Obesity Does Not Increase Rates of Major Complications or Conversion in Minimally Invasive Hysterectomy

Abstract

Objective: The aim of this study was to determine whether obese women undergoing minimally invasive hysterectomy are at increased risk of complications or conversions to open surgery. Design: This study was designed as a retrospective cohort study. Materials and Methods: All laparoscopic hysterectomies performed between 2008 and 2012 for benign pathology were included. The main outcomes analyzed, across the three body mass index (BMI) groups (normal, overweight, and obese), were operative time; hemoglobin drop; conversion to open hysterectomy; bleeding requiring blood transfusion; damage to the bladder, ureter, bowel, or vessels; return to the operating theater; readmission to hospital; and length of postoperative stay. Results: There were 186 women (124 laparoscopic hysterectomies, 62 laparoscopic-assisted vaginal hysterectomies). Of these women, 62 (33.3%) were obese, 77 (41.4%) were overweight, and 47 (25.3%) had normal BMIs. The rate of major complications was 11.3% (21/186), with conversion to open surgery being the most common (17/186; 9.1%). There were no significant differences in any of the main outcomes among the BMI categories—except for the duration of surgery, which was significantly longer for patients in the obese than for those in the overweight category (p=0.015). Odds ratio analysis did not show that there were higher odds of complications or conversions in the obese group. The obese group was compared with the nonobese groups (overweight+normal BMI pooled together to form a “nonobese group” in this analysis), and the only difference was that the operative time was significantly longer (p=0.009) in the obese group. Conclusions: The findings in this study suggest that minimally invasive hysterectomy does not increase the risk of complications or conversions, but operative time appears to be longer, in obese women. (J GYNECOL SURG 29:190)

Introduction

Obesity has become a global epidemic and is a major chronic public health concern. Obesity is also a risk factor for heavy menstrual periods, pelvic-organ prolapse, fibroid tumors, and endometrial hyperplasia—all of which are indications for hysterectomy.¹ With the global problem of obesity, increasing numbers of obese women will present for hysterectomy. This is particularly true of the geographic area of this study, Dudley, United Kingdom, where 27.7% of the adult population is obese, a statistic that is higher than in England overall (24.1%) and higher than in manufacturing towns (25.5%).²

Conventionally, abdominal hysterectomy in obese patients has been associated with infections, wound dehiscence, and prolonged recovery. Per a Cochrane review,³ ideally, vaginal hysterectomy would be the preferred option for all women with indications for this procedure, particularly obese women. When vaginal hysterectomy is not feasible, laparoscopic hysterectomy (LH) is an alternative. There are well-documented benefits of LH, and obese women are likely to benefit, as it is associated with less pain, earlier ambulation, and shorter hospital stay, with less thromboembolic and wound-infection morbidities. With advances in minimal-access techniques in obese patients in bariatric surgery,⁴ there is now an increased interest in LH in obese patients as an alternative to abdominal hysterectomy.

This article presents a retrospective cohort study that examined patient demographics, operative data, and complications of LH performed in a single unit in a health care setting, and outcomes were analyzed according to body mass index (BMI) categories to determine if obese women undergoing minimally invasive hysterectomy are at an increased risk for complications or conversions to open surgery. The main outcomes were duration of surgery, hemoglobin drop, conversion to open surgery, complication rate, and length of hospital stay.

Materials and Methods

All the LHs performed at the Dudley Group of Hospitals, in Dudley, between 2008 and 2012 for benign pathology were included. The operations were performed by Drs. Morsi and De Silva. The surgeons used either laparoscopic-assisted vaginal hysterectomy (LAVH) or LH, with the latter mainly being used for nulliparous women or for those with limited vaginal access or no uterine descent.

Exclusion criteria included malignant pathology, second/third-degree uterine prolapse, a uterus of >16 weeks of gestation, or suspected pelvic adhesions, for example, previous pelvic abscess or peritonitis. All patients provided fully informed consent. Patients with a BMI of ≥30 were considered as obese, those with a BMI ≥25 were considered overweight, and those with a BMI <25 were considered normal.⁵ Overweight and normal patients were also considered “nonobese,” when the two groups were pooled together. Investigational review board approval was not requested for this anonymous, retrospective, and data abstraction and analysis study.

