Anesthetic management for patients with morbid obesity undergoing robot-assisted gynecological surgery: pathophysiology, risks, and contemporary approaches (a narrative review)

Abstract

The prevalence of morbid obesity (BMI ≥40 kg/m²) among women of reproductive age is increasing, leading to a growing need for surgical treatment of gynecologic pathology. Robot-assisted procedures expand the possibilities of minimally invasive surgery but create specific anesthetic challenges: the need for pneumoperitoneum and steep Trendelenburg position exacerbates obesity-related respiratory impairment. This review systematizes current data on perioperative management of patients with morbid obesity undergoing robot-assisted gynecologic surgery, based on analysis of 57 publications from PubMed, Embase, the Cochrane Library, and eLIBRARY.RU (2000–2025). We consider pathophysiologic changes in the respiratory and cardiovascular systems, strategies for screening obstructive sleep apnea (STOP-Bang), airway management, lung-protective ventilation, and multimodal analgesia. Perioperative risks in patients receiving glucagon-like peptide-1 receptor agonists are discussed. Practical recommendations based on synthesis of the literature and the authors’ expert opinion are proposed.