Robotic-Assisted Surgery in Extremely Obese Patients. A Multidisciplinary Approach for a Patient with a BMI of 101.7 kg/m²

Robotic-Assisted Surgery in Extremely Obese Patients. A Multidisciplinary Approach for a Patient with a BMI of 101.7 kg/m² | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report Robotic-Assisted Surgery in Extremely Obese Patients. A Multidisciplinary Approach for a Patient with a BMI of 101.7 kg/m² Roland Csorba, Zeynep Atas Elfrink, Paul Buderath, Martin Britten This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5924531/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The prevalence of obesity has risen significantly, affecting over 19% of the German population. Obesity is frequently associated with endometrial cancer, presenting considerable challenges in pre-, intra- and postoperative management. Challenges with intubation, patient positioning, respiratory and cardiac complications as well as wound dehiscence are commonly encountered in this patient population. For patients with uterine cancer, surgical intervention is essential for staging, symptom control, and potential cure. Minimally invasive approaches, particularly robotic-assisted surgery, have expanded the possibilities for treating morbidly obese patients. Robotic systems facilitate navigation around anatomical barriers and reduce surgeon fatigue. However, despite the technological advancements, morbidly obese patients often face increased perioperative risks and prolonged postoperative recovery. Laparoscopic procedures in steep Trendelenburg position for morbidly obese patients pose unique challenges, particularly in anesthesiological management. These challenges necessitate individualized ventilatory and hemodynamic support to ensure patient safety. This case highlights a multidisciplinary approach to managing a patient with extreme obesity (BMI 101.7 kg/m²) undergoing robotic-assisted surgery for uterine cancer. It underscores the importance of comprehensive preoperative planning, intraoperative considerations, and postoperative care in minimizing complications and optimizing outcomes. Robotic-assisted surgery for endometrial cancer in obese patients has proven to be a safe and feasible option, characterized by a low complication rate, minimal blood loss, and a short hospital stay. endometrial cancer morbid obesity robotic surgery cancer-field surgery multidisciplinary management anaesthesiology Figures Figure 1 Figure 2 Key Points Obesity is a significant risk factor for endometrial cancer, and its increasing prevalence underscores the importance of developing effective surgical techniques to manage these patients. Minimally invasive approaches, particularly robotic-assisted surgery, have expanded the possibilities for treating morbidly obese patients. Robotic systems facilitate navigation around anatomical barriers and reduce surgeon fatigue. Laparoscopic procedures in steep Trendelenburg position for morbidly obese patients pose unique challenges, particularly in anesthesiological management. These challenges necessitate individualized ventilatory and hemodynamic support to ensure patient safety. Robotic-assisted surgery for endometrial cancer in obese patients has proven to be a safe and feasible option, characterized by a low complication rate, minimal blood loss, and a short hospital stay. Introduction Obesity affects approximately 19% of the German population [ 1 ]. A Body Mass Index (BMI) of 40 or higher classifies a patient as Obesity Class III, signifying a high risk of obesity-related diseases and a significant impact on quality of life. Obesity is frequently associated with endometrial cancer and presenting challenges in surgical management [ 2 ]. The intersection of these conditions creates a complex clinical scenario requiring careful consideration. Obesity increases the risk of complications such as wound dehiscence, respiratory and cardiac issues, and challenging intubations. In patients with uterine cancer, surgery remains essential for both staging and treatment. The introduction of the DaVinci™ robotic surgical system has expanded the options for minimally invasive procedures, offering potential benefits for high-risk patients. While surgery is the cornerstone for managing uterine cancer, morbidly obese patients experience increased perioperative complications and prolonged postoperative recovery [ 3 ]. In this context, a minimally invasive approach, enhanced by robotic assistance, can provide a viable alternative. We report the case of a patient with a BMI of 101.7 kg/m² who underwent a robotically assisted total laparoscopic hysterectomy performed as peritoneal mesometrial resection (PMMR) and bilateral salpingo-oophorectomy with pelvic targeted compartmental lymphadenectomy (TCL) using the DaVinci™ robotic system. This case represents the largest patient, weighing 287 kg, to undergo robotic cancer-field surgery. We emphasize the multidisciplinary management approach, involving gynecologic oncology and anesthesiology to successfully address the unique challenges posed by this complex case. To our knowledge, this is the largest patient reported in the literature to undergo a robotic procedure of this nature. Case report A 57-year-old nulligravid Caucasian female with a BMI of 101.7 kg/m² (height 168 cm, weight 287 kg) presented with postmenopausal vaginal bleeding persisting for four months. Her medical history was notable for arterial hypertension, recurrent abscesses, hypothyroidism following thyroidectomy, psychogenic eating disorder, anxiety, and borderline personality disorder. Her surgical history included laparoscopic ovarian cyst removal (1998), dilation and curettage (2000), and thyroidectomy (2005). The patient was not sexually active, and her Eastern Cooperative Oncology Group (ECOG) performance status was 1. On physical examination, she was 168 cm tall and weighed 287 kg, with circumferences of 130 cm and 118 cm for the right and left thighs, respectively. Bilateral pitting edema grade 2 + was observed in her thighs. Otherwise, her general and pelvic examinations were unremarkable. Her initial laboratory evaluation revealed hemoglobin of 12.4 g/dl, mean corpuscular volume (MCV) of 89.8 fl, and CA 12 − 5 levels of 22 U/ml. Her Pap smear showed no abnormalities. A preoperative CT of the thorax and abdomen demonstrated an asymmetrical uterine form and enlarged retroperitoneal lymph nodes. The lung fields were clear with no evidence of metastatic disease, and the heart size was within normal limits. A CT of the skull showed no signs of metastasis. Given her immobility and significant comorbidities, the patient displayed signs consistent with congestive heart failure, leading to a high perioperative risk. In order to evaluate cardiac function, transthoracic