**9. Intraoperative considerations**

#### **9.1 Trocar placement**

After properly positioning the patient and obtaining adequate pneumoperitoneum, the surgeon must determine adequate and safe port site placement. This step can be more challenging in obese patient as traditional landmarks may be altered. The surgeon should choose trocars that are adequate in length. Although extra-long trocars, up to 150 mm, are available and may be useful in patients with very thick anterior abdominal walls, they are often not necessary [29, 37]. In order to safely place accessory trocars, some authors recommend increasing the insufflation pressure to 25 mmHg to increase the distance for trocar placement in order to avoid vascular and visceral complications [37]. Once the initial trocar is placed and pneumoperitoneum is achieved, ancillary trocars can be placed under direct visualization after localization with a spinal needle [37]. In general, most authors recommend more cephalad and lateral placement of ancillary port in obese women. This is due to the difficult visualization of the inferior epigastric vessels and the extent of the panniculus [11, 29, 38]. When placing ancillary trocars, they should be angled toward the operative field to prevent slippage and torquing of the instruments [15]. Surgeons should have a low threshold for adding additional ports that may improve ergonomics, triangulation, or retraction [29, 38].

#### **9.2 Exposure and uterine manipulation**

Surgical exposure can be challenging in obese patients. This is due to increased visceral adiposity, a fatty rectosigmoid colon, or limited Trendelenburg positioning due to difficulty with ventilation [29, 32]. Mobilizing the cecum and sigmoid

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

reflection from their lateral peritoneal attachments can help facilitate moving the large bowel out of the pelvis [29]. Additionally, the rectosigmoid colon can be retracted by using a puppet stitch to pull the epiploic appendices to the anterior abdominal wall [11]. Another option is using a pre-tied endoscopic loop that can be brought through the anterior abdominal wall using a fascial closure device or bringing the suture through a trocar to be tied off [29, 38].

Effective uterine manipulation is especially important to perform laparoscopic and robotic hysterectomies safely in obese patients. This is because the amount of Trendelenburg may be limited and exposure to the pelvis may be challenging [37]. There are many uterine manipulation devices available including the Zinnati Uterine Manipulator injector (ZUMI) (Cooper Surgical, Trumball, CT), the VCare (ConMed Endosurgery, Utica, NY), and the Reusable Uterine Manipulator Injector (RUMI) Arch (Cooper Surgical, Trumball, CT). It is recommended that surgeons choose a device that will be applicable to the majority of their cases so that the entire surgical team can become familiar with its use, allowing for reliable uterine manipulation [37].

### **9.3 Closure techniques**

As with non-obese patients, closure of the fascia is recommended in incisions greater than 10 mm to prevent port site evisceration. Exposure to the fascia can be more challenging in obese patients. Facial closure devices like the reusable Carter-Thomason CloseSure System XL device (Cooper Surgical, Trumball, CT) allow for the closure to be performed under direct visualization. If the device is not long enough, the disposable Endoclose device (Covidien, Norwalk, CT) can be used [37].

Many studies have compared vaginal vs. laparoscopic vaginal cuff closure with more recent data showing a reduction in vaginal cuff dehiscence with laparoscopic closure (1% vs. 2.7%) [24]. A study by Uccella et al. further demonstrated a reduction in vaginal bleeding (2.7% vs. 4.9%), vaginal cuff hematoma (0.9% vs. 2.3%), need for vaginal re-suturing (0.9% vs. 2.3%) and postoperative infection (0.9% vs. 2.3%) [39]. In obese patients with limited vaginal access due to weight distribution or a large panniculus, laparoscopic closure may also be more accessible.

Some research suggests that obesity may be a protective factor against vaginal cuff dehiscence and evisceration. One study found that after laparoscopic hysterectomy, obese women were 86% less likely to experience vaginal cuff dehiscence than non-obese women [40, 41]. Although intercourse is a significant risk factor for cuff dehiscence, it is hypothesized that positioning during intercourse may be different for obese women, resulting in the application of less physical force at the apex of the vagina [40, 41]. The authors further also postulate that an increase in adipose tissue leads to less energy being delivered to the vaginal tissue during the creation of colpotomy, which can improve healing by causing less tissue desiccation.

### **10. Post-operative care**

Studies have shown that the incidence of postoperative complications increases as BMI increases. However, when surgeries are performed in a minimally invasive fashion, complication rates for obese patients are similar to non-obese patients [29].

Patients with known or presumed cardiovascular disease, OSA, or high perioperative risk should be monitored closely in the postoperative period. Patients who have OSA should be observed overnight because of the increased risk of pulmonary complications [11, 29]. A multi-modal approach to analgesia is recommended

to limit narcotic analgesic which can worsen atelectasis and hypoxia. This may include acetaminophen, nonsteroidal anti-inflammatory agents, cyclooxygenase-2 inhibitors, gabapentin, or pregabalin as well as local or regional anesthesia [29, 42]. Early ambulation and the use of incentive spirometry can help inflate dependent lung regions and decrease impairment of lung function induced by anesthesia. As discussed above in the thromboembolism section of this chapter, morbidly obese patients are at increased risk for VTE and may benefit from from extended VTE prophylaxis for 10–35 days following surgery [11, 23].
