What the data show. Several studies have addressed these issues, including one by Pratt and Daikoku18 and another by Rafii and colleagues,19 both of which demonstrated that obese patients have a complication rate roughly equivalent to that observed in patients of normal weight, although obese patients have a greater decrease in hemoglobin level and a slightly higher incidence of postoperative fever.
Similarly, in a retrospective study, Pitkin20 found no significant difference between the complication rates of obese and nonobese patients.
Another argument for the self-retaining retractor. From a technical standpoint, achieving good exposure is the primary challenge of vaginal surgery and usually requires two or more assistants—who themselves have limited or no direct view of the field—who must stand for long periods. Again, a viable alternative is use of a self-retaining retractor. One in particular, the MiniOmni retractor, is a small, uncumbersome, table-fixed system that can be maneuvered so that vaginal and perineal structures are readily accessible.
Choice of stirrups is also relevant. Exposure can be affected by the type of stirrups used. “Candy cane” stirrups facilitate exposure more than fixed stirrups (eg, Allen stirrups) do. Regardless of the stirrups selected, however, it is important to avoid excessive or prolonged hip flexion, or nerve injury may result.
How to minimize postoperative complications
After surgery, an obese patient requires close and continuous monitoring to avert complications and detect any that occur. Consider the following measures:
- A stint in the intensive care unit. In the morbidly obese patient, massive fluid shift (eg, extensive blood loss, prolonged surgery with losses from the peritoneum, etc.) or concern about sleep apnea may justify close monitoring in an intensive care unit or similar setting—at least briefly. Later, as the patient recovers, sleep studies may indicate whether apnea is present.
- Document fluid intake and output, especially in the elderly and in women with cardiorespiratory disease.
- Give analgesics in an amount sufficient to control pain and minimize activity that might place excessive tension on the abdominal incision, but also allows the patient to remain alert enough to ambulate effectively and perform pulmonary toileting.
- Begin ambulation on the first postoperative day—or on the evening after surgery, if circumstances permit. This helps clear secretions from the respiratory tract, reduces the risk of thromboembolism, and speeds the return of normal bowel function. Hourly incentive spirometry is also recommended for the first few days after surgery.
- Continue heparin. In patients at moderate or high risk of thromboembolism, continue low-dose heparin until discharge or for 7 days, whichever comes first.
- Keep other physicians involved. If the patient has a significant comorbidity, such as cardiorespiratory disease or uncontrolled diabetes, she should remain under the care of her internist or other primary care provider.
- Closely monitor the surgical wound for early signs of infection, which include inflammation and collections of serous fluid, blood, pus, or a mixture of these. If retention sutures were placed, check them frequently to ensure that they are not cutting into the skin of the abdomen.
- Strongly recommend weight loss. At the time of the last postoperative visit, tell the patient in clear language that obesity is extremely bad for her health and strongly encourage her to lose weight under the supervision of her primary care provider. If she has no such provider, make the appropriate referral.