Increased Body Mass Index In Patients Research Articles

Growing pains: strategies for improving ergonomics in minimally invasive gynecologic surgery.

To evaluate factors contributing to the development of work-related musculoskeletal disorders (WMSDs) and review strategies for mitigating ergonomic strain in minimally invasive gynecologic surgery. Factors associated with increased ergonomic strain and the development of WMSDs include increasing patient body mass index (BMI), smaller surgeon hand size, noninclusive design of instruments and energy devices and improper positioning of surgical equipment. Each type of minimally invasive surgery (laparoscopic, robotic, vaginal) confers its own ergonomic risk to the surgeon. Recommendations have been published regarding optimal ergonomic surgeon and equipment positioning. Intraoperative breaks and stretching are effective in reducing surgeon discomfort. Formal training in ergonomics has not yet been widely implemented, but educational interventions have been effective in reducing surgeon discomfort and can improve surgeon recognition of suboptimal ergonomics. Considering the serious downstream effects of WMSDs on surgeons, it is imperative to implement strategies for WMSD prevention. Optimal positioning of the surgeons and operative equipment should be routine. Intraoperative breaks and stretching should be incorporated during procedures and between every case. Formal education in ergonomics should be provided to surgeons and trainees. Additionally, more inclusive instrument design by industry partners should be prioritized.

Increasing Patient Age, Ambulatory Surgery Center Setting, and Surgeon Experience Are Associated With Shorter Operative Duration for Anterior Cruciate Ligament Reconstruction

PurposeTo identify variables associated with operative duration and intraoperative or perioperative complications after primary anterior cruciate ligament reconstruction (ACLR).MethodsSurgeons who performed a minimum of 20 arthroscopic cases per month were recruited for participation through the Arthroscopy Association of North America from 2011 through 2013. All participants agreed to voluntarily submit data for 6 months of consecutive knee and shoulder arthroscopy cases. Only subjects coded for ACLR were analyzed, whereas revision cases were excluded. ACLRs were subdivided into isolated ACLR, ACLR with minor concomitant procedures, and ACLR with major concomitant procedures. Patient, surgeon, and surgical variables were analyzed for their effect on operative duration and complications.ResultsOne hundred thirty-five orthopaedic surgeons participated, providing 1,180 primary ACLRs (399 isolated ACLRs, 441 ACLRs plus minor procedures, and 340 ACLRs plus major procedures). Most surgeons were in private practice (72.8%). Most patients were male patients (58.8%), and the mean body mass index (BMI) was 26.2 ± 5.1. The overall mean operative duration was 95.9 ± 42.0 minutes (isolated ACLRs, 88.4 ± 36.8 minutes; ACLRs plus minor concomitant procedures, 90.1 ± 37.6 minutes; and ACLRs plus major concomitant procedures, 118.5 ± 112.4 minutes; P < .001). Patient age was inversely correlated with operative duration (ρ = –0.221, P < .001). Surgical procedures performed in an ambulatory surgery center had a shorter mean operative duration (91.5 ± 40.4 minutes) compared with those performed in a hospital setting (105.0 ± 43.8 minutes, P < .001). There were 22 intraoperative and 47 early postoperative complications, with the most common being deep vein thrombosis (n = 15). Surgical volume (knee arthroscopy cases per month) correlated inversely with operative time (ρ = –0.200, P = .001) and complication rate (ρ = –0.112, P < .001). Patient BMI was associated with increased odds of early postoperative complications on multivariate analysis (odds ratio, 1.060; P = .044; 95% confidence interval, 1.002-1.121).ConclusionsIncreasing patient age, private practice, ambulatory surgery center setting, and surgeon experience are associated with a shorter operative duration for ACLR. Although an increasing number of arthroscopic knee procedures performed by surgeons correlated with fewer complications, only increasing patient BMI significantly predicted odds of complications.Level of EvidenceLevel IV, prognostic case series.

The effect of obesity on cost of total laparoscopic hysterectomy.

