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Surgery in Morbidly Obese Patients

9/1/2014 - Philip J. DiSaia, MD

Editor:  Roger P. Smith, MD

REVISED PEARL - January 2015

The prevalence of obesity in the United States is climbing at an alarming rate.  There are a number of special considerations and challenges in managing the morbidly obese patient.  The use of laparoscopic or robotic approaches for these patients has become more common and is the primary approach by many surgeons.  However, minimally invasive procedures can be technically difficult or not feasible in morbidly obese patients.  

There are many complications that are increased in morbidly obese patients:  wound infection, adhesion formation, thromboembolism, and anesthetic.  Several techniques have been helpful for minimizing these risks.

When performing a laparotomy, the location of the incision should be determined with the patient in the standing position.  A periumbilical incision (higher than the usual midline incision) is often preferable as the panniculus can be reflected downward toward the toes of the patient, leaving the thinner periumbilical area for the incision.  This also allows better visualization of the pelvis.  Wound complications can be reduced by leaving a minimum amount of fulgurated material in the subcutaneous fat layer.  The use of a Bookwalter retractor, with the post moved lower on the table than usual, aids visualization.  Long instruments are essential, as is good lighting.  Many surgeons use a headlamp or a sterile fiber-optic light source.  

Following completion of the intra-abdominal surgery, the incision should be closed with a mass closure technique such as the running Smead-Jones closure using a loop of delayed absorbable suture.  The optimal wound closure technique is controversial.  Drains and closure of the subcutaneous dead space with rapidly absorbable suture are used by some providers.  Prophylactic antibiotics are important to reduce the risk of wound complications.

As with all surgical procedures, the tissues should be handled with the utmost care, and sharp dissection is preferable to blunt dissection and excessive use of cautery.

Revised 1/2015; Reaffirmed 7/2016


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