Data collected included age, parity, BMI, indication for surgery, specimen weight, uterine length, and previous pelvic surgery. The main outcomes analyzed, across the three BMI groups (normal, overweight, and obese) were: operative time (calculated from insertion of a Veress needle to skin closure at the last trocar site); hemoglobin drop (difference between preoperative level and postoperative level on day 1); conversion to open hysterectomy; major complications (intra- or postoperative bleeding requiring blood transfusion; damage to the bladder, ureter, bowel, or major vessels; return to operating theater; or readmission to hospital within 6 weeks); and length of postoperative hospital stay.

After bladder emptying, a uterine manipulator was inserted. One 10-mm intraumbilical port and two or three 5-mm ports were inserted, both suprapubically and in the lower right and left abdominal quadrants. The ureter trajectory was visualized. Reusable laparoscopic instruments were used. The energy source was the Enseal®Trio (Ethicon Endo-Surgery, Berkshire, UK), a reusable laparoscopic bipolar forceps and a monopolar diathermy hook/scissors for colpotomy. Pedicle desiccation started at the left round ligament followed by opening of the anterior leaf of the broad ligament. If the adnexae were to be removed, the ureters were identified at the pelvic brim and the desiccation of the infundibulopelvic ligaments was performed “flush” with the ovaries. The bladder peritoneum was opened and extended medially. The same steps were repeated on the other side. The bladder was then mobilized downward. The uterus was then pushed inward with maximum pressure to displace the bladder and ureters down and laterally away from the uterine vessels. The posterior leaf of the broad ligament was then opened, away from the pelvic wall, down to the insertion of the uterosacral ligaments to expose the uterine vessels at the brim of the cup. In LAVH, anterior colpotomy was performed using a diathermy hook against a sponge forceps introduced vaginally to distend and delineate the anterior fornix. The rest of the operation continued vaginally. In LH, with maximum cephalad pressure, the skeletonized uterine arteries were desiccated above the level of the cup using the bipolar forceps initially followed by cutting using the Enseal device. Once the pedicle was cut, this exposed the cervicofascial ring. The uterine pedicle was mobilized further by cutting the exposed cardinal ligament fibers anteriorly, posteriorly, and in an inferomedial direction, staying intrafascially (in the plane between the uterine wall and the uterine pedicle). Uterine blanching was observed. Once the uterine pedicle fell laterally outside the cup rim, with maximum cephalad pressure, circumferential colpotomy was then performed using a diathermy hook at the stretched cervicovaginal junction. The uterus was removed/morcellated vaginally, and the vaginal vault was closed vaginally. A second-look laparoscopy was performed at the end, to ensure hemostasis at low pressure. Cystoscopy was performed in some cases of LH at the discretion of the surgeon. An intraperitoneal drain and urinary catheter were left in until the following day.

Data are summarized as medians and quartiles or as counts and percentages. Mann–Whitney–U or Fisher's exact tests were used for comparisons of two groups, and Kruskal–Wallis or Fisher's exact tests were used for comparisons of three groups. Dichotomous variables were created for continuous variables by using the medians to categorize values as high or low. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the normal BMI group as the reference category. Statistical analysis was performed using PASW Statistics 18 (SPSS Inc., Chicago, IL).

Results

This was a retrospective study involving a total of 188 cases (124 LH and 64 LAVH). Two LAVH cases had no BMI recorded and therefore were excluded. For the 186 remaining patients the mean BMI was 28.4±4.86 (range 17.5–43.7). Based on their BMI, 62 (33.3%) were classified as obese, 77 (41.4%) were classified as overweight, and 47 (25.3%) were classified as normal. The mean BMI of the obese group was 33.9±3.34 (range 30–43.7), the mean BMI of the overweight group was 27.4±1.48 (range 25–29.9) and the mean BMI of the normal group was 22.8±1.54 (range 17.5–24.9).

The indications for surgery included heavy menstrual bleeding (resistant to the Mirena Intrauterine System® [Bayer, Berkshire, United Kingdom/Endometrial Ablation) and fibroid growths (66%), chronic pelvic pain (18%), and other indications (16%) when there were combined clinical indications; for example, menstrual dysfunction with complex benign ovarian cysts, premalignant cervical or endometrial lesions, endometriomas, or BRCA carrier status with a strong family history of genital malignancy.

Of the study population, 10 were nulliparous when the hysterectomies were completed laparoscopically except for 1 postmenopausal patient who needed conversion to an open procedure because of a large ovarian cyst.