To test for the association between increasing patient body mass index (BMI) and the cost of total laparoscopic hysterectomy (TLH). Secondary outcomes include the relationship between increasing BMI and both peri- and post-operative morbidity. Retrospective cohort study of patients (N= 510) who underwent TLH between January 2017 and December 2018 at a single public tertiary teaching hospital. Morbid obesity (n= 63) was associated with significantly higher total admission costs ($19 654 vs $17 475 Australian dollars, P= 0.002), operative costs ($9447 vs $8630, P= 0.017) and total costs including readmissions ($20 476 vs $18 399, P= 0.016) when compared to patients with normal BMI (n= 103) and adjusting for age, indication for surgery, additional procedures and conversion to total abdominal hysterectomy. Costs for overweight (n= 134) and obese (n= 210) BMI groups did not differ from costs for the normal BMI group. Increased operative costs observed in the morbidly obese group, were largely driven by the time associated with set-up, transfer and anaesthetic time while surgical and recovery times were not statistically significant. The total cost of TLH is increased in the morbidly obese category of patients. The operative costs appear to be related to pre-operative measures such as theatre set-up and anaesthetic requirements. TLH in the obese and morbidly obese category group is not associated with increased intra-operative or post-operative complications. There may be a role for exploring improvements in managing morbidly obese patients in the pre-operative setting.

The Relationship between Increasing Patient Body Mass Index and Operating Room Scheduling Inaccuracies at the Time of Hysterectomy

<h3>Study Objective</h3> To assess the relationship between patient body mass index (BMI) and operating room (OR) scheduling inaccuracies at the time of hysterectomy. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Academic medical center. <h3>Patients or Participants</h3> Scheduled hysterectomies (n=951) performed from 11/2017 through 02/2020 for any gynecologic indication. <h3>Interventions</h3> Hysterectomy by any route. <h3>Measurements and Main Results</h3> The primary outcome was operating room time scheduling inaccuracy in minutes, defined as the difference between the scheduled and the actual operating room time. The mean scheduling inaccuracy for women with normal weight, overweight, and class I, II, and III obesity was 22.2, 28.4, 33.5, 38.3, and 48.2 minutes, respectively (p<0.001). Multivariable linear regression analysis adjusted for patient age, the presence of major cardiopulmonary comorbidities, ASA category, anesthetic type, abdominal surgical history, number of procedures performed, procedure route, and uterine weight. Normal and overweight women were similarly under-scheduled. Compared with normal-weight women, those with class 1 and 3 obesity were, on average, 12.7 (95% CI 2.1-23.3, p=0.019) and 18.9 (95% CI 4.4-33.3, p=0.010), respectively, more minutes under-scheduled. (The average scheduling inaccuracy of women with class 2 obesity did not differ significantly from women with normal weight.) Obese women whose surgeries were under-scheduled, compared to those who were not, spent a significantly greater proportion of their operating room time in operative time (82.6% vs. 74.6%, p<0.001) as compared to pre-operative positioning time (12.1% vs. 18.3%, p<0.001) or non-operative anesthetic time (15.6% vs. 21.0%, p<0.001). <h3>Conclusion</h3> When adjusted for key factors that may affect operating room time, obese women were significantly more under-scheduled than women of normal weight. Obese women with under-scheduled cases spent proportionally more OR time in operative as opposed to non-operative time. Future studies can assess whether awareness of this tendency helps surgeons more accurately predict operating room time required for hysterectomy for obese women.

66 The association between increasing patient body mass index and gynecologic operating room scheduling inaccuracies

66 The association between increasing patient body mass index and gynecologic operating room scheduling inaccuracies

Patient Body Mass Index and Occupational Radiation Doses to Circulating Nurses During Coronary Angiography

