction wounds should be midline ,
and expect larger incisions to accommodate the larger - sized
specimen .
The size of the extraction site—already remarkably small
given the body habitus—should not inhibit specimen extraction. Although all the reported sites can work (lateral,
Pfannenstiel, lower quadrant), when faced with a diffi cult
dilemma, the midline represents the shortest distance from
the root of the mesentery to the abdominal wall. Invariably,
small amounts of the mesentery must still be divided and
complete extraction facilitates any extracorporeal dissection.
Also, take into account that exteriorization of the right colon
can be more diffi cult through a small incision, as classically
both ends are brought out and divided extracorporeally. This
results in a larger specimen that has to be brought through
the wound. Consider dividing one end of the bowel intracorporeally or dividing through the incision prior to exteriorization. Be careful in both of these instances to maintain proper
orientation of the mesentery and avoid the 180° twist.
Another aspect of right colectomy should be the cranialcaudal position of the midline wound. When choosing your
incision site, ignore the umbilicus altogether. Exteriorization
of the transverse colon will be diffi cult if your wound is positioned too low. In an obese patient, the umbilicus is often
displaced caudally due to the size and weight of the pannus
(Fig.
26.6 ) and actually is a poor anatomic landmark of the
position of intraperitoneal organs. While an intracorporeal
anastomosis in the obese patient can be performed [ 21 ], an
extracorporeal anastomosis can be more easily performed by
moving the incision cranially. Though the wound becomes
more conspicuous, we cannot emphasize enough that cosmesis remains a secondary concern when attempting to perform
a critical step of a complex operation for serious pathology in
a challenging patient. The most pragmatic technical solution
to such challenges will prove most reliable and reproducible.
Use the midline and avoid being fooled by the umbilicus.
The Role of Hand-Assisted Laparoscopic Colectomy in the Obese Patient
Key concept : Hand - assisted laparoscopic colectomy may
provide another approach in obese patients to reduce the
conversion rates and operative times , with similar other outcomes when compared to straight laparoscopy .
The literature comparing laparoscopic colectomy in obese
(BMI > 30) to normal weight patients reveals increased
operative time and increased conversions in the obese patient.
Not surprisingly, there is a learning curve associated
Fig. 26.6 Caudally positioned umbilicus in a patient with large
pannus
specifi cally with laparoscopic colectomy in the obese patient,
further affi rming the complexity of this undertaking. Sarli
et al. found that after 80 cases, operative time and conversion
decreased to similar levels witnessed in the nonobese patient
[ 22 ]. This makes intuitive sense, as more experience with
complex, diffi cult operations results in improved profi ciency.
Yet, it also drives home the point that the learning curve varies based on the indication and specifi c patient operated on.
While the ASCRS consensus statement on laparoscopic colectomy for curable cancer recommends at least 20 baseline
cases performed for benign disease or metastatic cancer [ 23 ],
we recommend further preparatory experience when considering the added diffi culty encountered with obese patients.
Hand-assisted laparoscopic colectomy (HALC) offers a
technique that overcomes some the limitations of conventional
laparoscopic surgery. Rather than attempting to retract with
multiple miniature graspers, manual retraction proves atraumatic and effi cient. In particular, manual retraction enables
the surgeon to provide exposure where the planes of dissection
are kept “fl at” and linear. This allows a deliberate, continuous
dissection over greater distances with limited adjustments in
retraction and exposure. Hand assist also allows for dissection
412
J.E. Efron and H.D. Vargas
in a direction back towards the camera, again providing for
greater versatility in mobilization options. Lastly, palpation
enables surgeons (especially those early in their learning
curve) to confi rm vital structures when visual cues often can
be misleading due to the previously mentioned “yellow out”
phenomenon. Palpation takes a 2-dimensional laparoscopic
experience and transforms it to a 3-dimensional one, which
bolsters a surgeon’s confi dence in the precision of the dissection. Although some surgeons continue to question the merits
of hand-assisted laparoscopic colectomy, comparative studies
of HALC to conventional laparoscopic colectomy have generally demonstrated reduced operative times and reduced conversion rates [
and total abdominal colectomy, in particular, benefi t from a
hand-assisted technique with reduced operative times and
conversion. Specifi c to obese patients, data examining HALC
compared to straight laparoscopic in this population reported
reduced operative times and reduced conversion, without any
differences in pain, analgesic use, or length of stay [ 25 ].
