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Can Teamwork and High-Volume Experience Overcome Challenges of Lymphadenectomy in Morbidly Obese Patients (Body Mass Index of 40 kg/m2 or Greater) with Endometrial Cancer?: A Cohort Study of Robotics and Laparotomy and Review of Literature
  1. Hubert Fornalik, MD*,
  2. Temeka Zore, MD,
  3. Nicole Fornalik, PA-C*,
  4. Todd Foster, PhD,
  5. Adrian Katschke, MS and
  6. Gary Wright, DO§
  1. * St. Vincent Gynecologic Oncology,
  2. Department of Obstetrics and Gynecology,
  3. Office of Research & Clinical Trials, and
  4. § Northside Anesthesia Services, St. Vincent Indianapolis Hospital, Indianapolis, IN.
  1. Address correspondence reprint requests to Hubert Fornalik, MD, Goshen Center for Cancer Care, 200 High Park Ave, Goshen, IN 46526. E-mail: hubert.fornalik{at}


Objective This study aimed to compare surgical outcomes and the adequacy of surgical staging in morbidly obese women with a body mass index (BMI) of 40 kg/m2 or greater who underwent robotic surgery or laparotomy for the staging of endometrioid-type endometrial cancer.

Methods This is a retrospective cohort study of patients who underwent surgical staging between May 2011 and June 2014. Patients' demographics, surgical outcomes, intraoperative and postoperative complications, and pathological outcomes were compared.

Results Seventy-six morbidly obese patients underwent robotic surgery, and 35 underwent laparotomy for surgical staging. Robotic surgery was associated with more lymph nodes collected with increasing BMI (P < 0.001) and decreased chances for postoperative respiratory failure and intensive care unit admissions (P = 0.03). Despite a desire to comprehensively stage all patients, we performed successful pelvic and paraaortic lymphadenectomy in 96% versus 89% (P = 0.2) and 75% versus 60% (P = 0.12) of robotic versus laparotomy patients, respectively. In the robotic group, with median BMI of 47 kg/m2, no conversions to laparotomy occurred. The robotic group experienced less blood loss and a shorter length of hospital stay than the laparotomy group; however, the surgeries were longer.

Conclusions In a high-volume center, a high rate of comprehensive surgical staging can be achieved in patients with BMI of 40 kg/m2 or greater either by laparotomy or robotic approach. In our experience, robotic surgery in morbidly obese patients is associated with better quality staging of endometrial cancer. With a comprehensive approach, a professional bedside assistant, use of a monopolar cautery hook, and our protocol of treating morbidly obese patients, robotic surgeries can be safely performed in the vast majority of patients with a BMI of 40 kg/m2 or greater, with lymph node counts being similar to nonobese patients, and with conversions to laparotomy reduced to a minimum.

  • Robotic lymphadenectomy
  • Morbidly obese
  • BMI greater than 40
  • Endometrial cancer
  • High volume

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  • Present address of H. Fornalik and N. Fornalik is Goshen Center for Cancer Care, Goshen, IN.

  • Present address of T. Zore is University of California at Los Angeles, CA.

  • Present address of G. Wright is Exeter Hospital, NH.

  • The authors declare no conflicts of interest.

  • This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.