**3. Perioperative considerations**

It is imperative that morbidly obese patients who are seen for surgical consultation should have a comprehensive history and physical exam in addition to laboratory and diagnostic testing as their obesity can increase their medical complexity. During a physical exam, there should be documentation of the patient's body habitus, assessment of the uterine size, uterine mobility, and vaginal caliber. Proper evaluation of the patient's panniculus and body type is crucial for determining intravenous access, trocar placement, and positioning during laparoscopy [4]. Special attention must be paid to the distribution of the patient's weight (i.e. increased waist circumference vs. increased hip circumference). Patients with large adipose tissue centered on their waist are likely to be more technically challenging than patients whose adipose is centered on the hips [15]. In patients with large panniculus, trocar placement may be hindered not only by increased thickness but also by a lack of mobility. If the panniculus is soft and mobile, it can be repositioned easily using traction with weights or tape.

In general, preoperative testing should be tailored to the patient's risk factors. Basic laboratory assessment can include a complete blood count, blood glucose concentration, basic metabolic panel, and blood type and screening. Given the

*Laparoscopic Hysterectomy in Morbidly Obese Patients DOI: http://dx.doi.org/10.5772/intechopen.101307*

high predisposition for cardiovascular, pulmonary, and endocrine abnormalities in morbidly obese patients, evaluation by subspecialists for additional diagnostic testing should be performed. Informed consent should take into account both the increased medical and surgical complexity of the case and inform the patient of increased risk of infection, increased risk of VTE, and potential increased risk for conversion to laparotomy [11]. As pulmonary and cardiovascular changes are prominent in morbidly obese patients, there are numerous risks associated with general anesthesia including airway complications and oxygenation issues with induction of anesthesia, intubation, and extubation [4]. Increased communication with anesthesia and pre-operative evaluation with anesthesia may be beneficial for these patients. When considering antibiotic prophylaxis, the current standard for routine prophylaxis prior to hysterectomy is 2 g of cefazolin for patients under 120 kg and 3 g for patients over 120 kg [25]. With regards to mechanical bowel prep (MBP), the theoretical advantage is to reduce intestinal volume and mass to improve intraoperative manipulation and visualization. A meta-analysis of elective colorectal surgery has revealed no statistical advantage of MBP [4].