Comparative studies have looked at long-term outcomes such
as hernia formation and bowel obstruction and have not found
any differences when compared to conventional laparoscopic
colectomy [ 26 ]. Systematic reviews and meta- analyses have
confi rmed these fi ndings as well [ 27 ]. Thus, when faced with
a severely obese patient, and in particular abdominal/visceral
obesity, we feel you should strongly consider utilizing a handassisted technique. We should point out, however, that whether
your approach is hand-assisted or straight laparoscopic, the
recommendations regarding the conduct of a laparoscopic colectomy for malignancy remain identical.
24 ]. Complex operations such as left colectomy
Technical Considerations
Key concept : Obesity has specifi c considerations for each
procedure and / or colorectal disease process you may
encounter . Understand how it may impact your individual
patient and your management strategy .
Pelvic Dissection
is surprisingly easy to mistakenly enter the wrong plane of
dissection and inadvertently injure any of these structures.
We have found that initiating our pelvic dissection right at
the sacral promontory helps prevent inadvertent vascular
injury. Identifying the ureter is also challenging, as it may be
located deep in the retroperitoneum and encased in adipose
tissue. As stated before, consider placing ureteral catheters in
morbidly obese patients as this may make identifi cation of
the ureters easier. If not, the most common location for identifi cation remains the crossing at the iliac bifurcation. Do not
hesitate to attempt to look both medially and laterally if you
are unable to identify the ureter initially. We have even had
to go proximally, adjacent to the kidney in certain cases and
follow the ureter down into the pelvis. Never just assume the
ureter is out of the way.
In the open approach, attempting to operate through a
small incision in obese individuals often leads to inability to
visualize critical structures because of encroachment of fat
and loss of abdominal domain. These two factors make
retracting very diffi cult. By extending the size of the incision
for adequate visualization and retraction of abdominal structures, you can lower the risk of inadvertent injury of vital
structures. Even by placing the patient in a head down position, and packing the small bowel off, this may not be enough
in the obese patient. We have found that in the case of a proctectomy, proximal division and packing off the descending
colon in the upper abdomen allow for the distal aspect to be
used as a handle and frees up some space for dissection. The
lower you go in the pelvis, you may need to use more than
one pelvic retractor to displace excessive fat and tissue that
may encroach on the dissection. We prefer a St. Marks retractor, though Wylie renal vein retractors are often useful due to
their narrow profi le and “lipped” end. Customized longer
instruments may be needed for adequate retraction and exposure deep in the pelvis. This is particularly important when
retracting the vagina to divide the rectum and perform a stapled anastomosis under direct vision to avoid an iatrogenic
rectovaginal fi stula. We are also more apt to place an EEA
sizer in the vagina to aid in visualization of the posterior
vaginal wall or cuff and help with upward retraction.
Key concept : Obesity leads to distorted planes in the pelvis
with diffi culty identifying crucial structures .
When discussing pelvic dissections, we are primarily
referring to operating on the rectum at a level below the
sacral promontory. The diagnoses that lead to pelvic dissection include infl ammatory bowel disease, cancer, and functional disorders such as rectal prolapse. The pelvis in obese
patients (especially in the narrow male pelvis) can be
extremely hostile. The anatomy is often distorted due to retroperitoneal fat that displaces structures such as the iliac
arteries and the autonomic nerves anteriorly and medially. It
Ileal Pouch-Anal Anastomosis (IPAA) in the Obese Patient
Key concept : IPAA presents its own unique set of potential
complications in the obese patient , but the traditional “ pouch
principles ” of ensuring adequate length for the pouch to
reach and proximal diversion are similar to the nonobese
patient .
