Challenges in the Management of a Morbidly Obese Patient Undergoing Robotic Hysterectomy

Abstract

Dear Editor, We are writing to share our insights and experiences regarding the challenges encountered in the management of morbidly obese patients, particularly in the context of gynecological surgeries. The discussion stems from the case of a woman in her 40s with a body mass index (BMI) of 46 kg/m2, who underwent robotic-assisted hysterectomy and bilateral salpingectomy due to abnormal uterine bleeding with leiomyoma. This case highlights the intricate interplay of various factors that necessitate meticulous perioperative care strategies to mitigate potential complications. The patient presented with heavy menstrual bleeding for a year and had comorbidities including obstructive sleep apnea and hypertension. Examination revealed a BMI of 46.3 kg/m2 (weight: 120 kg and height: 161 cm). Pelvic magnetic resonance imaging indicated an intramural fibroid and an endometrial thickness of 17.2 mm. Endometrial biopsy showed hyperplasia without atypia. After declining medical management, the patient underwent robotic-assisted hysterectomy and bilateral salpingectomy using the da Vinci Xi system. Preoperative optimization included antihypertensive therapy and continuous positive airway pressure for sleep apnea. The perioperative plan focused on minimizing anesthesia-related complications, aspiration, and cardiovascular events. Entry was achieved using a supraumbilical approach with an optical trocar due to the patient’s substantial pannus. Bariatric-sized robotic cannulas (16 cm) minimized dislodging. The procedure required minimal Trendelenburg tilt (15°–20°) to manage elevated end-tidal CO₂ levels. Intraoperative blood loss was 100 mL, and postoperative recovery was uneventful, with a hospital stay of 36 h. Histopathology confirmed uterine leiomyoma. Morbid obesity is associated with higher surgical and anesthesia risks, including myocardial infarction, peripheral nerve injury, and surgical site infections.[1,2] Robotic surgery offers significant advantages for obese patients, such as enhanced dexterity, reduced force on the abdominal wall, and improved visualization, which contribute to better perioperative outcomes.[2] For obese patients, preoperative optimization of antibiotic dosages, minimizing aspiration risk, and managing cardiovascular stability are critical. Collaboration with anesthesiologists to anticipate elevated end-tidal CO₂ levels and implement strategies such as goal-directed fluid therapy is essential. Positioning the patient on a nonslip surface, ensuring proper alignment to prevent nerve damage, and securing the chest are crucial intraoperative steps [Figure 1].Figure 1: (a) Port placement, (b) Adequate securing of arms, chest, and use of shoulder padding, (c) Trendelenburg position after dockingRobotic surgery requires precise entry techniques to avoid complications such as preperitoneal insufflation. Supraumbilical or infraumbilical entry points should be selected based on the presence of a pannus. Using bariatric-sized cannulas and maintaining lower pneumoperitoneum pressures (10–12 mmHg) with a fan retractor can improve patient tolerance and visibility. Table 1 summarizes the anesthesia complications and their management.[3]Table 1: Intraoperative anesthesia challenges and managementEnhanced recovery protocols are vital for morbidly obese patients. Early mobilization, extended oxygen therapy, thromboembolism prevention measures, and multimodal postoperative nausea and vomiting prophylaxis are crucial. Utilizing a surgical site infection, prevention bundle is particularly important in this patient population. Navigating the complexities of managing morbidly obese patients in gynecological surgeries requires a comprehensive, multidisciplinary approach. By proactively addressing the challenges inherent in this patient population, health-care providers can enhance safety, optimize outcomes, and improve overall care quality. Further research to standardize perioperative management techniques is essential to establ