echocardiography was performed. The findings included pulmonary hypertension with a systolic pulmonary artery pressure of 38 mmHg (plus central venous pressure), moderate tricuspid valve insufficiency, and a preserved left ventricular ejection fraction of 50%. Mild mitral valve insufficiency was also noted and the aortic valve appeared normal. Based on these findings, the patient was classified as ASA IV according to the American Society of Anesthesiologists (ASA) Physical Status Classification System, indicating a severe systemic disease posing a constant threat to life. To perform the dilation and curettage (D&C), the patient's legs were placed on two stands, as they could not be positioned in stirrups for the lithotomy position due to their size. Postoperatively, the patient experienced a hypertensive crisis with a blood pressure of 240/100 mmHg, which was successfully managed with standard drug therapy. Histopathological analysis of the D&C specimen revealed endometrioid adenocarcinoma, FIGO grade 1. Subsequently, the patient underwent a robotically assisted total laparoscopic hysterectomy performed as peritoneal mesometrial resection (PMMR) and bilateral salpingo-oophorectomy with pelvic-targeted compartmental lymphadenectomy (TCL). A specialized surgical bed was utilized to accommodate the patient’s unique anatomical considerations. Due to the size of her legs, the patient could not be placed in the lithotomy position and was instead positioned supine. The surgical bed was padded with egg crate foam along its surface and edges to ensure pressure relief and minimize the risk of pressure-related injuries. Multiple bed extenders were attached to accommodate the width of the patient’s torso and legs. Circumferential padding and taping were applied around her lower legs and chest for additional stabilization and support. Arm sleds were repurposed to support her lower legs, positioned adjacent to the bed, ensuring optimal access for the surgical procedure (Fig. 1 ). Figure 1 A HOHL uterine manipulator was successfully placed in the vagina to distend the vaginal fornices and assist in performing the colpotomy. Long robotic trocars (120 mm length × 8 mm) were used to access the abdominal cavity and were configured in a five-trocar arrangement. The patient and bed were positioned at a 30° Trendelenburg angle, and the robotic system was docked at an oblique angle from the patient’s right side. Monopolar scissors, a PK coagulator, and Maryland graspers were employed via the robotic arms, while a 30° scope provided optimal visualization. Insufflation pressure was maintained between 12–15 mmHg throughout the procedure, with a reduction in pressure at the end to facilitate ventilation by the anesthesia team. The combination of the steep Trendelenburg position and pneumoperitoneum-induced hypercapnia has the potential to exacerbate pulmonary artery pressure and increase the risk of heart failure. To mitigate these risks, advanced hemodynamic monitoring was implemented, including continuous transesophageal echocardiography and the placement of arterial, central venous, and pulmonary artery catheters. Using this setup, a robotically assisted total laparoscopic hysterectomy and bilateral salpingo-oophorectomy with indocyanine green-near-infrared fluorescence guided, targeted sentinel lymphadenectomy could be performed. The uterus, fallopian tubes, ovaries, and lymph nodes were removed vaginally using an 800 mL Endobag. The vaginal cuff was closed robotically with a continuous V-Loc suture. An intraabdominal drain was placed in the pelvis. Figure 2 shows the situation after skin closure. Figure 2 Positioning and anesthesia time totalled 131 minutes, while the surgical procedure lasted 264 minutes. The overall operating room time was 437 minutes. The estimated blood loss during the procedure was 150 ml. Preoperatively, the patient received 3 g of Ampicillin/Sulbactam. Due to the high risk of pulmonary complications, the patient was admitted to the intensive care unit postoperatively. She was extubated and initially supported by non-invasive ventilation for several hours before being transferred to the general ward on the second postoperative day. Her postoperative course was uncomplicated. The patient was discharged on the twenty-second postoperative day, primarily due to non-gynecological chronic conditions, including mild vision loss from hypertensive retinopathy, as well as the need to address issues related to her immobility and plan post-discharge care. The patient declined our recommendation to present her case for bariatric surgery. Final pathology revealed a tumor in the uterus measuring 5.4 × 5.2 × 2.6 cm, diagnosed as FIGO grade 1 MSS endometrioid adenocarcinoma, p53 wild type, with 1 cm of myometrial invasion. No lymphvascular space invasion (LVSI) was identified. The final TNM classification was pT3a pN0 (0/1) L0 V0 Pn0 R0 G2. Further treatment recommendations included radiotherapy and adjuvant chemotherapy with Carboplatin and Paclitaxel administered intravenously every three weeks. Postoperatively, the case was discussed in the interdisciplinary conference and the patient was referred to radiation oncology to discuss adjuvant treatment options. During the consultation, various approaches were reviewed, including whole pelvic radiation, vaginal cuff brachytherapy (VBT), and a combination of both. After a thorough discussion of the risks and benefits of all options, the patient expressed significant concerns about the potential toxicity of the recommended therapy. Having undergone cancer-field surgery she decided to omit postoperative treatment. Discussion Obesity is a prevalent chronic disease, and morbid obesity is an increasingly alarming global problem. In Germany, 53.5% of the population (46.6% of women and 60.5% of men) is classified as overweight, including those with obesity. Obesity affects 19.0% of adults [ 1 ]. The management of extreme obesity - defined as a body mass index (BMI) ≥ 50 kg/m² or obesity classes IV, V, and VI - remains a significant challenge. Individuals with extreme obesity face an elevated risk of surgical complications, increased mortality, and multiple comorbidities. Endometrial cancer (EC) is a malignancy of the inner epithelial lining of the uterus, with a rising global incidence and associated mortality [ 4 ]. In Germany, EC is the most common gynecological malignancy. In 2020, there were 417,336 new cases of EC worldwide, making it the sixth most commonly occurring cancer among females [ 5 ]. The majority of cases occur between the ages of 65 and 75 years [ 6 ]. This type of cancer comprises a range of distinct histological subtypes and molecular phenotypes. Historically, EC has been classified into two categories: Type I, which is associated with