The most common operation performed for infl ammatory
bowel disease requiring a pelvic dissection is a restorative
proctocolectomy with ileal pouch-anal anastomosis for
26 The Morbidly Obese Patient
413
ulcerative colitis. Controversy exists as to the increase risk
found in the obese patient when performing an IPAA procedure. Kiran and associates examined their experience with
IPAA operations in obese patients (BMI > 32.7) [ 28 ]. They
found that obese patients had a signifi cantly higher rate of
wound infection, anastomotic separation, and bowel obstruction. Canedo et al. did not fi nd signifi cant difference in overall complications when comparing patients with a BMI
higher than 30 to a control group [
29 ]. One of the authors of
this chapter (JE) found a signifi cantly higher rate of pelvic
sepsis and perioperative morbidity in the obese group
(BMI ≥ 33.7) [ 30 ]. Integrity of the pouch-anal anastomosis is
clearly dependent on multiple factors including nutritional
status, medications, severity of disease, and technical competency. It is not surprising, therefore, that the literature
would vary in associating obesity as an independent risk factor for pouch problems. It should be noted that the literature
is fairly uniform in demonstrating that the majority of obese
patients will have equivalent pouch function if the procedure
is performed without signifi cant pelvic septic complications.
Only Wibmer and colleagues identifi ed obesity as a risk factor for permanent ileostomy formation after ileal pouch-anal
anastomosis [ 31 ]. Interestingly, a laparoscopic approach has
been associated with a lower complications rate for IPAA,
even when accounting for BMI [ 32 ].
There are several strategies when approaching obese
patients who are requesting an IPAA. If the patient has severe
disease and is on multiple immunosuppressants, performing
a total abdominal colectomy with ileostomy initially is a
fairly routine approach for most surgeons. This allows the
patient an opportunity to restore their nutrition reserves and
wean off all ulcerative colitis medications. Specifi cally to the
obese population, this strategy also provides the incentive
for the patient to lose excess weight prior to the proctectomy
and IPAA formation. We must admit, however, in our experience such weight loss is often not often achieved. Adequate
weight loss can be utilized as a potential “carrot,” although
patients with a BMI > 40 must clearly understand the risks
associated with the surgery.
Getting the pouch to reach without tension may be challenging if the patient has a long torso, but standard mobilization maneuvers will often allow it to reach the anus. Given
the available data that demonstrates higher pelvic sepsis
rates, every effort should be made to divert the stool stream
proximal to the pouch. In obese patients, the fatty mesentery
and the thickness of the abdominal wall makes creating the
loop ileostomy extremely diffi cult. Oftentimes a very proximal stoma is required to achieve diversion. While this will
result in high output from the ileostomy, possibly even
requiring long-term fl uid supplementation or TPN, we feel it
is required to avoid the sequela of pelvic sepsis in these
obese patients. We do discuss the potential problems with the
ileostomy (i.e., skin problems, pouching issues, high output)
in our preoperative counseling and emphasize to the patient
this is potentially a short-term tradeoff for the benefi t of
long-term good pouch function.
Another option for proximal diversion in the obese patient
is the formation of an end-loop stoma. This requires division
of the small intestine and careful division of the small bowel
mesentery so the proximal end of the diverted stoma can be
brought out as an end stoma. Care must be taken when dividing the mesentery of the small intestine so that you do not
disrupt the blood supply distally to the ileal pouch. This
stoma usually requires a laparotomy to close, as the distal
end stays within the abdominal cavity, though not always.
Despite this fact, it is still advisable to perform and end-loop
stoma when no other option exists for proximal diversion to
avoid the sequelae of pelvic sepsis.
Rectal Cancer in the Obese Patient
Key concept : Obesity has both technical and management
implications for patients with rectal cancer . Ensure you discuss the potential impact regarding the need for open surgery , possibility of requiring an APR for distal lesions and
overall worse outcomes .
Obesity has been shown to increase the conversion rate in
laparoscopic surgery for rectal cancer. In a recent review of
490 patients who underwent laparoscopic surgery for rectal
cancer, Denost et al. found that those patients with a BMI of
greater than 30 had a 32 % conversion rate. However, the
overall and cancer-specifi c survival, as well as the quality of
the mesorectal resection did not differ between groups [ 33 ].
