**4. Surgery and positioning**

Following induction of anesthesia, the patient's arms were tucked to her sides. She was secured in a low lithotomy position with liberal padding on the legs and arms (**Figure 4**). Additionally, stationary shoulder blocks were placed to maintain her at a 20-degree tilt in the Trendelenburg position. The bladder was emptied, and a nasogastric tube was inserted to ensure the stomach was not distended during trocar entry. We failed to place a uterine manipulator (RUMI®II Koh-Efficient system) into the uterine cavity due to obstruction of the endocervical canal and extreme deviation of the cervix to the right by the large mass.

*Abdominal entry & port placement:* Pneumoperitoneum is established using ENDOPATH® insufflation Needle Ultra Veress (UV120, 120 mm) inserted *via* intra-umbilicus (the thinnest skin-peritoneum distance), with insufflation pressure of 20 mmHg. The primary port was positioned on the midline of Le Hwang, slightly below the epigastrium, by using an Endopath Xcel® dilating tip trocar (100 × 12 mm, Ethicon® Endo-Surgery), which was driven into an incision against the abdominal pressure. The intraabdominal pressure was reduced to 16 mmHg and maintained throughout the surgery. Intra-abdominal visualization was achieved using a 12 mm, 30° telescope (Karl Storz, 4 K RUBINA ® 3D Telescope system). Three 5 mm ancillary ports were positioned on the left iliac fossa, the left paramedian at the level of the umbilicus lateral to the border of the rectus abdominis muscle, and the right

#### **Figure 4.**

*Following the induction of anesthesia, the patient's arms were tucked to her sides. She was secured in a low lithotomy position with liberal padding on the legs and arms to prevent pressure necrosis and tractional nerve injury.*

iliac fossa in parallel with the left side using Endopath Xcel® dilating tip trocar (100 × 5 mm, Ethicon Endo-Surgery) inserted under direct visualization of the telescope (**Figure 5**). The surgical table was tilted and placed a 15–20° head-down Trendelenburg position as agreeable by the anesthesiologist.

*The operation:* We used Maryland LigaSure™ Smart Bipolar forceps (36 cm × 5 mm) in this procedure for coagulation and cutting the pedicles and fibers throughout the procedure, bipolar Robby Kelly grasping forceps (Karl-Storz, 3.5 × 200 mm) to seal the vessels, and monopolar powered hook (Kar-Storz, 3.5 × 200 mm) for dissection. The first stage of the surgery involved freeing the large mass from the adhesion to the sigmoid colon (**Figure 6**) and freeing the sigmoid colon from its natural fixation to allow its mobilization to the upper abdomen.

We started with coagulating and transecting the ovarian pedicles and the round ligaments bilaterally with Maryland LigaSure™ forceps to improve the mobility of the uterus and reduce the blood flow. Attempt to approach and seal the uterine artery from its origin from medial and lateral approaches failed due to the obstructing large uterine mass limiting the space for maneuvering to the lateral spaces. At this juncture, due to a sizeable anterior fibroid obstructing the view to the pelvis and pelvic side wall, we decided to perform a myomectomy to reduce the size of the mass to facilitate handling and permit a view of the pelvis and lower part of the uterus (**Figure 7**). To control the blood loss, 40 ml of vasopressin (20 units in 100 ml saline) was injected into the fibroid capsule. A sizeable transverse incision was made across the anterior surface of the uterus. With the help of a myoma screw and the grasping forceps to countertraction, the monopolar powered hook and scissor were used to cut the fibers. The large myoma was finally enucleated with some difficulty due to its large size, location involving the

#### **Figure 5.**

*The primary port was positioned on the midline of Le Hwang, slightly below the epigastrium, by using an Endopath Xcel® dilating tip trocar (100 × 12 mm, Ethicon® Endo-surgery). Three 5 mm ancillary ports were positioned on the left iliac fossa, the left paramedian at the level of the umbilicus lateral to the border of the rectus abdominis muscle, and the right iliac fossa in parallel with the left side using Endopath Xcel® dilating tip trocar (100 × 5 mm, Ethicon Endo-Surgery) inserted under direct visualization of the telescope.*

*3D Total Laparoscopic Hysterectomy of a Very Large Uterine Myoma in a Super Morbidly Obese… DOI: http://dx.doi.org/10.5772/intechopen.113206*

#### **Figure 6.**

*(a) Shows the first stage of the surgery involved freeing the large mass from the adhesion to the sigmoid colon. (b) Shows the transaction of the ovarian ligament from the uterus.*

#### **Figure 7.**

*A sizeable anterior fibroid obstructing the view to the pelvis and pelvic side wall.*

anterior lower segment of the uterus, and its fibrotic surgical plane **Figure 8**). The bleeders and hemostasis were handled and secured with suturing and bipolar coagulation.