unopposed estrogen stimulation, features low-grade cells, is more common, and has a favourable prognosis; and Type II, which is not estrogen-driven, features high-grade cells, is less common, and has a poorer prognosis. Type I EC primarily includes grade I or grade II endometrioid adenocarcinomas, while Type II encompasses grade III endometrioid adenocarcinomas, serous carcinoma, clear cell carcinoma, undifferentiated carcinoma, and carcinosarcomas [ 7 ]. Several factors increase the risk of developing EC, including advanced age, certain ethnicities, higher BMI, endogenous or exogenous estrogen exposure, tamoxifen use, early menarche, late menopause, lower parity, metabolic syndrome, family history, and genetic predisposition. Conversely, factors such as maintaining a normal BMI, having higher parity, and using oral contraception are associated with a lower risk of EC [ 7 ]. To our knowledge, the case presented here involves the largest patient to undergo surgery for endometrial cancer using the DaVinci™ robotic system. This case highlights the feasibility and advantages of robotically assisted surgery in patients with morbid obesity even for complex procedures such as the oncological cancer-field surgery presented here. As cancer-field surgery by PMMR and TCL aims at reaching optimal locoregional control without the need for adjuvant radiotherapy, it may help to minimize treatment-related risks for this extremely vulnerable collective by avoiding both laparotomy as well as irradiation. Conventional laparoscopy is often impractical for such complex procedures while open surgery via laparotomy carries a significantly increased perioperative risk in this patient population [ 8 ]. Although the robotic-assisted laparoscopic approach is advantageous for morbidly obese patients, it presents significant anesthesiological challenges. Obesity reduces functional residual lung capacity and chest wall compliance, increasing airway resistance and the risk of atelectasis. These issues are exacerbated by the steep Trendelenburg position [ 9 ]. Ventilating a morbidly obese patient in a 30° Trendelenburg position becomes even more challenging with the addition of capnoperitoneum. To mitigate respiratory insufficiency, the application of adequate positive end-expiratory pressure (PEEP) is crucial [ 10 ]. In this case, optimal PEEP was determined through titration based on dynamic lung compliance. The patient was ventilated using pressure-controlled, low-tidal volume ventilation of 7 ml/kg ideal body weight, with a respiratory rate of 20 breaths per minute and an inspiratory-to-expiratory ratio of 1:1. The respiratory rate was further adjusted based on end-tidal capnometry. Following an initial recruitment manoeuvre, optimal compliance was achieved with a PEEP of 24 mbar and a peak airway pressure of 42 mbar. With a respiratory rate of 28 breaths per minute, a minute volume of 10.9 L was maintained. While high PEEP values in morbidly obese patients improve oxygenation, they do not necessarily lead to pulmonary barotrauma. Barotrauma depends on excessive transpulmonary pressure, which is calculated as the difference between intra-alveolar and intrapleural pressure. In this case, the elevated intrapleural pressure caused by the patient’s body weight in the steep Trendelenburg position, combined with increased intra-abdominal pressure during laparoscopy, allowed for higher intra-alveolar pressures to be well-tolerated. These pressures minimized atelectasis formation and potentially improved postoperative pulmonary function [ 11 ]. This approach - using a higher PEEP - reduces driving pressure during ventilation, a factor strongly associated with improved postoperative pulmonary outcomes [ 12 ]. Additionally, low tidal-volume ventilation of 7 ml/kg ideal body weight was shown to enhance postoperative outcomes, though it may complicate the maintenance of normocapnia [ 13 ]. In this case, arterial hypercarbia up to 67 mmHg was tolerated, as arterial pH remained above 7.2. Oxygenation was well-maintained, with an FiO₂ of 0.5 yielding arterial pO₂ values above 80 mmHg. Apart from the challenges associated with ventilation, hemodynamic changes during the steep Trendelenburg position are also significant, including increases in arterial and central venous pressures, cardiac output, systemic vascular resistance, and pulmonary artery pressure 8 . These changes may be further aggravated by high PEEP values and hypercarbia. With a pulmonary artery catheter in place, the mean pulmonary artery pressure in the supine position was initially measured at 45 mmHg, which increased to 69 mmHg during surgery. Inhalation of 20 µg Iloprost as a pulmonary vasodilator did not result in a significant decrease in pulmonary artery pressure. However, transesophageal echocardiography revealed that cardiac function remained compensated without signs of right heart failure, allowing surgery to proceed after a slight decrease in capnoperitoneal pressure. Arterial pressure was maintained through continuous infusion of noradrenaline. Given that we did not expect significant blood loss during surgery, infusion of balanced crystalloids was limited to a total of 500 mL. Although the patient's respiratory and hemodynamic status after surgery remained uneventful, we anticipated an increased risk of postoperative pulmonary complications. Postoperative pulmonary complications have been reported in 19% of patients following robotic-assisted surgery, and morbid obesity is known to further elevate this risk [ 14 ]. Consequently, the patient was transferred to our intensive care unit, where she was extubated and initially supported by non-invasive ventilation to optimize and maintain respiratory function. She was subsequently discharged from the ICU on the second postoperative day without incident. In summary, we report a case of multidisciplinary management for an extremely obese patient undergoing robotically assisted oncological surgery. This case is unique because it demonstrates how robotic surgery can address the challenges posed by extreme obesity. The complexities of surgical and anesthesiological management necessitate a multidisciplinary approach, often involving specialists in gynecologic oncology and anesthesiology. Future studies are needed to address the specific needs of patients with extreme obesity, as their outcomes are likely to differ from those of patients with a lower BMI. Conclusion Obesity is a significant risk factor for endometrial cancer, and its prevalence continues to rise. As such, the development of surgical techniques to manage these patients is crucial. Minimally invasive surgery, particularly with robotic assistance, has expanded the possibility of performing surgeries on morbidly obese women. It enables surgeons to