Super morbid obesity for laparoscopic hysterectomy

Gabrielle Morris

26yo, 197kg, female with grade 1 endometrial cancer for laparoscopic hysterectomy after failed treatment with Mirena for endometrial cancer.

Background:

  • Endometrial cancer – being treated with mirena/curettes. 
  • Nulliparous woman, keen to have children, may do so via surrogate with egg donation.
  • 2 x previous same procedure – one under GA igel 5, one under sedation with THRIVE. Both nil issues
  • OSA
    • Overnight oximetry with ODI 48/hr and witnessed apnoeas. 
    • Did not attend for review by respiratory physician despite repeated attempts from team.
    • HCO3 and PaCO2 normal on ABG, so no e/o obesity hypoventilation
  • High BMI ++ 

Issues

  • Unoptimised OSA 
  • Severe obesity, weight gain despite dietician review.

Discussion

  • Surgical options?
    • Maximum allowable time frame before surgery to allow optimisation?
    • Will laparoscopic be possible – open surgery can be more difficult in this setting.
    • Surgeon has been learning a new per-vaginal laparoscopic technique but doesn’t feel comfortable enough to try it in such a challenging patient.
  • Weight reduction surgery possible?
    • Information for Sydney clinic previously provided to GP however with COVID issues and need for expedited surgery, seems unlikely this will procced before hysterectomy.
    • Local options?
    • Would weight loss allow her cancer to be downgraded or avoid the need for surgery due to reduced hyper-oestrogenic state? See attached summary article on obesity-related gynaecological cancers.
  • OSA optimisation possible?
    • Local guideline (currently under development) would suggest that without OHS pre-op optimisation of OSA is not needed, due to lack of evidence suggesting improved perioperative outcomes.
  • Level of post-op care? If surgery able to proceed laparoscopically, ideal for patient, allowing normal ward care.

Plan

  • Speak with gynae surgeon to determine maximal timeframe for optimisation
    • 2 months
  • Speak with local bariatric surgeon
    • Yes, surgery possible locally in the public system. Gastric bypass for “severe reflux” or sleeve gastrectomy if patient gains support from local MP.
    • Weight list ~12mths however this timeframe is used to develop rapport and engagement with the service’s dietician which is essential for postop success.
    • Letter sent to GP with this info.
  • Ensure patient referred to gynae-oncology dietician
  • Ensure patient has appointment with resp team.
  • Notification to procedural anesthetist once surgery date and allocations known.