Challenges of Robotic Gynecologic Surgery in Morbidly Obese Patients and How to Optimize Success

Robotic approach for the treatment of gynecological cancers recurrences: A ten-year single-institution experience

INTRODUCTION

Although the management of gynecological cancers recurrences may be challenging, due to the heterogeneity of recurrent disease, the aim of this work is to present a descriptive analysis of gynecological malignancies recurrences in our institution treated by robotic approach.

MATERIALS AND METHODS

We performed a retrospective review and analysis of data of patients who underwent robotic surgery for recurrent gynecological malignancies at Catholic University of the Sacred Hearth, Rome, from January 2013 to January 2024.

RESULTS

A total of 54 patients underwent successful robotic cytoreductive surgery. The median age was 63 years; the median BMI was 33 kg/m2 and most of the patients (59 %) were obese. In 12 cases (22 %) the relapse presented was the second or third relapse. The most frequent patterns of recurrence were represented by lymph nodes (41 %), followed by peritoneal (26 %), pelvic (22 %) and parenchymal (11 %). In all patients complete cytoreduction was achieved. In 29 patients (54 %) the surgical field was previous treated. The median operative time and estimated blood loss were, respectively, 270 min and 100 ml. There were 2 intraoperative complications, managed endoscopically; 10 early postoperative complications, and 3 late postoperative complications. The 2-year progression-free-survival and overall survival were, respectively, 39.8 % and 72.3 %.

CONCLUSION

Robotic approach in the treatment of recurrent gynecological cancers should be considered in selected patients with oligometastatic disease, in high-volume centers with expert surgeons, particularly in obese patients.

Reproductive Surgery in Females with Obesity: Reproductive Consequences of Obesity and Applications for Surgical Care

Obesity is the most common medical problem in women of reproductive age. The surgical applications for this population, many of who are interested in current or future fertility, are critical to safe and effective evaluation and management of issues that impact the reproductive system. As rates of obesity continue to rise worldwide, it is projected that one in two individuals will have obesity by 2030 leading to increasing numbers of individuals affected by a disease process that has implications for their gynecologic surgical care, fertility-related assessment, and infertility treatment. Offering patients with obesity access to safe reproductive surgery is a cornerstone of reproductive autonomy. This review will summarize current recommendations regarding surgical concepts for the operating room, office hysteroscopy, oocyte retrieval, and embryo transfer in female patients with obesity.

Robotic CME in obese patients: advantage of robotic ultrasound scan for vascular dissection

Complete mesocolic excision (CME) in right-sided colon cancers appears to confer oncological benefits compared to conventional colectomy. Identification of the superior mesenteric vein (SMV) remains challenging. We describe the novel use of intra-operative robotic ultrasound scan (rUSS) in obese patients (BMI ≥ 29). All consecutive patients having robotic CME for colon cancer between 2014 and 2017 were included in this retrospective cohort study. Data were recorded on an ethics approved prospective database and included patient demographics, clinical and oncological outcomes. Patients were divided into group 1 (BMI ≤ 28) and group 2 (BMI ≥ 29). SMV first approach was employed in all cases and SMV detection was aided using rUSS in group 2. Primary outcome was postoperative morbidity. Secondary outcomes included conversion rate, operative time and length of stay (LOS). 41 (group 1, median 66 years) were compared to 32 patients (group 2, median 63 years). There were no conversions to laparoscopy or laparotomy. Median operative times for group 2 were 30 min longer (186 vs. 216 min, p = 0.05). Overall morbidity was similar (20% vs. 19% in group 1 and 2, p = 0.26). There was no significant difference between the two groups with regard to LOS (median 7 vs. 6 days, p = 0.48), readmissions (2 vs. 5, p = 0.13), R0 resection rate (98% vs. 94%, p = 0.43) and lymph node harvest (median 31 vs. 30, p = 0.28).CME can be technically more challenging than conventional colectomy in obese patients and is associated with longer operative times. The use of rUSS in obese patients can help to identify SMV and allow safer dissection.

A Practical Approach to Total Laparoscopic Hysterectomy in a Morbidly Obese Patient: A Case Report and Literature Review

Morbid obesity, traditionally considered to be a contraindication to total laparoscopic hysterectomy, is now evolving into an indication. Innovations and advancements in minimally invasive surgical techniques have significantly improved patient morbidity and mortality rates, reduced operational costs, and provided patients with an overall safer surgical experience. Although the laparoscopic approach is associated with several physiologic and technical challenges in the morbidly obese, it is plausible that these patients stand to benefit the most from minimally invasive surgery. This report highlights the methods of preoperative optimization, intraoperative considerations, and postoperative management strategies employed to achieve a successful total laparoscopic hysterectomy, bilateral salpingo-oophorectomy and pelvic lymph node dissection in a patient with a BMI of 45kg/m², diagnosed with grade 1 endometrial adenocarcinoma and several obesity-related comorbidities.

