News for Your Practice

Risks and remedies when your surgical patient is obese

OBG Manag. 2007 October;19(10):34-54

Richard A. Jackson, MD

James D. Perkins, MD

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

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IN THIS ARTICLE

Ten preoperative steps
Panniculectomy: Old technique with a new purpose
Selecting an incision
Postoperative concerns

References

1. Gallup DG. Modifications of celiotomy techniques to decrease morbidity in obese gynecologic patients. Am J Obstet Gynecol. 1984;150:171-178.

2. Pitkin RM. Abdominal hysterectomy in obese women. Surg Gynecol Obstet. 1976;142:532-536.

3. Antibiotic prophylaxis for gynecologic procedures. ACOG Practice Bulletin No. 74. Washington, DC: American College of Obstetricians and Gynecologists; July 2006.

4. Bookwalter JR. A new table-fixed retractor. Surg Clin North Am. 1980;60:399-405.

5. Noldus J, Graefen M, Huland H. Major postoperative complications secondary to use of the Bookwalter self-retaining retractor. Urology. 2002;60:964-967.

6. Prevention of deep vein thrombosis and pulmonary embolism. ACOG Practice Bulletin No. 21. Washington, DC: American College of Obstetricians and Gynecologists; October 2000.

7. Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg. 1994;79:1165-1177.

8. Perkins JD, Dent LL. Avoiding and repairing bowel injury in gynecologic surgery. OBG Management. 2004;16(8):15-28.

9. Cressey DM, Berthoud MC, Reilly CS. Effectiveness of continuous airway pressure to enhance preoxygenation in morbidly obese women. Anesthesia. 2001;56:670-689.

10. Jordan H, Perlow MD, Mark A, Morgan MD. Massive maternal obesity and perioperative cesarean morbidity. Am J Obstet Gynecol. 1994;170:560-565.

11. Hood DD, Dewan DN. Anesthetic and obstetric outcome in morbidly obese parturients. Anesthesiology. 1993;79:1210-1218.

12. James CF, Gibbs CP, Banner T. Postpartum perioperative risk of aspiration pneumonia. Anesthesiology. 1984;61:756-759.

13. Manchikanti L, Colliver JA, Marrero TC, Roush JR. Ranitidine and metoclopramide for prophylaxis of aspiration pneumonitis in elective surgery. Anesth Analg. 1984;63:903-910.

14. Morrow CP, Hernandez WL, Townsend DE, DiSaia PJ. Pelvic celiotomy in the obese patient. Am J Obstet Gynecol. 1977;127:335-339.

15. Montz FJ, Creasman WT, Eddy G, DiSaia PJ. Running mass closure of abdominal wounds using absorbable looped suture. J Gynecol Surg. 1991;7:107-110.

16. Ramsey PS, White AM, Guinn DA, et al. Subcutaneous tissue reapproximation, alone or in combination with drain, in obese women undergoing cesarean delivery. Obstet Gynecol. 2005;105:967-973.

17. Soisson AP, Olt G, Soper JT, Berchuck A, Rodriguez G, Clarke-Pearson DL. Prevention of superficial wound separation with subcutaneous retention sutures. Gynecol Oncol. 1993;51:330-334.

18. Pratt JH, Daikoku NH. Obesity and vaginal hysterectomy. J Reprod Med. 1990;35:945-949.

19. Rafii A, Samain E, Levardon M, Darai E, Deval B. Vaginal hysterectomy for benign disorders in obese women: a prospective study. Br J Obstet Gynaecol. 2005;111:223-227.

20. Pitkin RM. Vaginal hysterectomy in obese women. Obstet Gynecol. 1977;49:567-569.

21. Kelly HA. Excision of the fat of the abdominal wall—lipectomy. Surg Gynecol Obstet. 1910;10:229-231.

22. Wright JD, Rosenbush EJ, Powell MA, et al. Longterm outcome of women who undergo panniculectomy at the time of gynecologic surgery. Gynecol Oncol. 2006;102:86-91.

23. Hopkins MP, Shriner AM, Parker MG, Scott L. Panniculectomy at the time of gynecologic surgery in morbidly obese patients. Am J Obstet Gynecol. 2000;182:1502-1505.

Fast Track

The risk of thromboembolism remains heightened as long as 3 weeks after hospital discharge

Ask an obese surgical patient about less obvious disorders such as sleep apnea, which can have grave postoperative implications

Consider regional anesthesia when it is feasible; it can limit complications related to diminished pulmonary function

Use extra-long instruments in an extremely large patient, especially if she has a “deep” pelvis

Begin ambulation on the first postoperative day—or on the evening after surgery, if circumstances permit

If the patient has a significant comorbidity, she should remain under the care of her internist or other primary care provider

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

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
Order a chest radiograph and electrocardiogram
Test pulmonary function only if the patient has a history or suspected history of obstructive lung disease
Order echocardiography only if the electrocardiogram or history suggests compromised cardiac function
Instruct the patient on the use of incentive spirometry
Prescribe a mechanical bowel-cleansing regimen if inadvertent injury is likely
Notify anesthesiology and operating room personnel before the patient’s arrival
Give 1 g of cefoxitin or another cephalosporin 60 minutes before the start of the procedure³
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
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.