Morbidly Obese Man

SavageGlow · #1 ● 06-22-2024, 05:52 PM

A 58-year-old morbidly obese male with a body mass index (BMI) of 77 was referred several times to the emergency room due to scrotal pain and increasing swelling (Fig. 1).

Previously, the patient had failed to complete an outpatient weight loss program in preparation for bariatric surgery. More than 3 years after his first visit to the emergency department, the patient was referred to our facility. Physical examination revealed a gigantic mass measuring ~48 × 34 × 46 cm, with the mons pubis and scrotal skin burying the penis in a >40-cm long fistula. The skin was thick and fibrotic with multiple nodules (Fig. 2). The patient had great difficulty walking and managing hygiene, voiding and had lost sexual function of the penis. Hence, a joint-venture surgical approach involving plastic surgeons and urologists was planned with a palliative intent.

The preoperative computed tomography (CT) scan showed enlarged lymph nodes along the iliac vessels bilaterally and in the groin. Apart from massive edema that had increased more than 10-fold in volume over 2 years, it revealed a network of enlarged veins and intact testicles at the end of a 17-cm long furnicle with no radiological signs of malignancy or herniation (Fig. 3).

Prior to surgery, a bariatric bed and a bariatric ambulance were acquired. The large abdominal pannus led to concern of accessibility of the excision area. Sterile S-hooks from a butcher were used in order to lift the pannus mechanically and ensure proper surgical access (Fig. 4).

Once the patient was sedated, the urethra was located with a flexible cystoscope and a guidewire was placed. Both the cystoscope and urine catheters were insufficient in length to reach the bladder, and eventually an open-end nasogastric tube was placed.

Excision of the scrotal mass began with a sagittal incision over the urinary catheter through the mons pubis until the glans penis was exposed and secured. Due to the gravitational force of the edematous tissue, the penile skin had been invaginated out over the glans and could not be spared (Fig. 5). During the procedure, several lymphatic cysts were found and numerous dilated vessels ligated. With the assistance of perioperative ultrasound, testis and furnicles were located, but due to the fibrosis of the adherent tissue and the furnicle length, they could not be spared (Fig. 6). Lateral flaps from the primary scrotal area were preserved and brought medially to shape the neoscrotum. The penis remained degloved until later reconstruction with a split-skin graft (Fig. 7).

After several hours in the operating room, a combined mass of 26 kg was removed (Fig. 8) and a total amount of 300 separate cloths of gauze weighed in at 14 kg. It resulted in an immediate postoperative weight loss from 255 to 231 kg and a BMI reduction of seven points.

Histopathological analysis showed no signs of malignancy and no dysplasia. The patient received testosterone supplementation shortly after surgery and was discharged 23 days post-surgery.

At 6-month follow-up, there was no recurrence of lymphedema, and the penis was clinically visible and could be reached by the patient (Fig. 9). The patient continued to struggle with commencing weight loss efforts, and for that reason abdominal panniculectomy is not planned yet.