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Obesity is having an increasingly significant impact on health care services across the developed world. Although initially laparoscopic surgery was thought to be contraindicated in cases of obesity, surgeons, including gynaecologists, are now routinely performing laparoscopic surgery on obese patients. Limited research has been conducted into the effect of obesity on outcomes of major laparoscopic pelvic surgery. Some authors report worsening outcomes in obese women having laparoscopic hysterectomies; others suggest that complication rates do not increase, but operating times are longer. Here, we report our experience from 250 total laparoscopic hysterectomies performed for benign, malignant and pre-malignant conditions, and we compare outcomes among normal, overweight, obese and morbidly obese patients. We used a composite score index calculated on the basis of operating and theatre times, estimated blood loss, length of stay and number and severity of complications for our comparisons. Our conclusions suggest that meticulous, consistent surgical technique may produce similar outcomes in normal and obese patients having total laparoscopic hysterectomy, with longer operating/theatre times noted only at BMI levels >40.

Background and Aims: The evolution of robotic technology has enhanced the scope of laparoscopic surgery. Morbid obesity [body mass index (BMI) >40 kg/m2] due to significant physiological attributes presents a significant surgical and anaesthetic challenge. Robotic surgery in this subset of patients can present with its own problems due to surgical requirements of prolonged pneumoperitoneum and steep Trendelenburg position. Methods: We reviewed the anaesthetic management of 46 morbidly obese patients undergoing robotic-assisted laparoscopic gynaecology surgery. Patient characteristics, anaesthetic management, length of hospital stay (LOS), complications, and readmissions within 30 days were noted. Mean with standard deviation was used for statistical analysis. Results: The mean [standard deviation (SD)] weight and BMI were 121.2 (18.49) kg and 47.83 (7.89) kg/m2, respectively. The mean (SD) anaesthetic and surgical times were 229 (75.9) and 167.7 (62.7) min, respectively. The mean (SD) LOS was 1.57 (1.03) days. About 70% of patients were discharged on the first day after surgery. Six patients needed critical care support. There were two readmissions within 30 days. Conclusion: Good preparation, teamwork, and multidisciplinary input helped us to conduct complex robotic-assisted and long-duration surgery in morbidly obese patients with minimal complications.

Surgical site infection can result in increased morbidity for the patient, prolonged hospital stay and hospital readmission. Preoperative antibiotics reduce the incidence of such infections, particularly in open surgery. Universal use of antibiotic prophylaxis, however, is not recommended due to the risks of adverse reactions, generation of resistant bacteria and additional cost. Endoscopic procedures carry low risk of wound contamination and infection. Limited data suggest wide variability in antibiotic prophylaxis in gynaecological surgery and potential overuse of antibiotics in gynaecological endoscopic surgery. Bringing together the existing evidence allows for a consensus proposal for the use of preoperative antibiotics in gynaecological endoscopy.

Key content Injury of the urinary tract is the most common major complication of gynaecological laparoscopic surgery. Injury to either bladder or ureter results in significant morbidity for the patient and may lead to litigation. Knowledge of pelvic anatomy, training and meticulous technique are of paramount importance in reducing the incidence of urinary tract injury. Ideally an injury should be identified and repaired during the primary operation, but vigilance in the immediate postoperative period may result in early recognition and intervention. Learning objectives To understand the common risk factors of urinary tract injury at laparoscopy. To learn strategies to prevent injury where possible. To learn strategies for intraoperative and postoperative recognition and repair of such injuries. To understand the significance of multi-disciplinary management of such injuries. Ethical issues Limited evidence shows that laparoscopic hysterectomy may carry a higher risk of urinary tract injury compared with abdominal hysterectomy. Should patients be counselled accordingly?