BackgroundPatient BMI is associated with radiation doses received by interventional cardiologists, yet the association between patient BMI and nurse radiation doses is unknown. This study evaluated the association between patient body mass index (BMI) and nurse radiation doses during coronary angiography. MethodsNurse radiation doses were collected by real-time dosimeters during consecutive coronary angiography procedures and are reported as the personal dose equivalent (Hp10). Patient radiation doses were estimated using dose area product (DAP). Patient BMI was categorized in kg/m2 as <25.0, 25.0–29.9, 30.0–34.9, 35.0–39.9, and ≥40. Multiple regression analysis determined procedural factors independently association with nurse radiation doses. ResultsIn 643 consecutive coronary angiography procedures, patient radiation doses increased significantly across increasing patient BMI categories (p < 0.001). Compared to a patient BMI <25, a patient BMI ≥40 was associated with a 2.3-fold increase in DAP (p < 0.001). Significant differences were also observed in nurse radiation doses across patient BMI categories (p = 0.036). Compared to a patient BMI <25, a patient BMI ≥40 was associated with a 4.0-fold increase in nurse radiation dose (BMI < 25: 0.3 [0.1, 1.3] μSv; BMI ≥ 40: 1.2 [0.2, 2.9] μSv; p = 0.003). By multiple regression analysis, each 1-unit kg/m2 increase in patient BMI was associated with a 3.3% increase in nurse radiation dose (p = 0.002). ConclusionsPatient BMI was significantly associated with nurse radiation doses during coronary angiography. These observations may have important implications on nurse radiation safety, especially in the setting of the ongoing obesity epidemic.

From the Circulation Family of Journals.

From the Circulation Family of Journals.

TCT-557 Impact of a Suspended Lead Suit on Physician Radiation Doses Across Patient BMI Categories During Coronary Angiography

Increasing patient body mass index (BMI) results in greater scatter radiation and leads to increased physician radiation exposure during coronary angiography. It is unknown if use of a suspended lead suit rather than standard lead garments can offset the increased physician radiation doses typically

Impact of patient obesity on radiation doses received by scrub technologists during coronary angiography.

The impact of patient obesity on scrub technologist radiation dose during coronary angiography has not been adequately studied. Real-time radiation exposure data were prospectively collected during consecutive coronary angiography cases. Patient radiation dose was estimated by dose area product (DAP). Technologist radiation dose was recorded by a dosimeter as the personal dose equivalent (Hp (10)). Patients were categorized according to their body mass index (BMI): <25.0, lean; 25.0-29.9, overweight; ≥30.0, obese. The study had two phases: in Phase I (N = 351) standard radiation protection measures were used; and in Phase II (N = 268) standard radiation protection measures were combined with an accessory lead shield placed between the technologist and patient. In 619 consecutive coronary angiography procedures, significant increases in patient and technologist radiation doses were observed across increasing patient BMI categories (p < 0.001 for both). Compared to lean patients, patient obesity was associated with a 1.7-fold increase in DAP (73.0 [52.7, 127.5] mGy × cm2 vs 43.6 [25.1, 65.7] mGy × cm2, p < 0.001) and a 1.8-fold increase in technologist radiation dose (1.1 [0.3, 2.7] μSv vs 0.6 [0.1, 1.6] μSv, p < 0.001). Compared to Phase I, use of an accessory lead shield in Phase II was associated with a 62.5% reduction in technologist radiation dose when used in obese patients (p < 0.001). During coronary angiography procedures, patient obesity was associated with a significant increase in scrub technologist radiation dose. This increase in technologist radiation dose in obese patients may be mitigated by use of an accessory lead shield.

Anatomical Look Into OnabotulinumtoxinA Injection for Chronic Migraine Headache.

While existing studies about onabotulinumtoxinA for chronic migraines have focused on injection location and appropriate dosing, little consideration has been given to patient body habitus and its potential impact on efficacy. We hypothesized that with increasing patient body mass index (BMI) there would be more subcutaneous fat separating targeted muscle groups from the skin surface, such that standard 0.5-inch needles used in existing protocols may not allow intramuscular injection. This may have implications for treatment planning. Anatomically normal computed tomography scans of the head, neck, and face were randomly selected. Subjects were stratified into 4 groups based on BMI, with 30 patients in each group. Four standardized locations were chosen to obtain measurements from the skin surface to the underlying muscle fascia, including (1) frontalis, (2) temporalis, (3) semispinalis capitis, and (4) trapezius. Median depth for the temporalis was 12.65 mm (Q1 = 9.32 mm, Q3 = 15.08 mm) for the BMI greater than 35 kg/m group. Median depth for the semispinalis capitis was 13.77 mm (Q1 = 10.3 mm, Q3 = 15.7 mm) for the BMI 30 to 35 kg/m group, and 14.75 mm (Q1 = 11.00, Q3 = 17.00 mm) for the BMI greater than 35 kg/m group. Median depth for the trapezius was 13.95 mm (Q1 = 10.18 mm, Q3 = 19.00 mm) for the BMI greater than 35 kg/m group. These medians exceeded the length of the standard 0.5-inch (12.-mm) needle used in existing protocols. Our study demonstrates that with increasing BMI there is a greater distance between the skin surface and the muscle fascia of muscles that are targeted for injection in standard chronic migraine botulinum toxin injection protocols. Because of this, patient body habitus may be an important factor in injection technique.