navigate around anatomical barriers and reduces surgeon fatigue. While it presents complex challenges for anesthesiologists, surgical nurses, and surgeons, these challenges can be managed through individualized and interdisciplinary approaches. With regard to anesthesia, optimized ventilation with adequate PEEP is critical for preventing hypoxemia and excessive hypercapnia. Additionally, individualized management of hemodynamic changes, particularly in patients with known cardiac dysfunction, is essential. Given the rising rates of obesity and the high prevalence of uterine cancer, there is a growing need for safe and effective therapeutic options for this population. Robotic-assisted surgery for endometrial cancer in class VI obese patients is a safe and feasible option, offering low complication rates and comparable oncologic outcomes. Declarations Author Contribution Authorship contribution statementR. Csorba and AtasElfrink contributed conception and design of the case report.P. Buderath and M. Britten contributed to patient care.M. Britten and R. Csorba conducted the literature review and drafted the manuscript.P. Buderath provided expert review and oversight. All authors have read and agreed to the published version of the manuscript.Acknowledgements: noneFunding: This research received no external funding.Patient consent: The patient provided written informed consent for the publication of the clinical details and images. Ethics: Our institution does not require ethical approval for case reportsConflict of interest statement: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.Authors` note: Case reporting was done ethically. Neither this case nor others about the same patient have been previously published. Acknowledgement none References Schienkiewitz A, Kuhnert R, Blume M, et al. Overweight and obesity among adults in Germany - Results from GEDA 2019/2020-EHIS. J Health Monit. 2022; 7(3):21–28. doi: 10.25646/10293 . PMID: 36188152; PMCID: PMC9520353. Lechartier C, Bernard J, Renaud MC, et al. Robotic-assisted surgery for endometrial cancer is safe in morbidly and extremely morbidly obese patients. Gynecol Oncol. 2023; 172:15–20. doi: 10.1016/j.ygyno.2023.02.014 . Epub 2023 Mar 9. PMID: 36905768. C. Lim, T.A. Mahmood. Challenges in gynecological surgery in obese women. Obesity and gynecology, Elsevier (2020), pp. 217–222 Henley SJ, Ward EM, Scott S, et al. Annual report to the nation on the status of cancer, part I: National cancer statistics. Cancer. 2020; 126(10):2225–2249. doi: 10.1002/cncr.32802 . Epub 2020 Mar 12. PMID: 32162336; PMCID: PMC7299151. Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021; 71(3):209–249. doi: 10.3322/caac.21660. Epub 2021 Feb 4. PMID: 33538338. Morice P, Leary A, Creutzberg C, et al. Endometrial cancer. Lancet. 2016; 387(10023):1094–1108. doi: 10.1016/S0140-6736(15)00130-0 . Epub 2015 Sep 6. PMID: 26354523. Colombo N, Creutzberg C, Amant F, et al. ESMO-ESGO-ESTRO Endometrial Consensus Conference Working Group. ESMO-ESGO-ESTRO Consensus Conference on Endometrial Cancer: diagnosis, treatment and follow-up. Ann Oncol. 2016; 27(1):16–41. doi: 10.1093/annonc/mdv484 . Epub 2015 Dec 2. Erratum in: Ann Oncol. 2017; 28(suppl_4):iv167-iv168. doi: 10.1093/annonc/mdx258. PMID: 26634381. Lai TJ, Roxburgh C, Boyd KA, et al. Clinical effectiveness of robotic versus laparoscopic and open surgery: an overview of systematic reviews. BMJ Open. 2024; 14(9):e076750. doi: 10.1136/bmjopen-2023-076750 . PMID: 39284694; PMCID: PMC11409398. Arvizo C, Mehta ST, Yunker A. Adverse events related to Trendelenburg position during laparoscopic surgery: recommendations and review of the literature. Curr Opin Obstet Gynecol. 2018; 30(4):272–278. doi: 10.1097/GCO.0000000000000471 . PMID: 29939851. Chiumello D, Coppola S, Fratti I, et al. Ventilation strategy during urological and gynecological robotic-assisted surgery: a narrative review. Br J Anaesth. 2023; 131(4):764–774. doi: 10.1016/j.bja.2023.06.066 . Brandao JC, Lessa MA, Motta-Ribeiro G, et al. Global and Regional Respiratory Mechanics During Robotic-Assisted Laparoscopic Surgery: A Randomized Study. Anesth Analg. 2019; 129(6):1564–1573. doi: 10.1213/ANE.0000000000004289 . Neto AS, Hemmes SNT, Barbas CSV, et al. Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anesthesia: a meta-analysis of individual patient data. Lancet Respir Med. 2016; 4:272–280. doi: 10.1016/S2213-2600(16)00057-6 . Buonanno P, Marra A, Iacovazzo C, et al. Impact of ventilation strategies on pulmonary and cardiovascular complications in patients undergoing general anesthesia for elective surgery: a systematic review and meta-analysis. Br J Anaesth. 2023; 131(6):1093–1101. doi: 10.1016/j.bja.2023.09.011 . Assessment of Ventilation during General Anesthesia for Robotic Surgery (AVATaR) Study Investigators, PROtective VEntilation (PROVE) Network. Ventilation and outcomes following robotic-assisted abdominal surgery: an international, multicenter observational study. Br J Anaesth. 2021; 126(2):533–543. doi: 10.1016/j.bja.2020.08.058 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5924531","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":409537124,"identity":"9def5e61-9c57-41f8-ac7d-dffe8c49308f","order_by":0,"name":"Roland Csorba","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABFklEQVRIiWNgGAWjYBAC+wbmBgYGNgZ5BhDJUMFgAJNhbMChxeAAI1iLIZhkOEOClgQwydhGjJbjjY2fC8oYEuTbe589+DnvsDEDe/vjDx93MMj24/JLz8Fm6RnnGBIMzhw3N+zddtiMgeeMmeTMMwzGM3FYYyeR2CDN2wbUIpHGJsG77bCN/Y0cNmagSOKGA9i1GEskNv8GaZGfkcYm+XfOYRsG+eePP/8FatmPQ4vhjMQ2sC0NN9LYpHkbgA6TYDCQZgTZgsv7Zw62WfOckzDccOYYu7HMsXRjBp4cM8neNgnjGThsMTjefPg2T5mNvHx7G9vDNzXWhg3sxx9/+NlmI9uPw/tQIEGEyCgYBaNgFIwC4gEAECBbr94gWxQAAAAASUVORK5CYII=","orcid":"","institution":"University of Duisburg-Essen","correspondingAuthor":true,"prefix":"","firstName":"Roland","middleName":"","lastName":"Csorba","suffix":""},{"id":409537126,"identity":"61569713-b3a6-48b0-a977-e84442df3855","order_by":1,"name":"Zeynep Atas Elfrink","email":"","orcid":"","institution":"University of Duisburg-Essen","correspondingAuthor":false,"prefix":"","firstName":"Zeynep","middleName":"Atas","lastName":"Elfrink","suffix":""},{"id":409537128,"identity":"8786bae3-815f-4802-86f7-f9443b9e69a0","order_by":2,"name":"Paul Buderath","email":"","orcid":"","institution":"University of Duisburg-Essen","correspondingAuthor":false,"prefix":"","firstName":"Paul","middleName":"","lastName":"Buderath","suffix":""},{"id":409537130,"identity":"9c4543b9-b10d-4084-8daf-32fbcb564d7b","order_by":3,"name":"Martin Britten","email":"","orcid":"","institution":"University of Duisburg-Essen","correspondingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Britten","suffix":""}],"badges":[],"createdAt":"2025-01-29 13:23:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5924531/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5924531/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":75409049,"identity":"0e65f914-67a2-4ca6-9170-e8fb9dad7d0e","added_by":"auto","created_at":"2025-02-04 09:02:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":375978,"visible":true,"origin":"","legend":"\u003cp\u003eA specialized surgical bed was utilized to accommodate the patient’s unique anatomical considerations. The patient was positioned supine.