The overall rate of major complications was 11.3% (21/186) with conversion to open surgery being the most common (17/186; 9.1%). The majority of conversions to open surgery were for intraoperative bleeding or excessive adhesions. There were no cases of bowel or ureter injury, postoperative vaginal vault cuff dehiscence, or hospital readmission within 6 weeks. There were 4 (2.2%) women with bladder injury. Of the 4 women, 2 were in the obese, 1 was in the overweight, and 1 was in the normal group. Of those 4 women, 3 had had previous surgery in the form of multiple cesarean sections and open myomectomy. One woman had had no previous surgery. One bladder injury was repaired laparoscopically by intracorporeal sutures, whereas 2 patients needed laparotomy to repair the bladders and complete the hysterectomies. One patient needed a laparotomy 2 days later for signs of intraperitoneal bleeding, after a failed attempt with laparoscopy to control bleeding from the infundibulopelvic pedicle, and inadvertent bladder injury occurring during the laparotomy. There were 5 (2.7%) women who needed blood transfusions; 3 of the women were overweight and 2 were obese.

The categories of BMI were treated as ordered (i.e., looking for a trend across categories) and unordered (i.e., looking for any differences among categories). Table 1 shows that there was no significant difference between the normal and the combined (overweight and obese) groups in terms of age, parity, uterine length, or specimen weight. Similarly, when the overweight group and the obese group were independently compared with the normal BMI group, there was no significant difference in any of those variables.

Table 1.

Comparisons Between the Different BMI Categories and the Normal BMI Group

Variable	Normal BMI (n=47) median (lower-upper quartile)	Combined overweight+obese (n=139) median (lower-upper quartile)	p	Overweight (n=77) median (lower-upper quartile)	Obese (n=62) median (lower-upper quartile)	p
Age	45 (40–49)	45 (41–49)	NS	45 (41–49)	45 (41–50)	NS
Parity	2 (2–3)	2 (2–3)	NS	2 (2–3)	2 (2–3)	NS
Uterine length (cm)	10.0 (8.5–10.5)	9.5 (8.0–11.0)	NS	9.0 (8.0–11.0)	10.0 (8.9–11.0)	NS
Specimen weight (g)	150 (100–208)	149 (108–230)	NS	138 (99–207)	162 (118–261)	NS

BMI, body mass index; NS, not significant.

Table 2 shows the main study outcomes analyzed across the different BMI categories. There were no significant differences in any of the main study outcomes comparing the normal BMI group and the combined (overweight+obese) group or the overweight/obese groups independently. The only significant result found was in the duration of surgery (“total minutes”), which was significantly longer for the obese category than for the overweight category (p=0.015).

Table 2.

Comparison of Outcome of Operations in Normal BMI and Overweight/Obese Groups

Variable	Normal BMI (n=47) median (lower-upper quartile)	Combined overweight+obese (n=139) median (lower-upper quartile)	p	Overweight (n=77) median (lower-upper quartile)	Obese (n=62) median (lower-upper quartile)	p
Total minutes	112 (90–133)	112 (88–130)	NS	108 (85–120)	120 (95–150)	0.015^*
Hb drop	1.8 (1.1–2.6)	1.9 (1.3–2.5)	NS	1.9 (1.3–2.5)	1.8 (1.4–2.6)	NS
Length of hospital stay	2 (1–3)	2 (1–2)	NS	2 (1–2)	2 (1–3)	NS
Complications	7 (15%)	14 (10%)	NS	5 (6%)	9 (15%)	NS
Conversion to open surgery	5 (11%)	12 (9%)	NS	4 (5%)	8 (13%)	NS

BMI, body mass index; Hb, hemoglobin, NS, not significant.

Significant.

Table 3 shows the ORs with 95% CI for the main study outcomes according to the BMI categories. In the obese category, the ORs do not show that there are higher odds of hemoglobin drop >1.8 g/dL, long hospital stay, complications, or conversion to open surgery. The ORs for these outcomes in the obese group are close to 1, indicating that obesity does not appear to affect the odds of those study outcomes. Even though the OR for operative time of >112 minutes in the obese group is 1.445, the 95% CI is considerably wide, and spans the null value.

Table 3.