A general rule of thumb (especially early in your experience)
is that large tumors in obese males should be considered for
an open operation, despite the potential increase in wound
complications.
With advances in technology, the hope is to decrease
some of these risks and to improve outcomes. At present,
there is minimal data published on robotic proctectomy for
rectal cancer in obese patients. Baek et al. have retrospectively reviewed their experience utilizing the robot for rectal
cancer and have found adequate lymph node yield, mesorectal quality, and comparable 5-year survival to open procedures [ 34 ]. No one has yet reported their experience
specifi cally in obese individuals. Similar positioning and
dissection tips as previously discussed are applicable here as
well. This especially pertains to securing the patient to the
table to avoid slippage, as the patient is normally in steep
Trendelenburg for extended periods.
resect without performing an abdominal-perineal resection
in the obese patient. The anal canal is often long, the low
rectum and perineum are diffi cult to adequately visualize,
and a hand-sewn colo-anal anastomosis may be diffi cult
414
J.E. Efron and H.D. Vargas
(if not impossible) to perform. Your patients need to be
informed of that possibility preoperatively. Some tips for
handling the perineum when having to perform an APR or a
hand-sewn colo-anal anastomosis include the following: (1)
rolls of blankets or gelfoam bolsters should be placed under
the sacral and lumbar spine, as this helps to elevate the
perineum and gives improved exposure; (2) tape the patient’s
buttocks apart prior to prepping the perineum to provide better exposure; (3) place the legs in the steep modifi ed lithotomy position when performing the perineal dissection to
help retract some of the buttock tissue and open the space
exposing the anus; (4) use long narrow vaginal retractors to
help in retracting excess tissue during the perineal dissection; and (5) the prone position may provide better exposure
for the perineal dissection and may require “fl ipping” the
patient for this portion of the dissection.
There is debate as to whether or not obese individuals
have worse oncological outcomes from rectal cancer surgery
than nonobese patients. There is no defi nitive evidence to
support this, but we do consider treating with neoadjuvant
chemoradiation for distal tumors where the dissection is
going to be diffi cult. Again this should be discussed with
patient, weighing the risk of radiation therapy compared to
the risk of local recurrence due to a diffi cult dissection resulting in positive margins.
Anorectal Surgery in the Obese Patient
Key concept : Exposure is the key to anorectal surgery in the
obese patient .
Successful anorectal surgery with any patient is dependent upon positioning and exposure. While either the prone
jackknife or the lithotomy position can provide adequate
exposure to the anus, focus should be on taping the buttock
cheeks apart with the use of benzoin to improve access.
When in the prone jackknife position, appropriate padding
at all pressure points, and even ensuring the pannus is adequately padded, is necessary. It is important to recognize
this position reduces some loss of ventilatory capacity that
occurs from the abdominal pressure on the diaphragm. In
either position, sedation may also lead to collapse of the
posterior pharynx and obstructed breathing that requires a
nasal or oral airway. There are even special Allen stirrups
made to accommodate obese individuals to avoid compression complications such as lower extremity ischemia or
nerve injury.
The use of self-retaining retractors such as the Lonestar
helps gain access to the anal canal by effacing redundant tissue near the anus. The use of larger anoscopes also helps
facilitate exposure. We also prefer advanced bipolar vesselsealing devices to help reduce bleeding and thereby facilitate
visualization in a tight area. Unfortunately, obesity has been
shown to independently affect the outcome of various anorectal operations (see below).
Anorectal Fistulas
Key concept : Adhere to standard principles when delineating
and managing obese patients with anorectal fi stulas .
Anorectal fi stulas can be technically diffi cult in obese
patient similar to nonobese patients. Occasionally with the
size of the perianal subcutaneous fat, the tracts are deeper. In
addition, in those patients with muscular or large buttocks,
visualization of the proximal anal canal, and even the dentate
line, can be more challenging. We prefer to position the
patient in either the prone jackknife or modifi ed lithotomy
position based on the suspected location of the internal opening of the fi stula. Those with posterior openings are performed in the modifi ed lithotomy position, while those with
anterior internal openings should be operated on in the prone
jackknife position. The use of a Lonestar retractor or any
other self-effacing anal retractor is advised.