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5924531/v1/4b583a07b2f4a5202d80d684.png"},{"id":75409047,"identity":"9821e914-27a2-473a-b29a-6fa13961510c","added_by":"auto","created_at":"2025-02-04 09:02:13","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":491169,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperativ situs with intraabdominal drain after removing the trocars\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5924531/v1/3a38369eddadb49b9cb18d0d.png"},{"id":75442820,"identity":"ba32d7b2-7dd8-4fd6-ba00-c9ab1dd60a4e","added_by":"auto","created_at":"2025-02-04 15:54:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1407830,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5924531/v1/2b8bb97c-7d24-4a9a-a35c-e00da76a50a4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Robotic-Assisted Surgery in Extremely Obese Patients. A Multidisciplinary Approach for a Patient with a BMI of 101.7 kg/m²","fulltext":[{"header":"Key Points","content":"\u003cp\u003eObesity is a significant risk factor for endometrial cancer, and its increasing prevalence underscores the importance of developing effective surgical techniques to manage these patients.\u003c/p\u003e\n\u003cp\u003eMinimally invasive approaches, particularly robotic-assisted surgery, have expanded the possibilities for treating morbidly obese patients. Robotic systems facilitate navigation around anatomical barriers and reduce surgeon fatigue.\u003c/p\u003e\n\u003cp\u003eLaparoscopic procedures in steep Trendelenburg position for morbidly obese patients pose unique challenges, particularly in anesthesiological management. These challenges necessitate individualized ventilatory and hemodynamic support to ensure patient safety.\u003c/p\u003e\n\u003cp\u003eRobotic-assisted surgery for endometrial cancer in obese patients has proven to be a safe and feasible option, characterized by a low complication rate, minimal blood loss, and a short hospital stay.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eObesity affects approximately 19% of the German population [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A Body Mass Index (BMI) of 40 or higher classifies a patient as Obesity Class III, signifying a high risk of obesity-related diseases and a significant impact on quality of life. Obesity is frequently associated with endometrial cancer and presenting challenges in surgical management [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The intersection of these conditions creates a complex clinical scenario requiring careful consideration. Obesity increases the risk of complications such as wound dehiscence, respiratory and cardiac issues, and challenging intubations. In patients with uterine cancer, surgery remains essential for both staging and treatment. The introduction of the DaVinci™ robotic surgical system has expanded the options for minimally invasive procedures, offering potential benefits for high-risk patients.\u003c/p\u003e \u003cp\u003eWhile surgery is the cornerstone for managing uterine cancer, morbidly obese patients experience increased perioperative complications and prolonged postoperative recovery [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In this context, a minimally invasive approach, enhanced by robotic assistance, can provide a viable alternative. We report the case of a patient with a BMI of 101.7 kg/m² who underwent a robotically assisted total laparoscopic hysterectomy performed as peritoneal mesometrial resection (PMMR) and bilateral salpingo-oophorectomy with pelvic targeted compartmental lymphadenectomy (TCL) using the DaVinci™ robotic system.\u003c/p\u003e \u003cp\u003eThis case represents the largest patient, weighing 287 kg, to undergo robotic cancer-field surgery. We emphasize the multidisciplinary management approach, involving gynecologic oncology and anesthesiology to successfully address the unique challenges posed by this complex case. To our knowledge, this is the largest patient reported in the literature to undergo a robotic procedure of this nature.\u003c/p\u003e"},{"header":"Case report","content":"\u003cp\u003eA 57-year-old nulligravid Caucasian female with a BMI of 101.7 kg/m² (height 168 cm, weight 287 kg) presented with postmenopausal vaginal bleeding persisting for four months. Her medical history was notable for arterial hypertension, recurrent abscesses, hypothyroidism following thyroidectomy, psychogenic eating disorder, anxiety, and borderline personality disorder. Her surgical history included laparoscopic ovarian cyst removal (1998), dilation and curettage (2000), and thyroidectomy (2005).\u003c/p\u003e\u003cp\u003eThe patient was not sexually active, and her Eastern Cooperative Oncology Group (ECOG) performance status was 1. On physical examination, she was 168 cm tall and weighed 287 kg, with circumferences of 130 cm and 118 cm for the right and left thighs, respectively. Bilateral pitting edema grade 2 + was observed in her thighs. Otherwise, her general and pelvic examinations were unremarkable.\u003c/p\u003e\u003cp\u003eHer initial laboratory evaluation revealed hemoglobin of 12.4 g/dl, mean corpuscular volume (MCV) of 89.8 fl, and CA 12 − 5 levels of 22 U/ml. Her Pap smear showed no abnormalities.\u003c/p\u003e\u003cp\u003eA preoperative CT of the thorax and abdomen demonstrated an asymmetrical uterine form and enlarged retroperitoneal lymph nodes. The lung fields were clear with no evidence of metastatic disease, and the heart size was within normal limits. A CT of the skull showed no signs of metastasis.\u003c/p\u003e\u003cp\u003eGiven her immobility and significant comorbidities, the patient displayed signs consistent with congestive heart failure, leading to a high perioperative risk. In order to evaluate cardiac function, transthoracic echocardiography was performed. The findings included pulmonary hypertension with a systolic pulmonary artery pressure of 38 mmHg (plus central venous pressure), moderate tricuspid valve insufficiency, and a preserved left ventricular ejection fraction of 50%. Mild mitral valve insufficiency was also noted and the aortic valve appeared normal.\u003c/p\u003e\u003cp\u003eBased on these findings, the patient was classified as ASA IV according to the American Society of Anesthesiologists (ASA) Physical Status Classification System, indicating a severe systemic disease posing a constant threat to life.