3D Total Laparoscopic Hysterectomy of a Very Large Uterine Myoma in a Super Morbidly Obese Woman of Body Mass Index 60 Kg/m2: A Case Report and a Literature Review

Abstract

A 40-year-old Malay nulliparous female, morbidly obese (height 161 cm, weight 158.5 kg, BMI 60.1 kg/m2) presented with a large uterine fibroid, FIGO Grade 4 with its upper border extending up to the 4 cm above the umbilicus. After 6 months of GnRH suppression, she consented to a total laparoscopic hysterectomy. Preoperatively, she was optimized, and bowel preparation was done with 3 days of liquid diet, a rectal enema, and antacid pre-induction. A nasogastric tube was inserted before port entry. The ports were placed higher, with the primary port at the epigastric region and the working ports on the left paramedian at the level of the umbilicus and ipsilateral left lumbar. Intracorporeal myomectomy was done to reduce the mass size before proceeding to a total hysterectomy in the usual manner. The patient was stable throughout the operation, and blood loss was approximately 900 mls. Postoperatively, the patient was fully ambulated and resumed a regular diet 24 hours after surgery, and was discharged home well. Operating a sizeable uterine mass in a super-morbidly obese woman laparoscopically is technically far more challenging for surgical and anesthetic management. Perioperative preparation, positioning, anesthetic management, and ergonomic port placement are paramount to surgical outcomes. Minimally invasive surgery is safe and feasible, and it is the best option for the morbidly obese patients as it allows early mobilization and spares them from tumultuous postoperative morbidity from open surgery, as proven by our case.