Minimally invasive gynecologic surgery in obese patients can present a number of challenges, even for the most experienced gynecologic surgeons. During the Friday clinical seminar “Gynecologic Surgery in the Morbidly Obese Patient,” Douglas N. Brown, MD, discussed some of the commonly experienced challenges faced by surgeons who provide surgical care for morbidly obese-complicated gynecologic patients.
Dr. Brown, assistant professor of obstetrics, gynecology and reproductive biology at Harvard Medical School and chief of minimally invasive gynecologic surgery and director of the Center for Minimally Invasive Gynecologic Surgery at Massachusetts General Hospital in Boston, started by introducing a typical scenario a surgeon might face in this patient population — a 36-year-old patient who weighs close to 400 pounds with a BMI somewhere around 65 who needs a hysterectomy.
“The first thing you have to do is stop and think about what you’re about to do because these patients who are morbidly obese with large BMI generally have multiple co-morbidities,” Dr. Brown said. “You want to make sure you have a solid indication for why you’re bringing her into the OR and whether there’s any other way to treat her.”
Before a final decision is made, Dr. Brown said it’s important to counsel the patient and make sure her expectations for the surgery are realistic.
“If that means you need to bring her back in specifically for a preoperative visit, and it’s going to take a full 30 minutes of your busy clinical practice, then you do that,” he said. “If at the end of the 30 minutes, you don’t feel like she grasped both the worst-case scenario and the best-case scenario, you may need to have another visit with her.”
Once the decision is made to proceed with surgery, Dr. Brown said assembling the right OR team and appropriately outfitting the OR is crucial. Ideally, the anesthesiologists, OR nurses, and surgical assistants will all have experience handling obese patients.
“You’ve got to have your surgical team organized because when you see the patient in the clinic, it’s a lot different and more anxiety-provoking when you see them on the table,” he said. “You have to sweat the little stuff. You are the commander of that ship, and you have to make sure that you have the right people and the right tools available.”
Dr. Brown said he relies on his military training and follows the surgical equivalent of a “pilot’s checklist” that covers all preoperative, intraoperative, and postoperative considerations—a practice he highly recommends. Preparation, he said, is the key to ensuring a good outcome.
“These can be exhausting cases, and you’re going to be thinking about a lot of different things, so you need to be as prepared and focused as possible so you can hone in on whatever the task is that you’re doing at any specific time,” Dr. Brown said. “It’s when we’re unprepared that everything goes wrong, and so you need to think ahead on this one. Be cautious, but be deliberate.”