\u003c/p\u003e\u003cp\u003eTo perform the dilation and curettage (D\u0026amp;C), the patient's legs were placed on two stands, as they could not be positioned in stirrups for the lithotomy position due to their size. Postoperatively, the patient experienced a hypertensive crisis with a blood pressure of 240/100 mmHg, which was successfully managed with standard drug therapy. Histopathological analysis of the D\u0026amp;C specimen revealed endometrioid adenocarcinoma, FIGO grade 1.\u003c/p\u003e\u003cp\u003eSubsequently, the patient underwent a robotically assisted total laparoscopic hysterectomy performed as peritoneal mesometrial resection (PMMR) and bilateral salpingo-oophorectomy with pelvic-targeted compartmental lymphadenectomy (TCL). A specialized surgical bed was utilized to accommodate the patient’s unique anatomical considerations. Due to the size of her legs, the patient could not be placed in the lithotomy position and was instead positioned supine.\u003c/p\u003e\u003cp\u003eThe surgical bed was padded with egg crate foam along its surface and edges to ensure pressure relief and minimize the risk of pressure-related injuries. Multiple bed extenders were attached to accommodate the width of the patient’s torso and legs. Circumferential padding and taping were applied around her lower legs and chest for additional stabilization and support. Arm sleds were repurposed to support her lower legs, positioned adjacent to the bed, ensuring optimal access for the surgical procedure (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e\u003cp\u003eA HOHL uterine manipulator was successfully placed in the vagina to distend the vaginal fornices and assist in performing the colpotomy. Long robotic trocars (120 mm length × 8 mm) were used to access the abdominal cavity and were configured in a five-trocar arrangement. The patient and bed were positioned at a 30° Trendelenburg angle, and the robotic system was docked at an oblique angle from the patient’s right side.\u003c/p\u003e\u003cp\u003eMonopolar scissors, a PK coagulator, and Maryland graspers were employed via the robotic arms, while a 30° scope provided optimal visualization. Insufflation pressure was maintained between 12–15 mmHg throughout the procedure, with a reduction in pressure at the end to facilitate ventilation by the anesthesia team.\u003c/p\u003e\u003cp\u003eThe combination of the steep Trendelenburg position and pneumoperitoneum-induced hypercapnia has the potential to exacerbate pulmonary artery pressure and increase the risk of heart failure. To mitigate these risks, advanced hemodynamic monitoring was implemented, including continuous transesophageal echocardiography and the placement of arterial, central venous, and pulmonary artery catheters.\u003c/p\u003e\u003cp\u003eUsing this setup, a robotically assisted total laparoscopic hysterectomy and bilateral salpingo-oophorectomy with indocyanine green-near-infrared fluorescence guided, targeted sentinel lymphadenectomy could be performed. The uterus, fallopian tubes, ovaries, and lymph nodes were removed vaginally using an 800 mL Endobag. The vaginal cuff was closed robotically with a continuous V-Loc suture. An intraabdominal drain was placed in the pelvis. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the situation after skin closure.\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003c/p\u003e\u003cp\u003ePositioning and anesthesia time totalled 131 minutes, while the surgical procedure lasted 264 minutes. The overall operating room time was 437 minutes. The estimated blood loss during the procedure was 150 ml. Preoperatively, the patient received 3 g of Ampicillin/Sulbactam. Due to the high risk of pulmonary complications, the patient was admitted to the intensive care unit postoperatively. She was extubated and initially supported by non-invasive ventilation for several hours before being transferred to the general ward on the second postoperative day. Her postoperative course was uncomplicated. The patient was discharged on the twenty-second postoperative day, primarily due to non-gynecological chronic conditions, including mild vision loss from hypertensive retinopathy, as well as the need to address issues related to her immobility and plan post-discharge care. The patient declined our recommendation to present her case for bariatric surgery.\u003c/p\u003e\u003cp\u003eFinal pathology revealed a tumor in the uterus measuring 5.4 × 5.2 × 2.6 cm, diagnosed as FIGO grade 1 MSS endometrioid adenocarcinoma, p53 wild type, with 1 cm of myometrial invasion. No lymphvascular space invasion (LVSI) was identified. The final TNM classification was pT3a pN0 (0/1) L0 V0 Pn0 R0 G2.\u003c/p\u003e\u003cp\u003eFurther treatment recommendations included radiotherapy and adjuvant chemotherapy with Carboplatin and Paclitaxel administered intravenously every three weeks. Postoperatively, the case was discussed in the interdisciplinary conference and the patient was referred to radiation oncology to discuss adjuvant treatment options. During the consultation, various approaches were reviewed, including whole pelvic radiation, vaginal cuff brachytherapy (VBT), and a combination of both. After a thorough discussion of the risks and benefits of all options, the patient expressed significant concerns about the potential toxicity of the recommended therapy. Having undergone cancer-field surgery she decided to omit postoperative treatment.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eObesity is a prevalent chronic disease, and morbid obesity is an increasingly alarming global problem. In Germany, 53.5% of the population (46.6% of women and 60.5% of men) is classified as overweight, including those with obesity. Obesity affects 19.0% of adults [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The management of extreme obesity - defined as a body mass index (BMI)\u0026thinsp;\u0026ge;\u0026thinsp;50 kg/m\u0026sup2; or obesity classes IV, V, and VI - remains a significant challenge. Individuals with extreme obesity face an elevated risk of surgical complications, increased mortality, and multiple comorbidities.