Introduction Obesity is increasing worldwide and has been associated with the development of endometrial cancer. Minimally invasive surgery in early-stage endometrial cancer with sentinel lymph node (SLN) biopsy provides superior surgical benefits over laparotomy without impairing oncological outcomes. Moreover, robotic-assisted laparoscopic surgery (RALS) is an attractive option for morbidly obese patients with several advantages over conventional laparoscopy. This video demonstrated pre- and intra-operative preparations, SLN biopsy using indocyanine green (ICG) with near-infrared (NIR) imaging, and hysterectomy technique by RALS in a morbidly obese patient.
Description We present a morbidly obese patient with a body weight of 127 kg and a BMI of 47 kg/m2. She was preoperatively diagnosed with early-stage endometrial carcinoma. The surgical anatomy from the CT scan was evaluated for extrauterine disease and to determine the accurate primary port insertion on the truncal adiposity. We also provided essential attention to patient positioning, maximal allowable steep head-down tilt, and the effect of pneumoperitoneum before starting the procedure to minimize the risk of complications. We injected ICG into the cervix before port placement and used NIR imaging to guide the SLN removal. The step-by-step hysterectomy and SNL biopsy by RALS were performed in a tertiary care academic center.
Conclusion/Implications RALS for early-stage endometrial cancer with SLN biopsy using ICG and NIR imaging in a patient with morbid obesity shows that it is feasible and should be widely introduced as a management option in Thailand. In addition, adequate preoperative and intraoperative preparations in patients with morbid obesity are also essential in achieving favorable outcomes.