Any discussion of obesity and wound infection must lead with the advantage of laparoscopy over open surgery. Whenever possible, staying laparoscopic is best. Nguyen et al. demonstrated this in a randomized trial on bariatric patents [7]. It is common sense that wound infection and hernia rates are lower with laparoscopy when compared to open procedures. Furthermore, when the patient has obesity, laparoscopy will often provide better visualization for the surgeon.

Pessaux et al., in a multivariate analysis of prospective multicenter data from 4718 patients, found obesity to be a risk factor for infection [8].

The recommended preoperative antimicrobial prophylaxis for most general surgical procedures is cefazolin (Ancef). The American Society of Health-System Pharmacists recommends increasing the dosage of cefazolin from 2 to 3 g for patients weighing more than 120 kg, and redosing 4 h later [9]. It is tempting to use broader spectrum antimicrobial agents, but evidence for this is lacking. Administer the first dose 30 min before skin incision to ensure adequate tissue penetration.

Glycemic control in diabetic patients will also aid in healing and diminish surgical site infection.

Kornblith and colleagues showed that obese patients were hypercoagulable and have 85 % increased odds of developing a thromboembolic complication after trauma for each 5 kg/m² increase in body mass index [10].

In a very large analysis of 30,000 patients for in-hospital venous thromboembolism events, major risk factors were alcohol use, open surgery instead of laparoscopic, and chronic renal disease. Other associated factors were congestive heart failure, male sex, and chronic lung disease [11]. Venous stasis disease has also been identified as a risk factor.

Consensus among obesity treatment experts exists regarding the need for deep venous thrombosis prophylaxis, but regimens vary. Sequential compression devices beginning prior to anesthesia intraoperatively and continuing through postoperative period are recommended. Heparin 5000 IU either q8 or q12 or enoxaparin 40 mg daily or twice a day [12] is used. Administer the first dose before surgery begins.

Before an elective case in a patient with a history of venous stasis disease, deep venous thrombosis, pulmonary embolism, BMI greater than 55, or known hypercoagulable disorder, an inferior vena cava filter could be considered [13, 14]. This is controversial and should be assessed on a case-by-case basis.

A recurring theme of this chapter is that the actions we take with all surgical patients need to be implemented even more carefully and urgently in patients with obesity. Any discussion of positioning must first begin with ensuring that appropriate equipment is present in the room. A table that can hold the weight of the patient, while still possessing its tilt functions, is fundamental. Some have side extenders for use when needed, or options for using arm boards to increase table width. Follow the manufacturer’s recommendations. Safety straps are always important, but even more so if the table angle will be altered during the case.

If reverse Trendelenburg position is planned, a footboard is an important part of the setup. Foley catheter insertion, pneumatic compression device or sequential stocking placement prior to the footboard will keep the team from positioning the lower extremities twice.

The weight of the patient places increased pressure on every point of contact, from the table itself to the positioning devices. The Association of Perioperative Registered Nurses recommends that padding and positioning devices maintain a normal capillary interface pressure of 32 mmHg or less [15]. Patients with obesity are more likely to sustain nerve injuries or pressure sores; even rhabdomyolysis has been described [16]. Foam pads have been proven ineffective because they compress excessively. Many different kinds of elasto-polymer gel pads exist, and they should be used liberally to protect the patient from pressure. For some surgical cases, a beanbag would be utilized, and careful assessment for pressure points must be performed after the beanbag is put to suction.

Transfers are so challenging for this patient population that it is good practice to move from operating room table onto an appropriately sized hospital bed where they can remain through the post-anesthesia care unit and then to the hospital room. Careful attention to both patient and personnel safety is needed to prevent injuries [17]. Some centers use specialized air mattress transfer devices to assist.

There is data that suggests repositioning patients every 2 h in the post-anesthesia care unit and beyond results in a significant reduction in pressure ulcers [18]. Devices such as nasogastric tubes, endotracheal tubes, and Foley catheters need evaluation for tissue pressure in the postoperative setting, too.

All operating room personnel are familiar with the electrosurgical unit technology that is used to cut and coagulate blood vessels. Brief knowledge of the principles of electricity is needed to keep patients safe during its use. The return electrode is designed to be placed over a large muscle. Any tissue with impedance greater than muscle can diminish dispersal of the current to the pad. Adipose tissue has a greater impedance than muscle. Impedance of the current causes tissue to heat and possible arcing of current to the electrode could result in a burn [19]. A larger dispersive pad surface area is needed to disperse the current density and complete the circuit to the generator [20]. Some machine manufacturers recommend the use of two grounding pads in patients who weigh more than 300 lb. It is important that the pads are positioned side by side, not on different body parts, to achieve desired effect of increased dispersive pad surface area to draw the current. If the pads were placed on different legs, for example, the current would choose the pathway of least resistance and go to one side preferentially. Some electrosurgical units have an adapter that can be used to connect two dispersive pads to the same generator. Other companies address this issue by manufacturing a larger size dispersive pad to use in patients with obesity. Follow the manufacturer’s guidelines on all electrocautery equipme nt.

Perioperative care of a patient with obesity is best accomplished by a team of experts, and the anesthesiologist and CRNA could be the most important members. They perform critical life support and monitoring functions when the patient is most vulnerable. The anesthesia team is often first to recognize an adverse perioperative event and their expertise can make the difference between a recognized and corrected problem and a tragedy.

Vascular access is understandably more difficult to achieve in the patient with obesity. Patience, a warm extremity, and good knowledge of the anatomy will improve success with peripheral venous access. Thick tissue unfortunately also diminishes visibility via ultrasound guidance. Careful central venous catheter insertion must be considered if peripheral access can’t be found. Under no circumstances should the surgical case proceed with tenuous vascular access.

Hypertension is a known weight-related comorbidity and management of blood pressure intraoperatively begins with its accurate measurement. An arterial line is ideal and should be utilized in patients with worrisome cardiopulmonary status, or when repeated arterial blood gases may be needed. Poorly fitting upper arm blood pressure cuffs give a falsely elevated reading. The length of the cuff bladder should be equal to at least 80 % of the measured circumference and width should be equal to at least 40 % of the measured arm circumference at the midpoint of the upper arm [21]. Appropriately sized cuffs should be standard hospital equipment, but LeBlanc et al. demonstrated that forearm blood pressure correlated well with invasive intra-arterial blood pressure measurement if cuff size or anatomic issues prevent utilizing the upper arm [22].