Obesity has been shown to be a negative predictor for
success in repair of complex anorectal fi stulas. Schwandner
examined the results from 220 patients who underwent
endorectal advancement fl ap for complex perianal fi stulas
[ 35 ]. He found a both higher recurrence rate (14 % vs. 28 %)
and reoperation rate for sepsis in the failure group in patients
with a BMI greater than 30. Multivariate analysis identifi ed
obesity as an independent predictor of failure. At present,
obesity has not been associated with worse outcomes (either
recurrence or functional) in those patients undergoing fi stulotomy for low-lying fi stula tracts.
Sphincteroplasty
Key concept : Small technical maneuvers may help with visualization , but sphincteroplasty in obese and nonobese is
associated with similar outcomes .
The technical aspects of sphincter repair in the obese
patient are essentially no different. We have anecdotally
noted that the Lonestar and Gelpi retractors may be more
crucial to ensuring adequate exposure of the planes. In addition, the muscle is not that much deeper compared to normalsized patients. Adequate lateral retraction of the buttocks is
probably the most important factor to provide good visualization. In terms of outcomes, Nikiteas and colleagues identifi ed obesity as a risk factor for poor outcomes following
sphincter repair in women that had experienced delayed
incontinence as a result of obstetric trauma [
not this translates to a modifi able issue (i.e., an earlier repair
36 ]. Whether or
26 The Morbidly Obese Patient
415
or subsequent weight loss leading to improved results) is less
clear. In general, obesity has not been defi nitively shown to
affect the outcome of overlapping sphincteroplasty.
Hemorrhoidectomy
Key concept : No defi nitive data has shown a difference in
outcomes following hemorrhoidectomy in obese versus nonobese patients .
There are few differences in hemorrhoid surgery in the
obese patient. We have found that exposure is usually better
in the prone jackknife position, if the patient can tolerate it.
If anesthesia has a concern about sedation in this position
(i.e., if you prefer local with conscious sedation), we will
leave the bed in the room to provide a quick “rollover” for
any airway issues. In either position, we highly recommend
taping apart the buttock cheeks and the using the previously
described methods for retraction. We feel that the use of a
vessel-sealing device signifi cantly reduces blood loss and
thereby improves visualization for hemorrhoidectomies. It
also signifi cantly decreases the length of the operation and
we recommend its use in obese patients.
Summary Pearls
Obese patients present a unique challenge to surgeons managing colorectal disease. Expect diffi culties with exposure for
both the laparoscopic and open approaches, as well as routine
anorectal procedures. Cases will generally be longer, and plan
accordingly. You may notice increased conversions when
compared to similar laparoscopic resection in a nonobese
patient. Try to avoid this by planning well in advance where
risk profi le assessment and intervention can lead to improved
outcomes. Do not underestimate the usefulness of a skilled
assistant. Add additional ports, move the bed to enhance gravity effects for exposure, employ a variety of mobilization techniques and use an energy device to reduce meddlesome
bleeding. Through it all, recognize that the learning curve
associated with any procedure is magnifi ed (and extended)
when applying it to obese patients. Finally, be honest with
your comfort and expertise level when dealing with this patient
population to mitigate complications and improve outcomes.
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The Pediatric Patient
Tiffany Tanner , Nathan P. Zwintscher , Robert A. Cusick ,
and Kenneth S. Azarow
2 7
Key Points
• Children have many of the same common anorectal
disorders as adults. While many are treated similarly, perianal abscesses and fi stula-in-ano are often
treated differently in children.
• Constipation is a signifi cant problem in childhood that
typically can be treated successfully with medication
and lifestyle modifi cations; however, it may be a
chronic condition in a signifi cant percentage of patients.
• Look for more extensive associated defects in children with fecal incontinence that may require more
extensive evaluation. The initial approach is most
often medical.
• Infl ammatory bowel disease in children may have a
more aggressive course.
• Polyps in children occur in the setting of genetic predispositions and should be evaluated accordingly.
