Read on: danhwilliams.com

Read time: 2 minutes

So, Amanda’s story told us how Obesity can play out for one person.
And last week we looked at the real-world outcomes of obesity for 100s of people.

As a reminder, obesity leads to:

1. Earlier joint replacement
2. Worse pain and function after surgery 
3. A higher chance of a negatively life changing event. 

I’ve covered a lot of the reasons why Obesity does this.
That are mainly Biomechanics + Biochemistry.
Mainly Patient factors.
 
However, this is the one Surgical factor is NOT often talked about...
 

The challenge of a THICK fat layer 

Operating on a patient with a normal BMI is usually straightforward. 
The fat layer is no more than a centimetre or two thick.
The soft tissues fall out of the way. 

It’s quick to safely cut through the superficial layers:
Skin, fat and fascia (the deeper tissue).
 
It’s straightforward to control bleeding.
Bleeding from small blood vessels within a thin fat layer are easily seen.

A diathermy stick passes an electric current to coagulate / burn body tissue.
One or two buzzes with the diathermy STOPs the bleeding 🔴
The operative field stays completely dry and clear.
Operating is easy 😎 

The structures immediately around the hip joint are right there.
The next steps take care of themselves (well, almost).

BUT…
 

Add a 10cm thick fat layer over the hip

And that same operation becomes more difficult
...from start to finish.

One of the places that excess body fat is laid down is around the hip.
And ‘around the hip’ is the way into the hip joint.

80% of people undergoing joint replacement are overweight or obese...
 ... so a 10 cm or more layer of fat here is common.

And every surgeon will quietly remember their standout cases…

‘10cm, that’s nothing…’ 
 
In a thick fat layer, there are MORE blood vessels..
(because there's more tissue).
 
And those blood vessels are harder to track down.
They retract, pull back and hide away in the globular fat.

Bleeding is more difficult to control. 

It can take 10 minutes to get good control of bleeding.
To get a clear operative field 😖 

Access to the deeper structures around and in the hip joint is then less straightforward.

It can feel like you are operating down a deep dark hole.

Like trying to fix a leaky pipe up underneath the kitchen sink.
In patchy half-light 🌚
 
Instead of making that repair sat comfortably at the kitchen table.
In bright daylight ☀

 
Difficult access leads to difficult surgery

We don’t much talk about it.

BUT that thick layer is partly why complications,
...and hip revision rates are higher in obese patients.

There is something to be said for making an operation as straightforward
...as possible for your surgical team.