CRT-400.02 The Impact of Patient BMI on Radiation Dose Among Scrub Technologists During Cardiac Catheterization

Increasing patient body mass index (BMI) results in greater scatter radiation during fluoroscopy, yet the impact of patient BMI on scrub tech radiation dose during coronary angiography has not been studied. Real-time radiation exposure data were prospectively collected during coronary angiography.

Validation of an automatic segmentation method to detect vertebral interfaces in ultrasound images

Aim of this study was to perform a detailed clinical validation of a new fully automatic algorithm for vertebral interface segmentation in echographic images. Abdominal echographic scans of lumbar vertebrae L1–L4 were carried out on 150 female subjects with variable age and body mass index (BMI). Acquired datasets were automatically processed by the algorithm and the accuracy of the obtained segmentations was then evaluated by three independent experienced operators. Obtained results showed a very good specificity in vertebra detection (93.3%), coupled with a reasonable sensitivity (68.1%), representing a suitable compromise between the detection of a sufficient number of vertebrae for reliable diagnoses and the limitation of the corresponding computation time. Importantly, there was only a minimum presence of ‘false vertebrae’ detected (2.8%), resulting in a very low influence on subsequent diagnostic analyses. Furthermore, the algorithm was specifically tuned to provide an improved sensitivity (up to 73.1%) with increasing patient BMI, to keep a suitable number of correctly detected vertebrae even when the acquisition was intrinsically more difficult because of the augmented thickness of abdominal soft tissues. The proposed algorithm will represent an essential added value for developing echographic methods for the diagnosis of osteoporosis on lumbar vertebrae.

Cumulative Radiation Exposure to Patients Undergoing Arthroscopic Hip Preservation Surgery and Occupational Radiation Exposure to the Surgical Team

To quantify cumulative radiation exposure in patients undergoing arthroscopic hip preservation surgery and occupational exposure to operating room (OR) personnel during such surgery; a secondary objective of this study was to identify factors affecting radiation exposure in patients undergoing hip arthroscopy. Radiation exposure from all preoperative and intraoperative imaging studies was determined for 52 patients undergoing hip arthroscopy. Cumulative and effective radiation doses were calculated and correlated with pathology and body mass index (BMI). Badge dosimeters were worn by OR personnel to measure cumulative occupational exposure. A highly sensitive portable ion chamber was used to evaluate the radiation scatter during surgery performed on a high-BMI patient and a low-BMI patient to reflect a "worst-case scenario" and "best-case scenario," respectively. Forty-three patients underwent procedures for femoroacetabular impingement (FAI) and 9 underwent procedures for soft-tissue pathologies (ST). The median cumulative exposure was 8.6 mGy and 5.0 mGy for FAI patients and ST patients, respectively (P= .01). The cumulative effective radiation dose was 490 mrem and 350 mrem for FAI patients and ST patients, respectively (P= .47). BMI significantly correlated with cumulative exposure (P= .0004) and trended toward significance with cumulative effective dose (P= .073). OR staff cumulative occupational exposure was low (9 mrem for the surgeon). Ion chamber data showed that increasing patient BMI resulted in increased occupational exposure. The median cumulative effective radiation dose to patients undergoing arthroscopic hip preservation surgery is 490 mrem and results in an excess lifetime risk of death from cancer of 0.025%. Greater BMI correlates with increased cumulative radiation exposure and may increase risk to OR personnel. Occupational exposure to the surgical team from hip arthroscopy ranges from 7 to 9 mrem per 50 hip arthroscopies (+0.0005% excess lifetime risk of death from cancer). Level IV, diagnostic.

The effect of patient body mass index on surgical difficulty in gynaecological laparoscopy.