T. Tanner , MD
Department of Surgery , University of Nebraska Medical Center ,
983280 Nebraska Medical Center , Omaha , NE 68198 , USA
e-mail: ttanner@unmc.edu
N. P. Zwintscher , MD
Department of Surgery , Madigan Healthcare System ,
9040 Jackson Ave , Tacoma , WA 98431 , USA
e-mail: npzwintscher@gmail.com
R. A. Cusick , MD (
Department of Pediatric Surgery , Children’s Hospital and Medical
Center, Omaha and University of Nebraska Medical Center ,
8200 Dodge Street , Omaha , NE 68114 , USA
e-mail: rcusick@childrensomaha.org
K. S. Azarow , MD (
Division of Pediatric Surgery, Department of Surgery ,
Oregon Health Science University , Doernbecher Children’s
Hospital , Portland , OR , USA
Oregon Health Science University, Doernbecher Children’s
Hospital , 3181 S.W. Sam Jackson Park Road ,
Portland , OR 97239 , USA
e-mail: azarow@ohsu.edu
*)
*)
Introduction
In many parts of the United States and world, pediatric patients
are cared for by pediatric specialists, with those requiring surgery managed primarily by pediatric surgeons. Furthermore,
to speak to the uniqueness of colorectal disease in this population, subspecialty training in pediatric colorectal surgery after
completion of a pediatric surgery fellowship has begun to
emerge. Yet, other locations do not have this situation, and
patients with common colorectal problems will still be
referred to general surgeons, colorectal surgeons, and general
pediatric surgeons. In many cases, “classic” surgical training
either does not apply or needs to be modifi ed to account for
growth, development, or a different natural history of disease
in this population. It is our intent that this chapter be used as a
guide to assist all those who are faced with management decisions for these patients both in and out of the operating room.
Anorectal Disease
Key Concept : Common anorectal complaints seen in adult
patients also occur in pediatric patients . In many cases ,
these are managed the same way , with the most common
exception of anorectal abscess and fi stula .
Perianal Abscess and Fistula-in-Ano
Key Concept : Perianal abscesses should be approached in a
stepwise fashion beginning with aspiration and antibiotics ,
with incision and drainage reserved for recurrent or more
severe cases . Many fi stulas will spontaneously close without
surgical intervention ( especially in infants ), and immediate
operative therapy should be avoided . Primary surgical treatment of a fi stula - in - ano should be reserved for older children
and failures to spontaneously resolve .
It is said that “the abscess is the parent of fi stula-in-ano,”
and both are typically diseases of the same origin, arising
S.R. Steele et al. (eds.), Complexities in Colorectal Surgery,
DOI 10.1007/978-1-4614-9022-7_27, © Springer Science+Business Media New York 2014
417
418
T. Tanner et al.
from abnormal crypt of Morgagni. In children, distinctions
between the two entities are not even made [
1 , 2 ]. Overall,
abscess and fi stula-in-ano occur not uncommonly in children, with an estimated rate of 0.5–4.3 % [
3 ]. While males
are predominately affected in children under 2 years of age
(12:1), the ratio becomes less extreme (2–3:1) for those older
[
4 ]. For those under 2 years, a congenital etiology has been
hypothesized, suggesting that the gender difference may be
explained by an androgen excess or androgen-sensitive
glands in utero, causing a formation of abnormal glands
[ 2 , 5 ]. Other postulated theories include entrapment of migra-
tory cells from the urogenital sinus during development of
the perineum, anal crypt infections, anal fi ssure, or dermal
infections [ 5 – 7 ]. These may account, in part, for some of the
rationale why we treat them differently than adults.