\u003c/p\u003e \u003cp\u003eEndometrial cancer (EC) is a malignancy of the inner epithelial lining of the uterus, with a rising global incidence and associated mortality [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In Germany, EC is the most common gynecological malignancy. In 2020, there were 417,336 new cases of EC worldwide, making it the sixth most commonly occurring cancer among females [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The majority of cases occur between the ages of 65 and 75 years [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This type of cancer comprises a range of distinct histological subtypes and molecular phenotypes. Historically, EC has been classified into two categories: Type I, which is associated with unopposed estrogen stimulation, features low-grade cells, is more common, and has a favourable prognosis; and Type II, which is not estrogen-driven, features high-grade cells, is less common, and has a poorer prognosis. Type I EC primarily includes grade I or grade II endometrioid adenocarcinomas, while Type II encompasses grade III endometrioid adenocarcinomas, serous carcinoma, clear cell carcinoma, undifferentiated carcinoma, and carcinosarcomas [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral factors increase the risk of developing EC, including advanced age, certain ethnicities, higher BMI, endogenous or exogenous estrogen exposure, tamoxifen use, early menarche, late menopause, lower parity, metabolic syndrome, family history, and genetic predisposition. Conversely, factors such as maintaining a normal BMI, having higher parity, and using oral contraception are associated with a lower risk of EC [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo our knowledge, the case presented here involves the largest patient to undergo surgery for endometrial cancer using the DaVinci\u0026trade; robotic system. This case highlights the feasibility and advantages of robotically assisted surgery in patients with morbid obesity even for complex procedures such as the oncological cancer-field surgery presented here. As cancer-field surgery by PMMR and TCL aims at reaching optimal locoregional control without the need for adjuvant radiotherapy, it may help to minimize treatment-related risks for this extremely vulnerable collective by avoiding both laparotomy as well as irradiation. Conventional laparoscopy is often impractical for such complex procedures while open surgery via laparotomy carries a significantly increased perioperative risk in this patient population [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough the robotic-assisted laparoscopic approach is advantageous for morbidly obese patients, it presents significant anesthesiological challenges. Obesity reduces functional residual lung capacity and chest wall compliance, increasing airway resistance and the risk of atelectasis. These issues are exacerbated by the steep Trendelenburg position [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Ventilating a morbidly obese patient in a 30\u0026deg; Trendelenburg position becomes even more challenging with the addition of capnoperitoneum. To mitigate respiratory insufficiency, the application of adequate positive end-expiratory pressure (PEEP) is crucial [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this case, optimal PEEP was determined through titration based on dynamic lung compliance. The patient was ventilated using pressure-controlled, low-tidal volume ventilation of 7 ml/kg ideal body weight, with a respiratory rate of 20 breaths per minute and an inspiratory-to-expiratory ratio of 1:1. The respiratory rate was further adjusted based on end-tidal capnometry. Following an initial recruitment manoeuvre, optimal compliance was achieved with a PEEP of 24 mbar and a peak airway pressure of 42 mbar. With a respiratory rate of 28 breaths per minute, a minute volume of 10.9 L was maintained.\u003c/p\u003e \u003cp\u003eWhile high PEEP values in morbidly obese patients improve oxygenation, they do not necessarily lead to pulmonary barotrauma. Barotrauma depends on excessive transpulmonary pressure, which is calculated as the difference between intra-alveolar and intrapleural pressure. In this case, the elevated intrapleural pressure caused by the patient\u0026rsquo;s body weight in the steep Trendelenburg position, combined with increased intra-abdominal pressure during laparoscopy, allowed for higher intra-alveolar pressures to be well-tolerated. These pressures minimized atelectasis formation and potentially improved postoperative pulmonary function [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis approach - using a higher PEEP - reduces driving pressure during ventilation, a factor strongly associated with improved postoperative pulmonary outcomes [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Additionally, low tidal-volume ventilation of 7 ml/kg ideal body weight was shown to enhance postoperative outcomes, though it may complicate the maintenance of normocapnia [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In this case, arterial hypercarbia up to 67 mmHg was tolerated, as arterial pH remained above 7.2. Oxygenation was well-maintained, with an FiO₂ of 0.5 yielding arterial pO₂ values above 80 mmHg.\u003c/p\u003e \u003cp\u003eApart from the challenges associated with ventilation, hemodynamic changes during the steep Trendelenburg position are also significant, including increases in arterial and central venous pressures, cardiac output, systemic vascular resistance, and pulmonary artery pressure\u003csup\u003e8\u003c/sup\u003e. These changes may be further aggravated by high PEEP values and hypercarbia. With a pulmonary artery catheter in place, the mean pulmonary artery pressure in the supine position was initially measured at 45 mmHg, which increased to 69 mmHg during surgery. Inhalation of 20 \u0026micro;g Iloprost as a pulmonary vasodilator did not result in a significant decrease in pulmonary artery pressure. However, transesophageal echocardiography revealed that cardiac function remained compensated without signs of right heart failure, allowing surgery to proceed after a slight decrease in capnoperitoneal pressure. Arterial pressure was maintained through continuous infusion of noradrenaline. Given that we did not expect significant blood loss during surgery, infusion of balanced crystalloids was limited to a total of 500 mL.\u003c/p\u003e \u003cp\u003eAlthough the patient's respiratory and hemodynamic status after surgery remained uneventful, we anticipated an increased risk of postoperative pulmonary complications. Postoperative pulmonary complications have been reported in 19% of patients following robotic-assisted surgery, and morbid obesity is known to further elevate this risk [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Consequently, the patient was transferred to our intensive care unit, where she was extubated and initially supported by non-invasive ventilation to optimize and maintain respiratory function. She was subsequently discharged from the ICU on the second postoperative day without incident.