Optimizing Robotic Hysterectomy for the Patient Who Is Morbidly Obese with a Surgical Safety Pathway

Study Objective: Obesity is a growing worldwide epidemic, and patients classified as obese undergoing gynecologic robotic surgery are at increased risk for surgical complications. This study aimed to evaluate the feasibility and outcomes of a surgical safety protocol known as the High BMI [Body Mass Index] Pathway (HBP) for patients with BMI ≥40 kg/m² undergoing planned robotic hysterectomy. Our primary outcome was the rate of all-cause perioperative complications in patients undergoing surgery with the use of the HBP. Design: A retrospective cohort study. Setting: An academic teaching hospital. Patients: A total of 138 patients classified as morbidly obese (BMI ≥40 kg/m²) undergoing robotic hysterectomy. Interventions: The HBP was developed by a multidisciplinary team and was instituted on January 1, 2016, as a quality improvement project. Patients classified as morbidly obese undergoing robotic hysterectomy after this date were compared with consecutive historical controls. Measurements and Main Results: Seventy-two patients underwent robotic hysterectomies on the HBP and were compared with 66 controls. There were no differences in age, BMI, blood loss, number of comorbidities, or cancer diagnosis. Since the implementation of the HBP, there has been a decrease in anesthesia time (–57.0 minutes; p =.001) and total operating room time (–47.0 min; p =.020), as well as lower estimated blood loss (median 150 mL [interquartile range 100–200] vs 200 mL [interquartile range 100–300]; p =.002) and reduction in overnight hospital admissions (33.3% vs 63.6%; p <.001). In the HBP group, there were fewer all-cause complications (19.4% vs 37.9%; p =.023) and infectious complications (8.3% vs 33.3%; p =.001), and there was no increase in the readmission rates (p =.400). In multivariable analysis, the HBP reduced all-cause complications (odds ratio 0.353; p =.010) after controlling for the covariate (total time in the operating room). Conclusion: The HBP is a feasible method of optimizing the outcome for patients classified as morbidly obese undergoing major gynecologic surgery. Initiation of the HBP can lead to decreased anesthesia and operating times, all-cause complications, and overnight hospital admissions without increasing readmission rates.