Following the myomectomy, the uterine manipulator (RUMI®II Koh-Efficient system) was successfully placed into the uterine cavity to manipulate the smaller uterus. We continued the dissection anteriorly from the round ligaments down to the vesicouterine peritoneal fold to find the correct plane. The course of the ureters was identified. With the help of a uterine manipulator, which pushes the uterus cephalad and away from the ureters, the ascending branch of the uterine vessels was ligated with a suture and divided at the level of the isthmus of the uterus (**Figure 9**).

#### **Figure 8.**

*(a) Shows the injection of vasopressin (20 units in 100 ml saline) into the fibroid capsule to reduce blood loss. (b) With the help of a myoma screw, the grasping forceps to countertraction, and the monopolar powered hook to cut the fibers, the large myoma was enucleated with some difficulty due to its large size, location involving the lower segment, and its fibrotic surgical plane.*

#### **Figure 9.**

*(a) Shows the image of the uterus after myomectomy. (b) With the help of a uterine manipulator, which pushes the uterus cephalad and away from the ureters, the ascending branch of the uterine vessels was ligated with a suture and divided at the level of the isthmus of the uterus.*

#### *3D Total Laparoscopic Hysterectomy of a Very Large Uterine Myoma in a Super Morbidly Obese… DOI: http://dx.doi.org/10.5772/intechopen.113206*

The bladder flab was pushed downward, and the anterior cervical fascia was exposed for dissection of the cervix below the cervicovaginal margin. The cardinal ligament fibers were incised posteriorly to the uterosacral ligaments and inferiorly, identifying the lowest limit of dissection as the cervicovaginal margin. The colpotomy was completed by incising the vagina with a monopolar-powered hook at the precise margin of the cervix along the impression of the rim of the RUMI's cup in the vagina. The smaller uterus was retrieved from the abdominal cavity through the vagina. However, due to a narrowed vagina, the large myoma was morcellated with Versator ™powered morcellator uncontained. In this case, it was challenging to do in-bag morcellation of the fibroid due to its large size, limited space of the abdominal cavity, and thick abdominal wall. The morcellated myoma was extracted *via* the left iliac fossa port under direct visualization of the telescope (**Figure 10**). The vaginal cuff was laparoscopically sutured with the Vicryl 1/0 suture continuously. There were no complications; the operating time was approximately 485 min. Intraoperative blood loss was about 900 ml. The final weight of the removed morcellated uterus with myoma was 1210 g (300 × 300 × 120 cm), and the findings of the pathologic examination were consistent with a benign fibroid uterus.

## **5. Postoperative care**

The postanaesthetic care unit (PACU) stay was uneventful with stable hemodynamic parameters, pulse oximetry of 100%, and a pain score of 1/10. Venous thromboembolic prophylaxis in stockings and subcutaneous low-molecular-weight heparin was utilized, and incentive spirometry was initiated on the first postoperative day. The patient's diet slowly advanced within 12 hours after surgery, and she was discharged from the hospital within 24 hours of the procedure in a satisfactory condition (**Figure 11**).

## **6. Discussion**

Traditionally, laparoscopic surgery was not recommended for individuals with obesity; nevertheless, recent research indicates that employing a minimally invasive approach for gynecological procedures in obese and severely obese patients (those with a body mass index, or BMI, of ≥35 kg/m2 ) yields superior outcomes compared to the conventional abdominal approach [3]. This approach has been proven feasible and is associated with reduced rates of postoperative complications such as shorter recovery periods, decreased hospital stays, diminished postoperative discomfort, lower instances of surgical site infections, venous thromboembolism, wound complications, reduced risk of hernias, and improved cosmetic results [7].

While preoperative weight reduction is the ideal course of action for severely obese patients needing gynecological surgery, it is often challenging to achieve. Performing laparoscopic surgery on a substantial uterine mass can pose technical challenges, particularly when surgical access is restricted due to excess intra-abdominal fat and the size of the uterine mass. However, with a well-considered surgical strategy encompassing preoperative planning and postoperative care, it can be successfully accomplished.

