**4. Operating room setup**

In order to complete laparoscopic surgery safely and efficiently for morbidly obese patients, proper preparation in the operating room is essential. Proper setup of the operating room will allow for mobility of the surgical team, quick access to instruments, increase patient safety, and the ability for the surgeon to successfully complete the procedure.

The first consideration needs to be placed on basic operating room equipment such as the operating room table and mechanisms for patient transfer. Patients are usually brought to the operating room in a stretcher. Lateral transfer devices that utilize hover technology (Hovermatt) can enable the team to move the patient to the operating room table and back to the transport stretcher in a secure and comfortable manner [26]. Operating room tables must have the capacity to support morbidly obese patients. Many standard tables have weight limits of 227 kg (500 lb). A bariatric bed is wider than traditional beds and can accommodate a weight of up to 1000 lb. If there is no availability of a bariatric bed, two standard operating room tables can be used together. Extra padding, blankets, sheets, or lifting devices may be needed to appropriately position an obese patient. Blood pressure cuffs and sequential compression devices will need to be of appropriate size to provide accurate readings.

An additional consideration should be placed on specialized laparoscopic instruments. Laparoscopes come in various sizes with a standard length of 32 cm and diameters ranging from 2 to 10 mm. There are various angled scopes available. In bariatric surgery, some surgeons endorse using a 45-degree angled scope or an extralong laparoscope (45 cm) to aid with viewing flexibility in extremely obese patients [27]. Laparoscopic assist trays may include extra-long laparoscopic instruments (41–45 cm), which may aid with the ability to complete the procedure successfully. Instruments such as long trocars, trocars with a non-latex balloon at the distal end for retention of the trocar tip in the abdominal cavity, or a long Veress needle (150 mm) may be used. Uterine manipulators should be considered for safe completion of hysterectomy. Although redundant perineal tissue or a large uterus may limit the full mobility of the uterus, the integrated cervical cup will allow for cephalad traction and proper identification of surgical landmarks for colpotomy creation and increase the distance of the uterine arteries from the ureters [4].
