Obesity is a major surgical obstacle. Obesity not only decreases access to the surgical field but also alters the anatomical relationships between the abdominal wall and the abdomen. The surgeon must understand not only anatomy in normal-weight women but also how obesity alters normal anatomy. Obesity affects the choice of incisions, size of incisions, closure of incisions, and choice of instruments (retractors, long instruments, etc.). Obesity affects these decisions about open surgery and minimally invasive surgery (MIS).
Before booking a case surgeons, must evaluate their own surgical skills, their hospital’s operating room, and the other specialists needed to care for the patient (Table 33-1). The skill and experience of the surgeon are paramount. If experienced in the needed operation, it may only be necessary to ask a more experienced surgeon who has dealt with obesity in the operation to assist. If the surgeon is relatively inexperienced, it may be prudent to refer the patient to a more experienced surgeon and serve as assistant at the operation if possible. The surgeon must be certain that the equipment needed is available, which may mean a wide operating table designed for obese patients, long instruments, proper retractors, and so on. Obesity is a significant problem for the anesthesiologist, and the surgeon must be certain that the anesthesiologist is comfortable with the anesthetic challenges posed by obese patients (see Chapter 25). Experienced assistants are important in an operation in which obesity is a significant problem. A preoperative conference with the operating room personnel, the anesthesiologist, and the assistants can be helpful in performing the operation safely.
TABLE 33-1Optimizing Outcome ||Download (.pdf) TABLE 33-1 Optimizing Outcome
|Resources || |
Skill/experience of surgeon
|Plan the operation || |
Route (vaginal, abdominal, minimally invasive)
Antibiotics, blood, VTE prophylaxis
|Postoperative care || |
GENERAL NEEDS OF OBESE PATIENTS REQUIRING SURGERY
Obese women may have important comorbidities. Primary care physicians and other subspecialists need to be aware of the upcoming surgery to advise the appropriate preoperative evaluation and treatment of medical problems. Routine preoperative clearance by the patient’s medical physician will identify problems and allow optimization of care for these diseases prior to surgery. This is especially true in patients with diabetes, hypertension, vascular disease, heart disease, and asthma. Nutritional assessment and recommendations should be addressed as many obese patients may have significant nutritional deficiencies.
Preoperative anesthesia evaluation is crucial. The anesthesiologist will evaluate the airway, plan for a difficult intubation, and evaluate medical problems of special importance to safe anesthetic care and identify any further preoperative workup that will be needed. Also, during this preoperative visit the anesthesiologist will have the opportunity to discuss these issues with the patient.