\u003c/p\u003e \u003cp\u003eIn summary, we report a case of multidisciplinary management for an extremely obese patient undergoing robotically assisted oncological surgery. This case is unique because it demonstrates how robotic surgery can address the challenges posed by extreme obesity. The complexities of surgical and anesthesiological management necessitate a multidisciplinary approach, often involving specialists in gynecologic oncology and anesthesiology. Future studies are needed to address the specific needs of patients with extreme obesity, as their outcomes are likely to differ from those of patients with a lower BMI.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eObesity is a significant risk factor for endometrial cancer, and its prevalence continues to rise. As such, the development of surgical techniques to manage these patients is crucial. Minimally invasive surgery, particularly with robotic assistance, has expanded the possibility of performing surgeries on morbidly obese women. It enables surgeons to navigate around anatomical barriers and reduces surgeon fatigue. While it presents complex challenges for anesthesiologists, surgical nurses, and surgeons, these challenges can be managed through individualized and interdisciplinary approaches. With regard to anesthesia, optimized ventilation with adequate PEEP is critical for preventing hypoxemia and excessive hypercapnia. Additionally, individualized management of hemodynamic changes, particularly in patients with known cardiac dysfunction, is essential. Given the rising rates of obesity and the high prevalence of uterine cancer, there is a growing need for safe and effective therapeutic options for this population. Robotic-assisted surgery for endometrial cancer in class VI obese patients is a safe and feasible option, offering low complication rates and comparable oncologic outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthorship contribution statementR. Csorba and AtasElfrink contributed conception and design of the case report.P. Buderath and M. Britten contributed to patient care.M. Britten and R. Csorba conducted the literature review and drafted the manuscript.P. Buderath provided expert review and oversight. All authors have read and agreed to the published version of the manuscript.Acknowledgements: noneFunding: This research received no external funding.Patient consent: The patient provided written informed consent for the publication of the clinical details and images. Ethics: Our institution does not require ethical approval for case reportsConflict of interest statement: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.Authors` note: Case reporting was done ethically. Neither this case nor others about the same patient have been previously published.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003enone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSchienkiewitz A, Kuhnert R, Blume M, et al. Overweight and obesity among adults in Germany - Results from GEDA 2019/2020-EHIS. J Health Monit. 2022; 7(3):21\u0026ndash;28. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.25646/10293\u003c/span\u003e\u003cspan address=\"10.25646/10293\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 36188152; PMCID: PMC9520353.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLechartier C, Bernard J, Renaud MC, et al. Robotic-assisted surgery for endometrial cancer is safe in morbidly and extremely morbidly obese patients. 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Br J Anaesth. 2023; 131(6):1093\u0026ndash;1101. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.bja.2023.09.011\u003c/span\u003e\u003cspan address=\"10.1016/j.bja.2023.09.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAssessment of Ventilation during General Anesthesia for Robotic Surgery (AVATaR) Study Investigators, PROtective VEntilation (PROVE) Network. Ventilation and outcomes following robotic-assisted abdominal surgery: an international, multicenter observational study. Br J Anaesth. 2021; 126(2):533\u0026ndash;543. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.bja.2020.08.058\u003c/span\u003e\u003cspan address=\"10.1016/j.bja.2020.08.058\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"endometrial cancer, morbid obesity, robotic surgery, cancer-field surgery, multidisciplinary management, anaesthesiology","lastPublishedDoi":"10.21203/rs.3.rs-5924531/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5924531/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe prevalence of obesity has risen significantly, affecting over 19% of the German population. Obesity is frequently associated with endometrial cancer, presenting considerable challenges in pre-, intra- and postoperative management. Challenges with intubation, patient positioning, respiratory and cardiac complications as well as wound dehiscence are commonly encountered in this patient population.\u003c/p\u003e \u003cp\u003eFor patients with uterine cancer, surgical intervention is essential for staging, symptom control, and potential cure. Minimally invasive approaches, particularly robotic-assisted surgery, have expanded the possibilities for treating morbidly obese patients. Robotic systems facilitate navigation around anatomical barriers and reduce surgeon fatigue. However, despite the technological advancements, morbidly obese patients often face increased perioperative risks and prolonged postoperative recovery. Laparoscopic procedures in steep Trendelenburg position for morbidly obese patients pose unique challenges, particularly in anesthesiological management. These challenges necessitate individualized ventilatory and hemodynamic support to ensure patient safety.\u003c/p\u003e \u003cp\u003eThis case highlights a multidisciplinary approach to managing a patient with extreme obesity (BMI 101.7 kg/m\u0026sup2;) undergoing robotic-assisted surgery for uterine cancer. It underscores the importance of comprehensive preoperative planning, intraoperative considerations, and postoperative care in minimizing complications and optimizing outcomes. Robotic-assisted surgery for endometrial cancer in obese patients has proven to be a safe and feasible option, characterized by a low complication rate, minimal blood loss, and a short hospital stay.\u003c/p\u003e","manuscriptTitle":"Robotic-Assisted Surgery in Extremely Obese Patients. A Multidisciplinary Approach for a Patient with a BMI of 101.7 kg/m²","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-04 09:02:08","doi":"10.21203/rs.3.rs-5924531/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"afbaf9a1-af10-4cd9-a0d4-494ea7d230ff","owner":[],"postedDate":"February 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-04T15:53:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-04 09:02:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5924531","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5924531","identity":"rs-5924531","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}