Odds Ratio (95% Confidence Intervals) in the Combined Group or the Other Individual BMI Categories Compared with the Reference Group (Normal BMI)

Variable	Combined overweight+obese (n=139)	p	Overweight (n=77)	p	Obese (n=62)	p
Total minutes >112	1.029 (0.531–1.993)	NS	0.783 (0.378–1.622)	NS	1.445 (0.674–3.097)	NS
Hb drop >1.8	1.077 (0.548–2.117)	NS	1.135 (0.540–2.387)	NS	1.012 (0.468–2.186)	NS
Length of hospital stay >1 day	1.319 (0.672–2.587)	NS	1.453 (0.689–3.066)	NS	1.173 (0.542–2.537)	NS
Complications	0.640 (0.241–1.696)	NS	0.397 (0.118–1.332)	NS	0.970 (0.333–2.828)	NS
Conversion to open surgery	0.794 (0.264–2.385)	NS	0.460 (0.117–1.809)	NS	1.244 (0.379–4.082)	NS

BMI, body mass index; Hb, hemoglobin; NS, not significant.

When the obese group was compared with a nonobese group (comprised of normal and overweight groups BMIs pooled together), the operative time was significantly longer (p=0.009) in the obese group, but no significant difference was found for hemoglobin drop (p=0.72), surgical complications (p=0.33), length of hospital stay (p=0.54), or conversion to open surgery (p=0.28).

Discussion

Conventionally, it has always been believed that obesity increases the risk of operative complications after most elective operations.⁶ The findings in this study suggest that compared with the combined group (overweight+obese) or compared with the overweight and normal BMI groups independently, obesity does not significantly increase the duration of surgery, risk of complications, conversions rates, intraoperative blood loss, or length of hospital stay. The duration of surgery was only significantly longer for the obese than for the overweight category, (p=0.015). Similar findings were seen by Bonilla et al.,⁷ who found no significant differences in intraoperative and postoperative complication rates of obese patients undergoing total LH. Also, Kondo et al.⁸ retrospectively compared 2088 nonobese women with 183 obese women undergoing total LH and found that obesity does not have an adverse effect on the feasibility and safety of LH when performed by experienced personnel. When comparing the two groups, these researchers also found that there was no difference in the operative time (121.3 versus 122.5 minutes; p=0.71), in pre- and postoperative hemoglobin levels (1.8 versus 1.6 g/dL; p=0.28), and in conversion rate (4.6% versus 5.5%; p=0.62). The overall intraoperative complication rate was 14.03% (n=293) and 13.66% (n=25) for nonobese and obese patients (p=0.89), respectively. In the current study, this facility's conversion rate and complication rate for the obese group were 13% and 15%, respectively. The operative times in this study were similar to those reported in Kondo's study, and no significant differences in any of the main outcomes (complication rates, conversion rates, hemoglobin drop, or hospital stay) were seen between the BMI categories.

Other studies have also shown that obesity does not affect outcomes adversely after LH. Holub et al.⁹ showed that the risk of intra- and postoperative complications was not increased in obese women undergoing LH, but the operative time was longer by 15 minutes. This was a prospective study involving 54 obese and 217 nonobese patients. LH was completed successfully in 98.89% of cases, compared with 91% of the total population and 87% of the obese patients in the current study reported in this article. Similar to the current study, Holub found no significant difference in estimated blood loss, length of hospital stay, and postoperative complications between women with high BMIs and those with low BMIs. The rate of major complications (5.55% versus 3.22%) was higher, and the duration of the operation was longer in obese women; however, the significance was only borderline (p=0.06). Similarly, Heinberg et al.¹⁰ studied 270 patients, of whom 106 (39.3%) were obese women. Procedures were completed in 253 cases (93.7%), LAVH was used in 7 cases (2.6%), and total abdominal hysterectomy was used in 10 cases (3.7%). Neither the twofold risk of conversion to LAVH (relative risk [RR]: 2.2; 95% confidence interval [CI]: 0.5, 10.1) nor the fourfold risk of conversion to abdominal hysterectomy (RR: 3.9; 95% CI: 1.0, 15.4) associated with obesity was statistically significant. Total LH for obese patients was 60% more likely to require at least 2 hours to complete (RR 1.6; 95% CI 1.2, 2.0) and was associated with a threefold risk of blood loss >500 mL, compared with nonobese patients. Risks of major and minor complications, hospital readmission, and repeat operations were similar for both groups. The researchers concluded that complication rates for total LH in obese patients were similar to those for nonobese patients.

