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3/1/2018

Surgery in Morbidly Obese Patients

Surgical complications such as infection, venous thromboembolism (VTE), and wound complications are a major source of morbidity in obese women, but may be reduced with attention to preoperative, intraoperative and postoperative factors.  Providers should be aware of the possibility to harbor implicit bias towards patients with obesity, work to identify any personal implicit bias, and address any identified biases to ensure it does not interfere with delivery of respectful care for patients with obesity.

Preoperative preparation for obese patients requires attention to health conditions more common with obesity, including coronary artery disease (CAD), hypertension, diabetes mellitus, and obstructive sleep apnea (OSA).  Anesthesiologist consultation is appropriate when these conditions are suspected. A physical exam revealing a short, thick neck with limited range of motion can be indicative of a difficult intubation. Women with risk factors for CAD (hypertension, diabetes, smoking, family history of CAD) should have a 12-lead electrocardiogram performed.  Pre- and post-operative glycemic control improves outcomes in patients with diabetes. Women with OSA are at increased risk for perioperative complications, such as oxygen desaturation, acute respiratory failure, post-operative cardiac events, and intensive care unit admission.  As in normal weight women, surgery should be performed utilizing the least invasive approach.

Perioperative management focuses on minimizing complications such as thromboembolism and infection.  Obesity is an independent risk factor for venous thromboembolism (VTE).  Sequential compression devices (SCDs), low molecular weight (LMW) heparin, and low-dose unfractionated heparin (UFH) are options for VTE prevention. The preferred method of prophylaxis is based on stratification by procedure type and duration, age, and presence of other VTE risk factors.  Mechanical prophylaxis (SCDs) or pharmacologic methods alone are appropriate in obese patients that are moderate risk, while a combination should be used in patients at high risk.  LMW heparin is preferred; however UFH is a suitable alternative in patients who have a contraindication to LMW heparin or where cost is a concern. Due to decreased tissue antibiotic concentrations, 2 grams of prophylactic cefazolin is recommended in patients over 80 kg, or 3 grams in patients over 120 kg.

Obese patients are at increased risk for soft-tissue pressure injuries and nerve injuries.  For laparoscopy, safe patient positioning includes careful padding, tucking arms with extenders if needed, and using anti-skid material on the bed.  Steep Trendelenburg must be used with caution as the increased weight of the abdominal contents can inhibit adequate ventilation. Long trocars and specialized instruments are often needed to navigate the increased abdominal wall depth. Caudal migration of the umbilicus necessitates consideration of alternate entry points for laparoscopic procedures such as the left upper quadrant.  The use of self-retaining and other specialized retractors can aid in exposure during vaginal and abdominal surgery.  The panniculus can distort abdominal skin tissue at laparotomy.  Incisions should be avoided within the overlapping fold of the panniculus because of increased risk of infection and poor wound healing.  It is also imperative to have an operating bed that can support the patient’s weight. 

Post-operatively, risk-reducing strategies include early ambulation, incentive spirometry, and consideration of extended VTE prophylaxis. Treatment with low molecular weight heparin for two to four weeks post-operatively is recommended for cancer patients and those with comorbid conditions such as immobility, history of VTE, inherited or acquired thrombophilia, or age > 60 years. Patients with OSA should not be discharged until baseline oxygen saturation is achieved on room air. 

 

Further Reading:

 

American College of Obstetricians and Gynecologists – Committee on Practice Bulletins – Gynecology; ACOG Practice Bulletin No. 232. Prevention of Venous Thromboembolism in Gynecologic Surgery. Prevention of Venous Thromboembolism in Gynecologic Surgery | ACOG

Committee on Gynecologic Practice. Committee opinion no. 619: Gynecologic surgery in the obese woman. Obstet Gynecol. 2015 Jan;125(1):274-8. doi: 10.1097/01.AOG.0000459870.06491.71.

Schorge JO. Minimally Invasive Surgery in Morbidly Obese Women. Obstet Gynecol. 2020 Jan;135(1):199-210. doi: 10.1097/AOG.0000000000003588. PMID: 31809420.

ACOG Committee Opinion No. 763: Ethical Considerations for the Care of Patients With Obesity. Obstet Gynecol. 2019 Jan;133(1):e90-e96. doi: 10.1097/AOG.0000000000003015. PMID: 30575680.

Initial Approval March 2018; Revised September 2019; Revised May 2021; Minor revision November 2022

 

 

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