In this case, a super-morbidly obese woman with a body mass index, BMI 60 kg/m2 with a large uterine mass underwent a total laparoscopic hysterectomy (TLH), although

#### **Figure 10.**

*(a) Shows the uncontained large myoma was morcellated with Versator ™powered morcellator. The morcellated myoma was extracted via the left iliac fossa port under direct visualization of the telescope. In this case, it was challenging to do in-bag morcellation of the fibroid due to its large size to fit the bag, limited space of the abdominal cavity, and thick abdominal wall. (b) Shows the morcellated myoma and the uterus extracted from the abdomen. The final weight of the removed morcellated uterus with myoma was 1210 g (300 × 300 × 120 cm).*

*3D Total Laparoscopic Hysterectomy of a Very Large Uterine Myoma in a Super Morbidly Obese… DOI: http://dx.doi.org/10.5772/intechopen.113206*

#### **Figure 11.**

*(a) Shows the patient is comfortable at 6 hours after surgery in high-dependency unit. (b) The patient's diet slowly advanced within 12 hours after surgery, and she was discharged from the hospital within 24 hours of the procedure in satisfactory condition. (Photos shown with permission from the patient).*

it took longer operative times; the operation was successful with no complications and postoperative morbidity. This case highlights the feasibility of laparoscopic surgery, and the technical challenges that surgeons may encounter when operating on a large uterine mass in an extremely obese patient.

Preoperative optimization is critical to ensure a safe surgical outcome in the morbidly obese. Preoperatively, obese patients should be thoroughly evaluated utilizing the New York Heart Association (NYHA) classification and the American Society of Anesthesiologists (ASA) score for any comorbidities affecting anesthetic management such as obstructive sleep apnea, diabetes, hypertension, and cardiovascular diseases [10, 11].

Preoperative mechanical bowel preparation for TLH has not been shown in randomized control studies to be beneficial in improving intraoperative visualization, bowel handling, or overall ease of performing the procedure [12]. However, in a complex case, in particular, operating a large uterine mass in a patient with excess visceral fat, as in our case, it might be helpful when the bowel and the stomach are decompressed to prevent inadvertent injury.

Proper patient positioning during induction and maintenance of anesthesia is also paramount important as obese patients are more prone to airway obstruction due to increased upper airway collapsibility and higher abdominal pressure [13]. Video laryngoscopy and awake intubation techniques may be necessary in some cases to improve airway visualization and reduce the risk of complications [14, 15].

Intraoperatively, maintaining adequate ventilation and oxygenation is crucial to prevent anesthesia-related complications, such as hypoxemia and respiratory acidosis [16]. Strategies to optimize lung function, such as positive end-expiratory pressure (PEEP) and recruitment maneuvers, may be necessary to improve oxygenation and reduce postoperative pulmonary complications [13]. Close monitoring of hemodynamic parameters, fluid management, and electrolyte balance is also essential in obese patients to prevent cardiovascular and metabolic complications [14].

During a total laparoscopic hysterectomy (TLH), patients are typically placed in the dorsal lithotomy or Trendelenburg position, inclined at an angle of 15–20 degrees. This positioning risks patient displacement or potential neurologic injuries [17]. To secure patients effectively in the Trendelenburg position, it is essential to provide leg support, ample arm and leg padding, stable shoulder blocks, and bean bags [16].

Additionally, although uncommon, nerve injuries to the upper and lower extremities are potential complications of laparoscopic gynecological surgery [17, 16]. To minimize the risk of unintended brachial plexus injuries, it is advisable to either tuck the patient's arms at their sides or limit arm abduction to less than 90 degrees when using extended arm boards [17].

The lithotomy position has also been associated with nerve injuries in the lower extremities, affecting nerves such as the femoral, lateral femoral cutaneous, sciatic, obturator, and common peroneal nerves, particularly in surgeries lasting longer than 2 hours [17]. Therefore, especially in super-obese patients, it is crucial to reduce the risk of neurologic injuries in the lower extremities through meticulous positioning and the use of booted stirrups to alleviate external pressure on the legs during the surgical procedure.