Perianal abscess and fi stula-in-ano most commonly occur
laterally (i.e., 3 and 9 o’clock) [
2 , 6 , 7 ]. Interestingly, cultures
taken from the abscesses vary between genders, with females
growing a predominance of skin fl ora (i.e., Streptococcus ,
Staphylococcus aureus ) and males having mostly enteric fl ora
(i.e., E . coli , Klebsiella , Enterococcus , Proteus ) [
2 ]. Although
the presence of mixed enteric organisms in the aspirate is suggestive of a fi stula, there has been no statically signifi cant correlation between its presence and the type of organisms in
culture [ 4 ]. Of note, there has been a signifi cant increase in the
incidence of methicillin-resistant Staphylococcus aureus
(MRSA) in both the hospital and community settings, and this
also holds true in the genital area [ 8 ]. In 2008, MRSA was
found to be the most common organism in superfi cial genitourinary abscesses in children [ 9 ]. In their single institution
study, Woods showed that nearly half of all MRSA abscesses
were found in the genital area [ 10 ]. Furthermore, they showed
that hospital wide, the rise in MRSA infections was predominantly in children 1–3 years of age (male > female) [ 10 ]. You
need to keep this in mind when choosing antibiotics or
encountering recurrent or recalcitrant disease.
Unfortunately, there is no straightforward recommendation for therapy. In fact, the treatment of abscess and fi stula
is widely debated in the literature [ 11 ] and ranges from anti-
biotics alone to aggressively probing for a fi stula and performing a fi stulotomy or fi stulectomy, when present. The
controversy is, in part, likely due to the wide range of concomitant and resultant fi stula formation (~20–85 %) [ 2 , 3 ] ,
and fi nding the balance between over- and undertreatment.
Those that propose a nonoperative management strategy
advocate a detailed hygiene plan, sitz baths, and antibiotics
[ 3 ]. They cite the fact that surgical drainage of an abscess
results in an ~40 % rate of development of fi stula-in-ano versus an ~6 % rate with nonsurgical drainage [ 3 ]. Admittedly,
this may have been secondary to ~10 % of their population
being immunocompromised and wanting to avoid a perineal
wound. However, even in this subset, nonoperative management resulted in no subsequent fi stula formation or need for
operative intervention [ 3 ].
Fig. 27.1 Perineal Crohn’s disease in an 8-year-old male showing
multiple fi stulas
Others advocate the similar use of local hygiene and sitz
baths for an early-stage perianal abscess but call for a progressive stepwise approach—starting with antibiotics and fi nally
aspiration drainage with an 18-gauge needle [ 7 ]. If there is no
resolution of the collection within 24 h, a formal incision and
drainage (I&D) is performed along with fi stulectomy for
patients with concomitant fi stulas (~11 %) [ 7 ]. Of note, in one
series, patients treated with needle aspiration had a 20 % failure rate requiring escalation of care [ 7 ], highlighting the need
for close follow-up evaluation. Afsarlar noted their recurrence
rate of a perianal abscess was 30 %, regardless of whether it
spontaneously drained or was I&D’d and with or without antibiotics [ 2 ]. Antibiotics have, however, been reported to
decrease the rate of fi stula development by ~12.5–50 %,
regardless of the antibiotics used [ 2 , 3 , 6 , 7 ]. Others have also
reported no difference in fi stula rates (~20–38 %) between
spontaneous and surgical drainage [ 2 ]. Even those treated
with observation alone (no antibiotics) have been associated
with fi stula resolution rates of 17–80 % within 1 year [ 2 , 6 ].
For children <2 years old, only 15–25 % will have a concomitant fi stula at the time of their primary surgery [ 4 , 11 ].
In this same cohort that undergoes I&D, ~6–15 % will ultimately develop a fi stula [ 4 , 11 ]. This is in contrast to children
over 8 years, where reported recurrence rates approach 50 %
and abscess to fi stula progression is ~25 % [ 4 ]. Important to
note, a signifi cant portion of children over 8 years that
develop fi stula recurrences are eventually diagnosed with
infl ammatory bowel disease (Fig. 27.1 ), and you should
work them up appropriately [ 4 , 11 ]. It is not surprising,
therefore, that immunosuppressive agents such as tacrolimus
have been associated with successful fi stula resolution without the need for operative intervention [ 4 ].
Hemorrhoids
Key Concept : Hemorrhoids are normally from constipation
and should almost always be treated nonoperatively .
Hemorrhoids are extremely uncommon in children, with
the prevalence increasing in older kids and teens [ 12 ].