Surgery in Morbidly Obese Patients
3/1/2018 - Bani M. Ratan, MD
Mentor: Sireesha Reddy, MD
Editor: Ches Thompson, MD
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). Anesthesia 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, especially those 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, patients should be counseled to have surgery performed through 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 with 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 such as renal insufficiency, or where cost is a concern. Because of decreased tissue antibiotic concentrations, two grams of prophylactic cefazolin is recommended in patients over 80 kg, with an increase to 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, arms tucked with extenders if needed, and use of 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. Because of caudal migration of the umbilicus, different points of entry should be considered, such as the right upper quadrant. Endoscopic techniques should be employed to adequately close the fascia. During vaginal surgery, Breisky-Navratil retractors can assist with visualization. The panniculus can distort abdominal skin tissue at laparotomy. Incisions should be avoided within the overlapping fold of the panniculus because of increased infection and poorer wound healing. The use of self-retaining retractors can aid in exposure.
Post-operatively, risk-reducing strategies include early ambulation, incentive spirometry, and consideration of extended VTE prophylaxis. Treatment with low molecular weight heparin for 2-4 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.
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. (Reaffirmed 2017)
Rahn DD, Mamik MM, Sanses TV et al. Venous thromboembolism prophylaxis in gynecologic surgery: a systematic review. Obstet Gynecol. 2011 Nov;118(5):1111-25. doi: 10.1097/AOG.0b013e318232a394.
Scheib SA, Tanner E, Green IC, Fader AN. Laparoscopy in the morbidly obese: physiologic considerations and surgical techniques to optimize success. J Minim Invasive Gynecol. 2014 Mar-Apr;21(2):182-95. doi: 10.1016/j.jmig.2013.09.009. Epub 2013 Oct 4.
Initial Approval March 2018 (replaces 2015 Pearl)
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