Long-Term Assessment of Pelvic Organ Prolapse Reoperation Risk in Obese Women: Vaginal and Laparoscopic Approaches

The aim of this study was to compare reoperation risks after pelvic organ prolapse repair at 5-year follow-up between obese, overweight, and normal-weight women and to assess these risks accounting for the surgical procedure. We performed a retrospective chart review of all the women who underwent POP repair by transvaginal mesh surgery between January 2005 and January 2009 or laparoscopic sacrocolpopexy between January 2003 and December 2013 at the Gynecologic Surgery Department of the Lille University Hospital. During the study period, 744 women who underwent POP repair were divided into three groups: 382 (51%), 240 (32%), and 122 (16%) in the nonobese group (BMI < 25 kg/m²), overweight group (25 kg/m² ≤ BMI < 30 kg/m²), and obese group (BMI ≥ 30 kg/m²), respectively. The primary outcome was global reoperation. The median duration of follow-up was 87 months. The risks of global reoperation did not significantly differ between the three BMI groups (adjusted HR (95% CI): 1.12 (0.69 to 1.82) for overweight women and 0.90 (0.46 to 1.74) for obese women compared to normal-weight women, adjusted p = 0.80), nor among the women who underwent transvaginal mesh surgery or laparoscopic sacrocolpopexy. The risks of reoperation for POP recurrence, stress urinary incontinence, or mesh-related complications did not significantly differ between the three BMI groups in the overall population nor accounting for the surgical procedure. In conclusion, obesity does not seem to be a risk factor of reoperation for POP recurrence, SUI, or mesh-related complications in the long term regardless of the surgical approach.

Perioperative Management of Robotic-Assisted Gynecological Surgery in a Super Morbidly Obese Patient

We report the perioperative management of a 32-year-old woman with super-morbid obesity (body mass index (BMI) of 60.9 kilograms per meter squared (kg/m²)) who underwent a robotic-assisted total laparoscopic hysterectomy in a hospital that was not specialized for obese patients. She successfully reduced her BMI by 10% using dietary restrictions in five weeks, and her surgery was performed two weeks later by consultation between gynecologists and anesthesiologists. This case demonstrates that the determination of the optimal time for surgery by consultation between physicians is crucial in the care of such a complex patient in hospitals that are not specialized for morbidly obese patients. Weight reduction in the preoperative period should be considered for super-morbid obesity patients with malignant diseases, even if the duration of preoperative optimization is shorter than four to eight weeks.

Individualized positive end-expiratory pressure with and without recruitment maneuvers in obese patients during bariatric surgery

This study aimed to determine whether regular recruitment maneuvers (RMs) are essential for obese patients (OPs) undergoing elective laparoscopic bariatric surgery (LBS) during intraoperative ventilation with individualized positive end-expiratory pressure (PEEP). Patients were randomly assigned to two arms: the RM + PEEP_-EIT arm consisted of individualized PEEP titrated by electrical impedance tomography (EIT) with two regular RMs and the PEEP_-EIT arm consisted of individualized PEEP titrated by EIT without additional RMs. For these two arms together, EIT-guided PEEP varied among individuals. The partial pressure of oxygen in arterial blood to fractional inspired oxygen (PaO₂ /FiO₂ ) ratio in the RM + PEEP_-EIT arm was higher than that in the PEEP_-EIT arm at 1 h after pneumoperitoneum (p = 0.024) and at the end of surgery (p = 0.035). There was no great difference in the PaO₂ /FiO₂ ratio between these two arms when measured 5 min prior to postanesthesia care unit (PACU) departure and on postoperative day 1. Compared with the PEEP_-EIT arm, patients in the RM + PEEP_-EIT arm had significantly higher intraoperative dynamic respiratory system compliance (p < 0.001) but consumed more vasopressors (p = 0.036). Postoperative pulmonary complications occurred in 1 of 29 patients in the RM + PEEP_-EIT arm compared with 2 of 31 patients in the PEEP_-EIT arm. Regular lung RMs can improve intraoperative oxygenation and respiratory system compliance among OPs undergoing LBS with EIT-guided individual PEEP. However, the improvement might disappear before leaving the PACU, and regular RMs resulted in more vasopressor consumption.

