Modified abdominal access for the obese population requiring laparoscopic cholecystectomy: Our recommendation

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INTRODUCTION: Conventional umbilical access can be time-consuming, surgically challenging due to inadequate 'Critical View of Safety' and pneumoperitoneum maintenance for high body mass index (BMI) patients undergoing laparoscopic cholecystectomy (LC). The aim of the study is to assess the feasibility, safety and outcome of our modified access for patients of BMI ≥30. PATIENTS AND METHODS: A prospective study of 1762 consecutive patients undergoing LC in a large district general hospital (2007-2023) that included age, sex, BMI, American Society of Anesthesiologists (ASA), grade of operation with stay and complications were analysed. Group A: Veress needle pneumoperitoneum through Palmer's point. After 2 L (minimum) insufflations, an optical port was introduced at the intersection of two imaginary lines: A 15-cm oblique line starting from where the right mid-clavicular line cuts the right lower costal margin and directed medially meeting the other vertical line running 3 cm to the right of midline. Remaining 3 ports at standard positions (10 mm epigastric port [I] at or just right of midline below the xiphoid process, 5 mm port [II] at the midclavicular line below the costal cartilage and another 5 mm port [III] between 5 cm and 10 cm lateral to port II) as used in LC. Group B (BMI <30): Conventional umbilicus entry followed by 3 standard remaining ports for LC (as above). RESULTS: Group A: 549 with female: male 4:1, the median of age 49 (16-83) years, BMI 36 (30-65), ASA 2 (1-3), Grade 1 (1-4), operating time 50 (15-200) min and post-operative (PO) stay 0 (0-15) day. One conversion, 2 bile leaks, 5 collections and 4 wound infections. Group B: 1213 with female: male 3:1, the median of age 53 (16-89) years, BMI 26 (17-29), ASA 2 (1-3), Grade 1 (1-4), operating time 45 (15-240) min and PO stay 0 (0-12) day. CONCLUSION: Our modified abdominal access is quick and safe that maintains sustained pneumoperitoneum and provides an excellent 'Critical view of Safety' for obese patients undergoing LC with a good outcome.

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