Effectiveness of a lower-abdominal incision in an extremely underweight patient with thin skin who underwent laparotomy during an upper abdominal surgery: A case report

INTRODUCTION: Although laparoscopic surgery is often difficult in patients with obesity, very few studies have investigated its difficulty in extremely underweight patients. PRESENTATION OF CASE: We present the case of a 44-year-old nulliparous woman with an extremely low body weight who underwent laparoscopic adnexal surgery. She had undergone laparotomy for partial hepatectomy and was referred to our hospital 6 months later for an ovarian tumor. She weighed 25.5 kg and had a body mass index of 10.6 kg/m(2). Abdominal magnetic resonance imaging revealed a relatively large rectus abdominis and a dilated bowel. An umbilical approach was considered dangerous because of the existing surgical scar. Thus, a small incision was made in the lower abdomen, and the first trocar was inserted under direct view. Laparoscopic resection of the right adnexa was performed; however, the operative time was longer than expected (96 min) because the dilated intestinal tract obstructed our view and the lower abdominal mini-incision approach with the EZ access device was used. DISCUSSION: Underweight patients are reportedly at an increased risk of subcutaneous emphysema and initial trocar puncture injuries. We avoided these by approaching through a small, lower abdominal incision. We considered the unexpectedly rapid and deep trocar entry to be dangerous and expected a hand-assisted approach to be safer. CONCLUSION: Our findings indicate that considerably difficulties are encountered during a laparoscopic surgery in extremely underweight patients with a history of laparotomy; thus, special care should be taken during such surgeries.