Friday, August 19, 2016

Obesity in the OR - Problems Beyond Your Wildest Dreams

Everyone is acutely aware that obesity is unhealthy and can compromise recovery from just about any illness from cancer to cardiovascular problems. Dr. Slambow frequently quipped that surgery on obese patients is like changing the spark plugs in your car engine while standing on a ladder. Some risks of obesity in the OR are subtle and not well known. Here are a few of the obscure risks.

Obesity dramatically increases the depth of that well known lint trap the umbilicus. The deeper that belly hole becomes the more area to accumulate lint, oil, and down right nasty,  foul smelling dirt. The depth of the hole not only increases the volume it can hold, it also further isolates it from oxygen in the atmosphere. Anaerobic bacteria have that characteristic foul smell that any sewer plant worker knows all too  well. Doing a surgical prep scrub on one of these deep, foul holes dislodges sludge that has probably been there since childhood. Unfortunately the patient is 38 years old. That belly button sludge has been fermenting longer than fine, aged cheese. I don't think that I will ever see Roquefort cheese in the same light after doing a prep on one of those coal mine belly buttons.

I'm not on the skinny end of the spectrum and when I required abdominal surgery one of my main fears was of those oversize instruments. My last memory before the Brevital clouded my consciousness was of those foot long pick-ups and how they would look buried in my sore belly. They looked plenty threatening from a patient's perspective and reinforced the humane practice of keeping instruments out of sight until the patient is asleep. I made a note to myself to keep that back table covered whenever the patient was awake in the OR.

 It's not those retractors that are big enough to hold the Grand Canyon open or those very long pick up forceps. Its the mindset they induce in the operative team. Surgeons and nurses see these huge instruments and then subconsciously adopt a Dr. Hulk or Nurse Bruiser mindset. Just because people are big doesn't mean their tissue is tough as nails. An obese patient's pancreas is just as friable as a beanpole patient. Bigness does not translate to toughness. A light, gentle touch benefits all surgical patients. Don't go roughly yanking on things like gall bladders and liver beds. "See with your fingers and lightly touch with your eyes." as Dr. Slambow often said.

Anesthesia personnel seemed to favor spinal anesthesia in some obese patients and after witnessing difficult intubations I can appreciate why. I once witnessed an intubation of a bull necked patient that involved attaching the laryngoscope handle after the blade was inserted. The patient's neck was simply too large to accommodate the laryngoscope handle and blade while it was assembled.. The problem with spinal anesthetics is that while sensory nerves are blocked, pressure sense remains intact. That poor patient can feel the hapless surgeon leaning against him with all his might while he is tying off that bleeder deep down in that wound. Anesthesia always seemed hesitant to heavily sedate obese patients and being awake while the surgeon takes out his frustration on the scrub nurse and leans into me would not be my idea of a good time.

About the only positioning aids available to us in the good old days of big open surgeries were 3 inch adhesive tape, bean bags, sand bags, and assorted permutations of rolled up towels and wash cloths. Lateral positioning of obese patients always scared the devil out of me because wherever that big belly went, the patient was sure to follow. That table was so narrow and that massive belly preparing to slide off was the stuff nightmares are made of. One of the safeguards  I used was aggressively taping the patient's  arm on top to the ether screen. Anesthesia always hated this maneuver because that giant ham hock of an arm could partially  obscure their view of the patients chest. Before all the fancy electronic monitoring aids were available, anesthesia constantly watched the patients chest rise and fall. Flexing the side lying patient's legs and running another course of 3 inch adhesive around the ankles and thighs was added security.

Distractions in the operating room are not a good idea. The surgeon and circulator often begin the "How are we going to get this guy off the table?" discussion just before closing the wound begins. They should be more concerned with sponge counts than who can bench press 150 pounds or more or how many people will be required to complete the table to litter transfer.

Even a dolt realizes that it is much more difficult to properly illuminate a surgical site that is essentially a valley in the middle of 2 mountains of fat. After carefully positioning the lights for optimal illumination of a deep wound things might not look quite the same as they would in a lean patient.. Dr. Slambow was an amateur photographer and had this mystery solved. The yellow fat tissue that surrounds the surgical site was actually changing the color temperature of the lighting. Instead of that nice, neutral white color the lighting had a yellowish cast.

Here is another way obesity may be a boon to the surgeon at the expense of the patient. While the patient is in the consent signing stage, the nurse is certain to mention that obesity confers additional risk to the procedure. This can be used to the surgeons advantage to explain almost any complication of the surgery. Instead of saying something like "That tie was not secured well enough on your cystic duct," the surgeon can dodge the issue and blame everything on the obesity.

This post has really stimulated my appetite and there is a cold Big Mac in the refrigerator. I am so old that if Big Macs were lethal that they would have certainly killed me by now.


  1. I once helped take care of a {non surgery} patient that weighed 900+ lbs.
    It took 12 of us to turn her.
    One day, her nurse was in the room with her, when we got a call asking about how she was doing. In that pre-HIPPA era, I told the female caller about her. Just as I finished, her nurse came out.. I handed her the phone. She spoke for a bit, then hung up.
    And then informed me that I had been speaking to Richard Simmons! The pt. had been part of his extremely overweight program and he/it was very concerned about her!!
    Who knew?!?!??!
    I had honestly thought it was a female I was talking to!

  2. Many modern surgeons favor the Alexis retractor to overcome the visualization problem you mentioned in your post. I attended a class recently in which instructor mentioned that it is now a rarity that any random nursing unit in a certain large urban hospital doesn’t have at least one patient > 400 pounds. Technology marches on, but nationwide obesity continues to be a challenge for both patients and nursing staff in the hospital environment.
    Thanks for another great post.