Chopin et al.¹¹ showed in their retrospective/prospective cohort study (1460 patients) that, provided that personnel have adequate experience, intra- and postoperative complications are not increased in obese women undergoing total LH. The operative time was, however, significantly longer in the obese patients than those who were nonobese. The researchers showed that obese patients experienced more hemorrhage, but with a value quite close to statistical significance (p=0.03), and that the rate of transfusion was not significant. The researchers, therefore, concluded that the rate of intraoperative hemorrhage was probably higher. The hospital stay was also significantly longer (p=0.004) in the obese group than in the nonobese group. The current study found that, compared with the normal BMI or the overweight group, neither the duration of the operation nor the hospital stay was significantly greater for the obese women. A possible explanation for this is that the sample population in the Chopin study was considerably larger than the study reported here. The reason for the lower number of cases in this study is that, in this unit, most of the hysterectomies are still performed by the abdominal and not the laparoscopic route, despite the recognized benefits of the latter approach. Barriers to wider implementation of LH were described by Cohen et al. in 2011,¹² and include perceived technological difficulties; inadequate training; potential for decreased reimbursement; and misconceptions about laparoscopic safety, cost, technical feasibility, and operating theater time, theater allocation, and theater team support.

Other researchers have also shown that operative time increases in obese women undergoing total LH. Morgan-Ortiz et al.¹³ found that the mean duration of total LH (p<0.001) and operative bleeding (p=0.002) were lower for patients with normal BMI than in overweight and obese groups. The rate of conversion to laparotomy was similar among the three groups. Overall, the frequency of complications was 6.2% (n=13/209); the frequency of complications was 2.6%, 4.8%, and 14% for the normal BMI, overweight, and obese groups, respectively (p<0.05). Major complications were more frequent among patients with obesity (p=0.010). The researchers, therefore, concluded that duration of surgical procedure and operative morbidity increased, mainly because of major complications among patients with obesity. Similarly, Siedhoff et al.¹⁴ retrospectively analyzed 834 patients who underwent LH for benign indications. The mean (standard deviation [SD]) BMI was 31.4 (8.1), mean (SD) uterine weight was 345 (388) g, and the mean operative time was 150 (61) minutes. The authors found that increasing BMI was associated with a longer operative time (p=0.03), total operating room time (p<0.01), greater blood loss (p<0.01), and complication severity (p=0.01). The researchers, therefore, suggested that there was a significant association of BMI with surgical outcomes in LH, and that the effect was most pronounced in morbidly obese patients. The current study also showed that, when the obese group was compared with the nonobese group (normal and overweight BMI pooled together), the operative time was significantly longer (p=0.009) in the obese group, but that no significant difference occurred with respect to any of the other surgical outcomes.

In the present study there was no significant difference in preoperative versus postoperative hemoglobin drop among the three BMI categories, indicating that higher BMI women undergoing LH were not at an increased risk of blood loss. There were only 5 (2.7%) patients who needed blood transfusion. Three were in the overweight category. Two patients were in the obese category, 1 of whom needed a laparotomy because of extensive bowel adhesions requiring surgical intervention. The other patient had a 457-g uterus, which was removed successfully by LH. Furthermore, in the present study, there were 17 (9.1%) patients who had conversions to open surgery, 8 (4.3%) of whom were in the obese category. None of those conversions were attributed to technical difficulties caused by the high BMI. Of those 8 conversions in the obese group, 2 were for extensive bowel adhesions necessitating surgical intervention, 2 were for repair of bladder injury (in 1 patient who had had two previous cesarean sections and in 1 patient who had had an open myomectomy), 2 for an 866-g uterus and another for a 16–18 week uterus, 1 for intraoperative bleeding, and 1 for a snapped intraperitoneal drain, to facilitate its retrieval. On the contrary, Shen et al.¹⁵ retrospectively studied 670 women having LAVH (162 with BMIs>25, 34 with BMIs<18.5, and 474 with BMIs 18.5–25). For women with high BMIs, 34 procedures (21.0%) were converted to laparotomy, compared with 48 (10.1%) for women of normal body weight and 3 (8.8%) for those with low BMI (p=0.001). Average blood loss was 299.3±87.8, 219.1±57.5, and 231.8±65.9 mL, respectively (p<0.001). The researchers concluded that obese women had increased likelihood of conversion to laparotomy and greater blood loss after LAVH than did nonobese women.

