Super morbid obesity, hysterectomy

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


  • 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 ++ 


  • Weight reduction surgery 
    • Surgery possible locally under the umbrella of ‘severe reflux surgery’ (allowing gastric bypass) or with support from a local MP (allowing a gastric sleeve)
    • GP to refer to local public surgeon
    • Wait time ~ 12mths which allows substantial engagement with the service’s dietician, which is critical to success of the procedure
  • Gynae surgery
    • Occurred several weeks ago.
    • Combination of intra-abdominal laparoscopic and per-vaginal endoscopic (“natural orifice surgery”) approaches used which allowed minimisation of Trendelenburg requirements and abdominal insufflation pressures, both of which were poorly tolerated due to this patient’s body habitus.
  • What is Natural Orifice Transluminal Endoscopic Surgery (NOTES) (from Uptodate)
    • Developed in 1990s
    • Initial route was per-gastric however other orifices used include transanal, transvaginal, transurethral/transcystic, and transoesophageal.
    • Has been used for peritoneal explorations, pancreatectomy, splenectomy, nephrectomy. 
    • Hypotheses
      • A hole in a viscus may be better tolerated than in the abdominal wall, leading to less pain, adhesions, hernias.
      • Absence of cosmetic scar
      • Better access to certain areas, especially in the super obese patient (relevant in this patient)
      • Possibly shorter hospitalisations and healthcare costs
    • Concern persists around risks of bacterial contamination and abscess formation.
    • Low incentive to move from the experimental phase (in most instances) due to lack of standardisation/protocols, training, and requirement for specialised instruments.