Robotic Surgery in the Obese Patient: Tips and Tricks for the Benign Gynecologist

Robotic-assisted surgery in gynecologic procedures continues to increase in numbers with several advantages over other types of minimally invasive surgery. Obese patients undergoing robotic surgery have shorter hospital stays, less blood loss, lower conversion rates and lower postoperative complications despite the increase in surgical complexity of their cases. Obese patients have the highest need for minimally invasive surgery because they have increased perioperative morbidity and mortality rates, as well as worse surgical outcomes and complications with increasing BMI. Minimally invasive surgery reduces the risk of venous thromboembolism, wound infections, ileus and postoperative fevers in obese women. Robotic-assisted surgery offers a minimally invasive surgical approach to the obese woman who cannot have vaginal or conventional laparoscopic surgeries due to the physical limitations of her redundant vaginal sidewall tissue and thick abdominal wall. The robotic approach takes less operating time than conventional laparoscopic surgery in the super morbidly obese population, and surgeons experience less fatigue and mental stress. In this review article, we provide the benign gynecologist with recommendations for the preoperative and postoperative periods when performing robotic-assisted surgery on the obese gynecologic patient. We also offer detailed suggestions for effective patient positioning of even the most super morbidly obese patients. We also explain several techniques to enter the abdomen, the step which often challenges the surgeon the most and can lead to pre-peritoneal insufflation and sub-optimal visualization during the case.