**1. Introduction**

Obesity worldwide has increased over time and is now considered an epidemic with significant health implications. Worldwide obesity has nearly tripled since 1975. In 2015–2016, the prevalence of obesity was 39.8% in adults and 18.5% in youth [1]. Body mass index (BMI) is a widely used method for estimating body fat mass. The World Health Organization defines class I obesity as BMI 30 to <35, class II obesity as BMI 35 to <40, and class III obesity as >40. The prevalence of clinically severe obesity (BMI > 40) is increasing at a much faster rate among adults in the United States than is the prevalence of moderate obesity [2]. In addition to the overall rising rates of severe obesity, the mean waist circumference (WC) has increased continuously among adults over the last 15 years. Abdominal fat deposition is a key component of obesity and some studies have shown that WC may be a better predictor for the risk of myocardial infarction, metabolic syndrome, and all-cause mortality than BMI [3].

From a surgical perspective, facilities need to consider the availability of specialized equipment for morbidly obese patients. Many facilities may lack the appropriate equipment for patient transfer, operating room tables that can accommodate the patient's weight, and specialized laparoscopic surgical equipment for minimally invasive surgery. Particular challenges of minimally invasive surgery for morbidly obese patients can be seen with central adiposity, which creates a thicker abdominal wall, larger visceral volume, and enlarged mesentaries, which can impact intraperitoneal visualization more difficult [4]. Central adiposity can also create technical challenges for entry into the abdominal cavity, difficulty with maneuvering laparoscopic instruments through a thick abdominal wall, and physiological stress of Trendelenburg position and pneumoperitoneum [5].

With respect to gynecologic minimally invasive surgery, obesity was previously considered a relative contra-indication. The first feasibility study of gynecologic laparoscopic surgery for obese patients was performed in 1976 [6]. With advances in minimally invasive technologies and increased operator experience, there has been growing evidence supporting minimally invasive surgery for obese patients. There is a large amount of data from gynecologic oncology indicating laparoscopic or robotic surgery resulted in shorter hospital stay, less postoperative pain, earlier return to normal activity, decreased postoperative complications, and fewer wound infections [7]. However, there are some studies indicating a higher conversion rate to laparotomy, which was dependent on BMI, noting that women who were morbidly obese had a 57% conversion rate to open laparotomy [8].

There is conflicting data regarding comparisons between robotic vs. conventional laparoscopic surgical outcomes. When looking at bariatric surgery studies, there is some evidence that robotic surgery results in shorter operative times with increased BMI [9]. However, other studies indicate that there are longer operative times [10]. One reason that surgeons may favor the use of robotic surgery is reduced surgeon fatigue, the utility of articulated wristed robotic instruments which allow for more fluid movements and less torque on the abdominal wall [11]. Further prospective studies are required to define the best and most cost-effective minimally invasive surgical method in obese women. Ultimately, every effort should be made to offer the least invasive procedure regardless of BMI, to maximize clinical benefits and quality of life [12].