There were, however, limitations to this study. The first limitation was the study's retrospective nature, with its potential for errors caused by confounding and bias, as well as the inability to control outcome assessment because of reliance on other personnel for accurate record keeping and clinical coding. The second limitation was the width of the 95% CI, which is used to estimate the precision of the OR. It is known that a wide CI implies poor precision of the OR, most likely because of an inadequate sample size. Furthermore, the fact that the CI spans the null value (1) cannot be used as evidence of the lack of association between obesity and the main study outcomes. This would have led to the conclusion that any observations that can be drawn from the data need to be replicated with a larger sample size. Given the rarity of complications noted here, it is possible that, with larger numbers of patients, significant differences would have been found among the different BMI categories.

Conclusions

Despite the the abovementioned limitations, it would seem that this study adds to the evidence provided from other studies that suggests that LH does not increase the risk of complications or conversion rates in obese women, compared to patients in other BMI categories. Operative time, however, would seem to be longer in obese patients undergoing this procedure, and this should be discussed in preoperative counseling. The authors of this study are currently undertaking a prospective trial on a larger number of patients undergoing this procedure to validate those results.

Footnotes

Disclosure Statement

No competing financial interests exist.

References

World Health Organization (WHO). Obesity: Preventing and Managing the Global Epidemic. Report of a WHO Consultation: WHO Technical Report Series 894. Geneva: WHO, 2000. http://whqlibdoc.who.int/trs/WHO_TRS_894.pdf. 2013 June 21.

Watson

, Hughes

, Kammerling

. Office for National Statistics (ONS). 2010. SEPHO South East Public Health Observatory. Cardiovascular Disease: PCT Health Profile. Dudley. www.sepho.org.uk/NationalCVD/docs/5PE_CVD%20Profile.pdf. 2012 December 24.

Nieboer

, Johnson

, Lethaby

, Tavender

, Curr

, Garry

, van Voorst

et al. Surgical Approach to Hysterectomy for Benign Gynaecological Disease. http://summaries.cochrane.org/CD003677/surgical-approach-to-hysterectomy-for-benign-gynaecological-diseases. 2012 December 24.

Korenkof

, Sauerland

. Clinical update: Bariatric surgery. Lancet, 2007; 370:1988.

Gilmore

. Body mass index and health. Health Rep, 1999; 11:31.

Choban

, Flancbaum

. The impact of obesity on surgical outcomes: A review. J Am Coll Surg, 1997; 185:593.

Bonilla

, Mains

, Rice

, Crawford

. Total Laparoscopic hysterectomy: Our 5-year experience (1998–2002) Oschner J, 2010; 10:8.

Kondo

, Bourdel

, Marengo

et al.

What's the impact of the obesity on the safety of laparoscopic hysterectomy techniques?

J Laparoendosc Adv Surg Tech A, 2012; 22:949.

Holub

, Jabor

, Kliment

, Fischlová

, Wágnerová

. Laparoscopic hysterectomy in obese women: A clinical prospective study. Eur J Obstet Gynecol Reprod Biol, 2001; 98:77.

10.

Heinberg

, Crawford

3rd , Weitzen

, Bonilla

. Total laparoscopic hysterectomy in obese versus nonobese patients. Obstet Gynecol, 2004; 103:674.

11.

Chopin

, Malaret

, Lafay-Pillet

M-C

, Fotso

, Foulot

, Chapron

. Total laparoscopic hysterectomy for benign uterine pathologies: Obesity does not increase the risk of complications. Hum Reprod, 2009; 24:3057.

12.

Cohen

, Einarsson

. Total and supracervical hysterectomy. Obstet Gynecol Clin North Am, 2011; 38:651.

13.

Morgan-Ortiz

, Soto-Pineda

, López-Zepeda

, Peraza-Garay

. Effect of body mass index on clinical outcomes of patients undergoing total laparoscopic hysterectomy. Int J Gynaecol Obstet, 2013; 120:61.

14.

Siedhoff

, Carey

, Findley

, Riggins

, Garrett

, Steege

. Effect of extreme obesity on outcomes in laparoscopic hysterectomy. J Minim Invasive Gynecol, 2012; 19:701.

15.

Shen

C-C

, Hsu

T-Y

, Huang

F-J

et al. Laparoscopic assisted vaginal hysterectomy in women of all weights and the effects of weight on complications. J Am Assoc Gynecol Laparosc, 2002; 9:468.