Robotic Hysterectomy for Patients with High BMI
Robotic assisted total laparoscopic hysterectomy, and bilateral salpingo-oophorectomy, is most commonly performed in patients with endometrial pathology, and an elevated body mass index (BMI > 40). By dramatically enhancing visualization, precision, control and dexterity, the robot overcomes the limitations of traditional laparoscopic technology, helping physicians to perform complex surgery in a manner never before experienced.
Benefits of Robotic Surgery in High BMI Patients
There are several benefits of using robotic assistance when performing laparoscopic hysterectomy in patients with elevated BMI. For instance, the robot acts to lift the patient’s abdominal wall through a phenomenon known as 'arm bumping'. This allows the surgery to be performed at a lower intra-abdominal pressure and facilitates improved ventilation in steep Trendelenburg.
Furthermore, the robot allows for improved ergonomics for the surgical team members and improves surgical feasibility in patients with elevated BMI. These technical enhancements include:
- Increased surgical dexterity: Robotic instruments can rotate a full 360 degrees and act like a human hand or wrist, making it easier to work in small spaces and at difficult angles.
- Visualization: The main advantages over traditional laparoscopic surgery are the ability to visualize the surgical field in 3-D (three dimensions) similar to natural, non-video vision.
- Additional instruments: The robot employs a third arm, which allows for the use of additional instruments that can aid in visualization and retraction through the surgery.
Patient Positioning and Preparation
During patient positioning, padding is placed around the shoulders, forearms, and wrist to avoid excess pressure throughout the case and decrease the risk of intra-op nerve injury. If there is a large pannus, sandbags are clipped to the patients pannus and pulled towards the patient’s feet once in Trendelenberg. This action takes pressure off the lungs to facilitate ventilation by anesthesia and helps to displace the pannus and return the umbilicus to a more natural position.
Placement of the uterine manipulator can be challenging in patients with elevated BMI and may require two assistants. For the optimal set up, the patient's legs should be brought upwards and outwards.
Surgical Setup and Considerations
Port placement configuration can differ depending on the robot used, such as the 'rainbow' pattern port placement. Once the ports are placed, prior to docking the robot, the surgical team should confirm with anesthesia that the patient is tolerating steep Trendelenburg, as the bed cannot move after the robot is docked. These enhancements allow the surgeon to perform complex gynecologic procedures, including cancer surgery, that could not be safely performed using traditional laparoscopic equipment.
Comparison of Robotic vs. Traditional Laparoscopy for High BMI
| Feature | Robotic Advantage |
|---|---|
| Dexterity | Instruments rotate 360 degrees, acting like a human wrist. |
| Visualization | Enhanced 3-D (three dimensions) visualization. |
| Abdominal Pressure | 'Arm bumping' allows for lower intra-abdominal pressure. |
| Retraction | A third arm provides superior visualization and retraction. |
While technology is constantly evolving, it does not replace the need for highly skilled surgeons. As the robotic system cannot be programmed nor make decisions on its own, it requires that every surgical maneuver be performed with direct input from the surgeon.