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Risks and remedies when your surgical patient is obese

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How to plan and safely manage surgery—and ensure that the patient’s expectations are realistic


 

References

The authors report no financial relationships relevant to this article.

The adverse consequences of obesity go far beyond aesthetic and psychosocial concerns. Patients who are markedly overweight face a real risk of developing severe health conditions—not just cardiac disease, diabetes mellitus, and hypertension, but also sleep apnea, venous thromboembolism, certain cancers (particularly breast and uterine), and biliary tract disease. Obesity also contributes to menstrual abnormalities and infertility and may complicate pregnancy.

Surgery in these patients poses a number of challenges. Not only does obesity frequently compromise the technical aspects of a procedure, it requires the surgeon to use certain measures in the preoperative and postoperative phases of management, such as counseling the patient extensively about the risks and potential complications she faces, initiating antibiotic prophylaxis, and ensuring early ambulation. These and other measures are especially important when uncontrolled, coexisting disease is present.

Not every obese patient is a significant surgical risk, so care should be individualized and use a team approach involving the gynecologist, anesthesiologist, primary care physician, and other appropriate subspecialists.

This article outlines the parameters of good surgical care in the obese patient, defined here as having a body mass index (BMI) of 30 kg/m2 or above, or 35 kg/m2 or above for morbid obesity. Whenever possible, we draw our recommendations from the published literature. In the absence of data, we base them on our surgical experience in the obese population.

Risks of surgery

It is imperative for the gynecologic surgeon to discuss the special risks of surgery with the obese patient well in advance of the operation and to formulate a systematic plan for evaluation, utilizing other members of the team when necessary. If the surgeon keeps the following risks in mind and is proactive, complications can be kept to a minimum.

Poor wound healing

Wound healing is a complex process involving several concurrent phases; an abnormality in any phase may impair healing. Those phases are:

  • inflammatory phase, in which fluid and cells are released to clean the wound and prepare for the next phase of healing
  • fibroplastic (proliferative) phase, in which fibroblasts accumulate and form collagen, the building block of connective tissue. This stage is marked by neovascularization and increased formation of granulation tissue
  • wound contraction
  • remodeling/maturation, in which new collagen is laid down as old collagen is broken down, resulting in scar formation.

Preparing for surgery in the obese patient: 10 preoperative steps
  1. Obtain a chemistry panel: complete blood count, prothrombin time, activated partial thromboplastin time, and arterial blood gas studies. Type and cross-match if significant blood loss is expected
  2. Order a chest radiograph and electrocardiogram
  3. Test pulmonary function only if the patient has a history or suspected history of obstructive lung disease
  4. Order echocardiography only if the electrocardiogram or history suggests compromised cardiac function
  5. Instruct the patient on the use of incentive spirometry
  6. Prescribe a mechanical bowel-cleansing regimen if inadvertent injury is likely
  7. Notify anesthesiology and operating room personnel before the patient’s arrival
  8. Give 1 g of cefoxitin or another cephalosporin 60 minutes before the start of the procedure3
  9. Give 5,000 U of subcutaneous unfractionated heparin at least 2 hours before the start of surgery, and administer it every 8 hours until discharge.6 Alternative regimens: 5,000 U of dalteparin, a low-molecular-weight heparin, 12 hours before beginning the procedure and every 12 hours until discharge, or 40 mg of enoxaparin 12 hours before beginning surgery and every 12 hours until discharge
  10. Apply a pneumatic calf-compression apparatus in the operating room

Obese patients possess a thick layer of adipose tissue, which by its nature and location is minimally vascularized. This tissue essentially becomes dead space, an ideal medium for bacterial growth. Many obese patients also have diabetes mellitus, malignancy, or other comorbidity that further impairs healing.

As a result, obese patients are at increased risk of wound complications, breakdown, and subsequent dehiscence and evisceration. This translates into increased febrile morbidity, prolonged hospitalization, and higher cost.

What the data show. A number of studies have documented a higher incidence of wound complications in obese patients. In one retrospective review, Gallup1 observed an increased risk of wound complications in obese patients, but the incidence diminished after implementation of a protocol of meticulous cleansing, subcutaneous heparin, and modified incision and closure techniques. In a similar retrospective study of 300 obese patients, Pitkin2 reported wound complications among approximately one third of patients and postoperative fever among more than three quarters. Surgical-site infections are thought to occur in as many as 5% of patients.

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