Anesthetic management for robotic hysterectomy in obese women

PURPOSE OF REVIEW

Obesity is a major health epidemic, with the prevalence reaching ∼40% in the United States in recent years. It is associated with increased risk of hypertension, diabetes, heart disease, stroke, obstructive sleep apnea (OSA), and gynecologic conditions requiring surgery. Those comorbidities, in addition to the physiologic changes associated with obesity, lead to increased risk of perioperative complications. The purpose of this review is to highlight the anesthetic considerations for robotic assisted hysterectomy in obese patients.

RECENT FINDINGS

In the general gynecologic population, minimally invasive surgery is associated with less postoperative fever, pain, hospital length of stay, total cost of care and an earlier return to normal function. This also applies to robotic surgery in obese patients, which is on the rise. The physiologic changes of obesity bring different anesthetic challenges, including airway management and intraoperative ventilation. Vascular access and intraoperative blood pressure monitoring can also be challenging and require modifications. Optimizing analgesia with a focus on opioid-sparing strategies is crucial due to the increased prevalence of OSA in this patient population.

SUMMARY

Anesthesia for obese patients undergoing robotic hysterectomy is challenging and must take into consideration the anatomic and physiologic changes associated with obesity.

Safety and efficacy of synchronous panniculectomy and endometrial cancer surgery in obese patients: a systematic review of the literature and meta-analysis of postoperative complications

Panniculectomy combined with gynaecological surgery constitutes an alternative approach for endometrial cancer (EC) in obese patients. The present study aimed to assess the current knowledge concerning the safety and efficacy of combining panniculectomy in surgical management of EC. Four electronic databases were systematically searched for articles published up to May 2019. A total of five studies, of which two were non-comparative and three comparative, were included. Meta-analysis of complications among panniculectomy and conventional laparotomy group revealed no difference in either intra- or post-operative complication rates. Moreover, no difference was reported in surgical site complications (p=0.59), while wound breakdown rates were significantly elevated in the laparotomy group (p=0.02). Panniculectomy combined surgery for the management of EC appears to be a safe procedure and results in comparable outcomes compared with conventional laparotomy with regard to complications and improved wound breakdown rates.

Effects of Obesity on Peri- and Postoperative Outcomes in Patients Undergoing Robotic versus Conventional Hysterectomy

STUDY OBJECTIVE

To assess if women with obesity have increased complication rates compared with women with normal weight undergoing hysterectomy for benign reasons and if the mode of hysterectomy affects the outcomes.

DESIGN

Cohort study.

SETTING

Prospectively collected data from 3 Swedish population-based registers.

PATIENTS

Women undergoing a total hysterectomy for benign indications in Sweden between January 1, 2015, and December 31, 2017. The patients were grouped according to the World Health Organization's classification of obesity.

INTERVENTIONS

Intraoperative and postoperative data were retrieved from the surgical register up to 1 year after the hysterectomy. Different modes of hysterectomy in patients with obesity were compared, such as open abdominal hysterectomy (AH), traditional laparoscopic hysterectomy (TLH), vaginal hysterectomy (VH), and robot-assisted laparoscopic hysterectomy (RTLH).

MEASUREMENTS AND MAIN RESULTS

Out of 12,386 women who had a total hysterectomy during the study period, we identified 2787 women with normal weight and 1535 women with obesity (body mass index ≥30). One year after the hysterectomy, the frequency of complications was higher in women with obesity than in women with normal weight (adjusted odds ratio [aOR]) 1.4; 95% confidence interval [CI], 1.1-1.8). In women with obesity, AH was associated with a higher overall complication rate (aOR 1.8; 95% CI, 1.2-2.6) and VH had a slightly higher risk of intraoperative complications (aOR 4.4; 95% CI, 1.2-15.8), both in comparison with RTLH. Women with obesity had a higher rate of conversion to AH with conventional minimally invasive hysterectomy (TLH: aOR 28.2; 95% CI, 6.4-124.7 and VH: 17.1; 95% CI, 3.5-83.8, respectively) compared with RTLH. AH, TLH, and VH were associated with a higher risk of blood loss >500 mL than RTLH (aOR 11.8; 95% CI, 3.4-40.5; aOR 8.5; 95% CI, 2.5-29.5; and aOR 5.8; 95% CI, 1.5-22.8, respectively) in women with obesity.

CONCLUSION

The use of RTLH may lower the risk of conversion rates and intraoperative bleeding in women who are obese compared with other modes of hysterectomy.