**8. Surgical approach**

Obesity is an important factor to consider when determining an appropriate surgical approach to hysterectomy. A systematic review published in 2015 by Blikkendaal et al., found that laparoscopic hysterectomy and vaginal hysterectomy are associated with significantly fewer postoperative complications and shorter lengths of hospital stay [31]. While vaginal hysterectomy is generally the preferred surgical approach and is associated with improved outcomes, it seems to be less favorable in obese patients due to large uterine size, early-stage endometrial cancer, or lack of vaginal access and exposure secondary to the patient's body habitus [31]. In patients who are not good candidates for vaginal surgery, conventional laparoscopic hysterectomy and robotic hysterectomy are alternative approaches that are shown to be safe and feasible in this patient population [31, 32].

The benefits of minimally invasive surgery are well studied. Compared to laparotomy, laparoscopic hysterectomy results in fewer postoperative complications, decreased blood loss, less time in the hospital, and faster recovery [31, 33]. One study showed that obese patients who underwent laparoscopic hysterectomy compared with laparotomy had fewer incidences of postoperative ileus (0% vs. 13.3%), less postoperative fevers (5.5% vs. 31.1%), and a decrease in wound infections (9% vs. 22%) [15]. Additionally, obese women undergoing laparoscopic hysterectomies, bilateral salpingo-oophorectomy, and lymph node dissection for stage I endometrial carcinoma were found to have shorter hospital stays (2.5 vs. 5.6 days), less pain (32.2 vs. 124.1 mg of pain medication), and earlier return to normal activity [15].

Despite the clear benefits of minimally invasive techniques, research evaluating surgeons' surgical preference shows that the rate of abdominal hysterectomy increases as BMI increases [31]. In fact, in the past obesity was considered a relative contraindication to laparoscopic surgery. This is due to associated difficulties with Verees needle placement, accumulation of fat in the omentum obstructing the operative field and manipulation of laparoscopic instruments [15]. However, more recent studies have shown that minimally invasive approaches including robotics and conventional laparoscopic techniques can be successful in obese patients with proper planning and appropriate laparoscopic surgical experience.

Robotic surgery may help overcome some of the inherent challenges of minimally invasive surgery in obese patients. Robotic surgery offers greater flexibility, articulation, and control of the instruments with reduced hand tremors. Improved ergonomics and the 3D-HD view allow for surgeons to more easily operate within the confined space of an obese abdomen and reduce surgeon fatigue [33]. This is especially relevant in obese patients with endometrial cancer when lymphadenectomy is required [34]. The advantages of robotic surgery may help facilitate the completion of hysterectomy using a minimally invasive approach, however, the cost is significant. Each robotic console has a direct cost of \$2.6 million USD and about \$2000 per surgical case [34].

While most studies comparing robotic surgery to laparoscopic surgery have not been able to show an improvement in safety or efficacy compared with conventional laparoscopy, there is evidence that robotic surgery may provide clinical benefits in specific populations like the morbidly obese [34–36]. In fact, there is evidence of cost neutralization with robotic procedures when the rate of conversion to laparotomy is decreased [34]. A recent systematic review and meta-analysis comparing laparoscopic and robotic hysterectomy in endometrial cancer patients with obesity found similar perioperative complication rates but a decrease in conversion to laparotomy in robotic procedures performed on patients with BMI > 40 kg/m2 (7.0% vs. 3.8%) [34]. Additionally, the qualitative reasons for conversion were different in robotic hysterectomy and conventional laparoscopic hysterectomy. Conversion to laparotomy from conventional laparoscopy was more often due to obesity-related anesthetic concerns (30% vs. 6%) while conversion from robotic assisted laparoscopy was attributed more frequently to increased uterine size [34].
