Unfortunately, significant weight loss may take years and, more often than not, is impossible. Weight loss prior to elective surgery in patients who are overweight or obese would be ideal. This second problem is probably related to increased volume of bowel, decreased elevation of a heavier anterior abdominal wall by the pneumoperitoneum, and the inability to place many patients who are obese in steep Trendelenburg position because of ventilation considerations.
Many intra-abdominal procedures become increasingly difficult because of a restricted operative field secondary to retroperitoneal fat deposits in the pelvic sidewalls and increased bowel excursion into the operative field. Bleeding from abdominal wall vessels may be more common because these vessels become difficult to locate. Placement of laparoscopic instruments becomes much more difficult and often requires special techniques. In women who are overweight, and even more so in those who are obese, every aspect of laparoscopy becomes more difficult and potentially more risky. In an average-sized woman of approximately 160 cm (64 in), these cutoff points correspond roughly to weights of 73 kg (160 lb) and 91 kg (200 lb), respectively. Women with a body mass index (BMI) greater than 25 kg/m 2 are classified as overweight, and those with a BMI greater than 30 kg/m 2 are considered obese. For laparoscopy, increased weight takes on a special significance. Obesity is a well-recognized factor that increases the risk of any abdominal surgery. Furthermore, patients must follow the recommendations for regular cervical cytology. However, an increased risk exists for reoperation for cervical bleeding and prolapse.
Proponents of LSH advocate that the operating room and recovery time are decreased and risk of both infection and ureteral injury are minimized. This approach eliminates vaginal and abdominal incisions, with no need to dissect near the uterine artery or ureter. Note: The risk of intraperitoneal dissemination of malignant tissue led to a 2014 FDA black box warning against the use of laparoscopic power morcellation to remove uterine fibroid tumors. A special instrument is used to core-out or cauterize the endocervix, and the uterus is then removed through a 12-mm port abdominally by morcellation or transcervically with a special morcellator. The technique begins again as for the LAVH, but proceeds with separating the entire fundus from the cervix after the proximal vessels are divided and the bladder is dissected away from the uterus. LSH is the third approach, being most often promoted for benign indications.