**3. Perioperative preparation and management**

She was asked to take only a liquid diet 3 days before admission for surgery. Preoperatively, bowel preparation was performed by giving a rectal enema the night before surgery. A bolus of intravenous Esomeprazole 40 mg was given before induction as a prophylaxis to gastric acid aspiration in anticipation of difficult intubation.

The patient was assessed preoperatively 1 week before the surgery. Upon arrival to the operating room, the patient was placed in the head elevated laryngoscopy position using the Troop Elevation Pillow for induction. A 20G peripheral venous access was initially obtained at her left antecubital fossa under ultrasound guidance and another 18G cannula at her right-hand post-induction (**Figure 3**).

The patient was ventilated using pressure-regulated volume control with a tidal volume of 320 ml, that is 6 ml/kg ideal body weight, generating peak airway pressure of 35 mm Hg, adequate to maintain ventilation with an end-tidal carbon dioxide value of 45 to 55 mmHg throughout pneumoperitoneum and surgery.

TCI propofol and remifentanil maintenance was at 3 μcg/ml and 8 ng/ml on average for maintenance titrated to an anesthetic depth bispectral Index (BIS) value of 40 to 60. A profound neuromuscular blockade was maintained throughout surgery and titrated to a neuromuscular monitoring (NMT) Tain-of-Four (TOF) ratio of 0/4. Multimodal analgesia with intravenous paracetamol, intravenous oxycodone 10 mg toward the end of the surgery, intravenous parecoxib 40 mg immediately after the surgery, and intravenous palanosetron 0.75 mg, and dexamethasone 8 mg were administered for postoperative nausea and vomiting prophylaxis.

Other than a brief period of hypotension post-induction, blood pressure and pulse rate were within 20% of the patient's baseline throughout the operation. She was given 3 liters of sterofundin and 1 liter of gelafusine with an estimated blood loss of 1 liter. Adequate urine output of 0.5 ml/kg/hr. was maintained throughout the surgery.

#### **Figure 3.**

*The anesthetist establishes peripheral venous access at her left antecubital fossa under ultrasound guidance to locate the vein.*

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