Abdominal entry and establishing a pneumoperitoneum can pose significant challenges when dealing with super-obese patients with large uterine masses. To enhance the success rate while minimizing complications, a strategy involves realigning the umbilical axis and initiating insufflation at a higher pressure, typically ranging from 20 to 25 mmHg, with a rapid flow rate. This approach has shown promise in reducing

*3D Total Laparoscopic Hysterectomy of a Very Large Uterine Myoma in a Super Morbidly Obese… DOI: http://dx.doi.org/10.5772/intechopen.113206*

complications such as preperitoneal insufflation, subcutaneous emphysema, visceral injury, vascular injury, penetration of an underlying skin fold, and postoperative wound complications [18].

In our specific case, where the uterine mass extended beyond the umbilicus, we successfully employed the Le Hwang line—a midline point between the umbilicus and the epigastrium—for abdominal entry. This was achieved using a 12 mm bladed trocar under an insufflation pressure of 20 mmHg. Using an optical access trocar can further enhance safety during abdominal entry, significantly lowering the risk of iatrogenic injuries [19].

Furthermore, in morbidly obese patients, access to deep pelvic structures and optimal visceral exposure can be compromised due to the increased thickness of the abdominal wall and excess intraabdominal adiposity [20, 21]. In cases involving large uterine masses, placing the working port higher along a diagonal line with the primary port, on the same side as the surgeon, has proven to provide better ergonomics for instrument handling and maneuvering toward the target area. Considering that standard laparoscopic instruments typically measure 33 cm, using bariatric instruments, which can extend up to 45 cm in length, offers improved access to deeper pelvic structures in morbidly obese patients, particularly when performing colpotomy procedures.

Performing a laparoscopic hysterectomy for a benign, large uterine mass can present technical challenges, particularly when it resides in the lower segment or extends into the broad ligament. Such masses tend to occupy the pelvis, making it difficult to visualize vital anatomical structures like the ureters. This can pose a risk of difficulty in accessing anatomical planes, potentially leading to hemorrhage or organ injury. Nevertheless, with the right strategy and technique, laparoscopic hysterectomy remains a safe and feasible option [6, 10].

In our case, we employed a technique described in the literature [6, 22], which involved intraoperative myomectomy to decompress the large uterus (as illustrated in **Figure 8a** and **b**) before proceeding with the hysterectomy. This approach is particularly useful when dealing with a large myoma located anteriorly, obstructing the vesicouterine reflection, complicating bladder dissection, or in cases with a sizable broad ligament fibroid, where normalization of anatomy is necessary before hysterectomy. In our specific case, given the substantial size and weight of the fibroid, we utilized a myoma screw through one of the 5 mm ancillary ports to apply traction and countertraction forces, facilitating the separation of the myoma from the uterus. Once the large myoma is successfully separated, the hysterectomy can proceed as usual.

Extracting a large specimen through the thick abdominal wall and a constricted vaginal canal can pose technical challenges. In our case, the smaller uterus was morcellated using a size 9 scalpel blade through the vagina, while the large myoma specimen was morcellated using a power morcellator (uncontained) through the left lumbar port site. It is worth noting that there is increasing evidence suggesting that intra-abdominal specimen morcellation is associated with a heightened risk of spreading occult cancerous tissues beyond the abdominal cavity, potentially impacting patient prognosis [23].

Similarly, when using the transvaginal approach for uterus specimen extraction, it may necessitate segmental resection, split-half resection, or piecemeal resection of the uterus, depending on its size and shape, due to the limited operative field. Consequently, the partially cut surface of the uterine body may be exposed to the pelvic cavity, and fragmental tissue resulting from piecemeal resection of the large uterine body might also enter the pelvic cavity. Therefore, if uterine sarcomas are

present, involvement of the abdominal and pelvic cavities may be unavoidable following the transvaginal removal of a large uterus [24]. Hence, comprehensive preoperative evaluation is crucial to minimize or exclude the possibility of potential malignant tumors, and obtaining informed consent from the patient is paramount.

In conclusion, there is an anticipated increase in the number of severely obese patients undergoing TLH. This trend will present specific physiological and technical difficulties that surgeons should be ready to address. However, TLH remains a secure, feasible, and practical approach to gynecologic surgery for morbidly obese patients with reasonable uterine size and has demonstrated low complication rates. A thorough preoperative risk assessment, optimizing patient's condition, implementing careful strategy of, TLH procedure, plus a meticulous postoperative care, are paramount importance as minimal-access surgery is progressively becoming the preferred method for gynecological procedures in morbidly obese patients.
