Total Laparoscopic Hysterectomy: Making It Safe and Successful for Obese Patients.

OBJECTIVE: To investigate outcomes and ascertain the safety and efficacy on patients having total laparoscopic hysterectomy (TLH), stratified by body mass index (BMI), focusing on high-BMI patients. METHODS: This was a retrospective cohort study that reviewed 2,266 patients with benign gynecologic diagnoses, early cervical, endometrial, and ovarian carcinoma from September 1996 to October 2017. BMI was from 14.5 to 74.2 and were classified as normal or underweight (<24.9); overweight (25.0-29.9); class I obese (>30.0-34.9); class II obese (35-39.9); or class III obese (>40.0). All patients underwent TLH. RESULTS: Patients' characteristics were similar across all BMI classes except for age, postoperative pathological diagnoses, and whether a cystoscopy was performed. Surgical duration, and estimated blood loss were similar across BMI classes. Overweight and obese class III patients had lower odds of staying >1 day compared to patients of normal BMI (OR = 0.65, P = .015). Obese class II patients had fewer complications compared to normal BMI patients (OR = 0.27, P = .013), but patients from other high BMI categories did not show any difference compared to patients with normal BMI. The rate of unplanned laparotomy was statistically, but not clinically, higher in obese class III patients (1.8% versus .7%, P = 0.011), most often due to large fibroids. The mean reoperation rate was 2.7%, with the lowest rate (.5%) among obese class II patients, and the highest rate (3.9%) among the normal BMI patients. CONCLUSION: TLH is feasible and safe for obese women, regardless of BMI. Obesity is not a contraindication to good outcomes from laparoscopic surgery.

Comprehensive laparoscopic lymphadenectomy from the deep circumflex iliac vein to the renal veins: Impact on quality of life.

OBJECTIVE: Compare quality of life metrics for consecutive patients having total laparoscopic hysterectomy, bilateral salpingo-oophorectomy (TLHBSO) with and without comprehensive pelvic/aortic lymphadenectomy (CPALND) from proximal to the distal circumflex iliac nodes and vessels to the renal vessels. METHODS: Analysis of mailed survey responses with 25 validated questions regarding musculoskeletal/lower extremity, gastro-intestinal, abdominal, urological, and energetic/activities of daily living. Data analyzed with Chi-Square tests of Association, Mann-Whitney U tests and follow up regression analysis. RESULTS: Of 533 surveys mailed, 197 (37%) responded; 57 (28.9%) received CPALND. Age and parity were not different between groups, but the TLHBSO group had a higher BMI (31.4 v. 25.8, p<0.001), and were less likely to receive chemotherapy (CT), radiotherapy (RT), or both (CT+RT). In the CPALND cohort, a mean of 47 nodes were removed, of which 26% were positive: 21% pelvic, 11% inframesenteric, 11% infrarenal. Both groups had similar total quality of life total scores of 86/92. Those having CPALND did not report more swelling but they did report more tingling/numbness (2.8 v. 3.5, p<0.001). A series of hierarchical regressions confirmed that CPALND, per se, did not significantly reduce lower extremity scores apart from CT (p=0.402) and CT+RT (p=0.108). However, CPALND did predict for lower extremity swelling after receipt of CT, RT, or CT+RT. Node count, in total, or from each basin, did not correlate with any QOL decrement. CONCLUSIONS: CPALND did not cause lymphedema or a reduction in overall quality of life. Only after controlling for BMI, and receipt of radiation and/or chemotherapy were QOL scores mildly reduced. Routine omission of the distal circumflex nodes from the dissection may account for the low risk of lymphedema from the dissection. Larger prospective studies are needed to determine the optimal staging protocols that address all the likely sites of metastasis and recurrence, and optimize survival, while maintaining our patients' quality of life.