Obese Women Have Unique Surgical Risks
December 30, 2014. Gynecologic surgeons should be familiar with the specific risks that obese women face, such as surgical site infection, venous thromboembolism, and wound complications, so as to counsel them about their individual risks before surgery, according to a committee opinion by the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice.
The opinion, published in the January 2015 issue of Obstetrics & Gynecology, also indicates that for obese women, as for women of normal weight, better outcomes and fewer complications are associated with vaginal hysterectomy compared with laparoscopic or abdominal hysterectomy.
According to the Centers for Disease Control and Prevention, 34.9% of US adults, or 78.6 million people, are obese. The opinion authors define three classes of obesity, with class 1 obesity applying to people whose body mass index (BMI) falls between 30 to less than 35 kg/m2. People whose BMI is from 35 to less than 40 kg/m2 fall under the class 2 obesity definition; class 3 obesity is defined as a BMI higher than 40 kg/m2.
“Adverse effects after gynecologic surgery such as surgical site infection (with a BMI greater than 35), venous thromboembolism (with a BMI equal to or greater than 35), and wound complications (10 times more likely with a BMI of 40–49 compared with normal-weight patients) are more prevalent in obese women than in normal-weight women,” the authors write.
Although obese people are at higher risk of dying and suffering from such chronic ailments as hypertension, diabetes, and obstructive sleep apnea, paradoxically, morbidity and mortality among obese patients who do not have metabolic complications are lower than for normal weight patients, the authors write. Obese patients with hypertension and diabetes, however, are at heightened risk for perioperative morbidity and mortality when compared with patients who are not overweight, defined as having a BMI of 8.5 to 24.9 kg/m2.
Vaginal hysterectomy, in general, is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomy, the authors write. For obese women who are not good candidates for vaginal hysterectomy, laparoscopic hysterectomy can be more complicated but may result in less blood loss and a shorter hospital stay; the procedure also is associated with higher quality of life 4 years after surgery compared with laparotomy.
“Every effort should be made to offer all patients, regardless of BMI, the least invasive procedure in order to decrease complications, length of hospital stay, and postoperative recovery time,” the authors note.
In addition, the authors suggest considering a presurgical consultation with an anesthesiologist for obese patients suspected of having obstructive sleep apnea, which can be associated with postsurgical complications, such as pneumonia or hypoxemia, or for patients who are at risk for coronary artery disease.
Additional precautions need to be taken for certain obese patients undergoing surgery lasting more than 45 minutes, such as prescribing low-molecular-weight heparin, because of moderate risk for venous thromboembolism. Because obese patients have more subcutaneous tissue, abdominal hysterectomies may take longer to perform and more than one skin preparation kit may be needed. In addition, two operating tables may need to be joined to accommodate the patient’s weight and girth, with sufficient belts and gel pads to limit the patient’s movement.
After surgery, hypoxemia, which occurs more often in obese patients, can be managed through aggressive incentive spirometry or continuous positive airway pressure. Wound complications and surgical site infections, however, are the most common postsurgical complication for obese patients who have undergone abdominal hysterectomy; subcutaneous placement of sutures, talc application, and wound vacuums have been associated with reduced complications. Preoperative or intraoperative nonsteroidal anti-inflammatories appear to work better than acetaminophen to reduce nausea and vomiting and decrease postoperative opiod use.
Obstet Gynecol. 2015;125:274-287. Full text