**5. Patient positioning**

Obese patients are at greater risk for pressure sores and nerve injuries when compared to non-obese patients. Duration of compression and compressive force applied influence the risk of nerve injuries. Prolonged compression for 6–8 hours can cause permanent nerve injuries [11, 28, 29]. For laparoscopic surgical procedures in gynecology, patients are placed in a dorsal lithotomy position with their arms tucked at their sides in a "military" position. It is recommended to initially position the buttocks slightly lower than the edge of the bed as the body will shift cephalad with the weight of the panniculus once in Trendelenburg position.

Several considerations should be taken when tucking the arms. It is important to ensure that all intravenous access and cardiopulmonary monitors are functioning appropriately. Adequate padding should be placed at the hands and elbows to minimze ulnar or branchial plexus injuries [29]. If the arms are hanging too far off the side of the bed, bed extenders or arm sleds can be used. If the patient slides cephalad with shoulder blocks in place or if the arms are extended. Two potential scenarios that can increase the risk of brachial plexus injury are if the patient slides cephalad with shoulder blocks in place or if the surgeon leans on the patient's extended arms [30]. The legs should be positioned in stirrups in a low lithotomy position with generous padding applied around the hips and knees. The most common stirrups available in the United States are the YellowFin, the YelloFin Elite, and the Ultrafin. The Ultrafin is capable of accommodating calves that are 13 inches wide and have a weight capacity of 800 lb. Appropriate selection of stirrups can potentially aid in decreasing nerve injury. Obese patients have an increased risk for brachial plexus injury given downward shifting in Trendelenburg [11]. There are multiple options to help reduce this cephalad shifting including gel padding, eggcrate foam, surgical bag, and a padded straps. Once the patient has been positioned a "tilt-test" can be performed where the patient is placed into Trendelenburg position for approximately 2–5 minutes in order to assess the stability of the patient's positioning and assess the impact on the respiratory and cardiac status. Some adjustments that can be made to help insufflation pressures would be to decrease the degree of Trendelenburg or reduce the insuflation pressure.

### **6. Panniculus management**

Management of the patient's panniculus in a caudad position during laparoscopic surgery can aid in improving the patient's ventilation and therefore potentially decreasing the conversation to laparotomy. One technique involves the use of a foley catheter that is passed through the patient's abdominal wall. The foley balloon is insuflated and the catheter is pulled up and clamped to a retractor attached to the foot of the bed [31]. A second technique involves using towel clips on the lower edge of the panniculus with 1-liter saline bags attached and hanging between the legs. Lastly, adhesive dressing can be used to secure the panniculus to the patient's thighs.

### **7. Abdominal access**

Morbid obesity can increase the difficulty of initial abdominal access in laparoscopic surgery due to the increased thickness of the abdominal wall and lack of reliable landmarks. Traditionally, the umbilicus is a common landmark used for abdominal entry as it may represent the thinnest part of the abdominal wall. *Laparoscopic Hysterectomy in Morbidly Obese Patients DOI: http://dx.doi.org/10.5772/intechopen.101307*

However, in obese patients, the umbilicus is often located at or cephalad to the aortic bifurcation. In obese women, the mean umbilical location was found to be on average 2.9 cm caudal to the aortic bifurcation in comparison to nonobese women in which the umbilicus was 0.4 cm caudual to the bifurcation [32]. Given this migration of the umbilicus, if it is used for entry into the abdomen, it may compromise adequate triangulation with the surgical pathology [11]. There are multiple techniques for abdominal entry including the Veress needle, use of an optical trocar, or an open technique. In obese patients, there is a higher likelihood for the Veress technique to result in a higher rate of false entry and preperitoneal insufflation [11]. If there is no substantial panniculus and the umbilical approach is chosen, a 90-degree entry can be used and the use of a long Veress needle (150 mm) may help decrease pre-peritoneal insufflation. If an optical trocar is used, it may be beneficial to use a long trocar to aid in correct placement. Supraumbilical and left upper quadrant are two alternative abdominal entry sites. If the left upper quadrant is used, a nasogastric or orogastric drainage tube should be placed to decompress the stomach. This site is contraindicated in patients who have a history of gastric bypass, splenectomy, and splenomegaly.