Over the past three decades, rates of overweight and obesity internationally have risen to epidemic proportions. There are currently no published prospective studies examining the effect of obesity on gynaecologic laparoscopy for benign indications within a population with obesity rates comparable to Australian women. To assess and quantify whether increasing patient body mass index negatively impacted upon the ability to successfully complete planned laparoscopic surgery. From January 2009 until October 2012, 307 women undergoing laparoscopic gynaecological surgery for benign pathology were recruited. Intra-operative variables included the following: ease of identification of anatomical landmarks, entry technique and number of attempts, conversion to laparotomy and any complications encountered. Any post-operative complications were recorded at the six week post-operative review. 94.46% of operations were completed as planned. As BMI increased, the ease of identification of important anatomical landmarks significantly decreased. There was no correlation between increasing BMI and surgical complication rates. Planned gynaecological laparoscopy can be performed in obese patients with a high likelihood of completion. In this study, obesity was not associated with a significant increase in complication rates or failure to complete the surgery as planned.

A comparison of colorimetric versus fluorometric sentinel lymph node mapping during robotic surgery for endometrial cancer

ObjectiveThe study objective was to compare the ability to detect sentinel lymph nodes (SLNs) in women with endometrial cancer (EC) or complex atypical hyperplasia (CAH) using fluorometric imaging with indocyanine green (ICG) versus colorimetric imaging with isosulfan blue (ISB). MethodsWomen underwent SLN mapping, with either ISB or ICG, during robotic-assisted total laparoscopic hysterectomy (RA-TLH) from September 2012 to March 2014. SLNs were submitted for permanent pathologic analysis. Completion lymphadenectomy and ultrastaging were performed according to institutional protocols. ResultsRA-TLH and SLN mapping was performed in 71 women; 64 had EC (64) and 7 had CAH. Age, body mass index (BMI), stage and tumor characteristics were similar in the ICG versus the ISB cohorts. Overall, SLNs were identified bilaterally (62.0%), unilaterally (21.1%), or neither (16.9%), and in 103 of 142 hemi-pelvises (72.5%). The mean number of SLNs retrieved per hemipelvis was 2.23(SD 1.7). SLNs were identified in the hypogastric (76.8%), external iliac (14.2%), common iliac (4.5%) and paraaortic (4.5%) regions. ICG mapped bilaterally in 78.9% of women compared with 42.4% of those injected with ISB (p=0.02). Five women (7%) had positive lymph nodes, all identified by the SLN protocol (false negative rate: 0%). On multivariate analysis, BMI was negatively correlated with bilateral mapping success (p=0.02). When stratified by dye type, the association with BMI was only significant for ISB (p=0.03). ConclusionsFluorescence imaging with ICG may be superior to colorimetric imaging with ISB in women undergoing SLN mapping for endometrial cancer. SLN mapping success is negatively associated with increasing patient BMI only when ISB is used.

Wound Infection After Elective Colorectal Resection

Surgical site infection (SSI) is a potentially morbid and costly complication following major colorectal resection. In recent years, there has been growing attention placed on the accurate identification and monitoring of such surgical complications and their costs, measured in terms of increased morbidity to patients and increased financial costs to society. We hypothesize that incisional SSIs following elective colorectal resection are more frequent than is generally reported in the literature, that they can be predicated by measurable perioperative factors, and that they carry substantial morbidity and cost. Over a 2-year period at a university hospital, data on all elective colorectal resections performed by a single surgeon were retrospectively collected. The outcome of interest was a diagnosis of incisional SSI as defined by the Center of Disease Control and Prevention. Variables associated with infection, as identified in the literature or by experts, were collected and analyzed for their association with incisional SSI development in this patient cohort. Multivariate analysis by stepwise logistic regression was then performed on those variables associated with incisional SSI by univariate analysis to determine their prognostic significance. The incidence of SSI in this study was compared with the rates of incisional SSI in this patient population reported in the literature, predicted by a nationally based system monitoring nosocomial infection, and described in a prospectively acquired intradepartmental surgical infection data base at our institution. One hundred seventy-six patients undergoing elective colorectal resection were identified for evaluation. The mean patient age was 62 +/- 1.2 years, and 54% were men. Preoperative diagnoses included colorectal cancer (57%), inflammatory bowel disease (20%), diverticulitis (10%), and benign polyp disease (5%). SSIs were identified in 45 patients (26%). Twenty-two (49%) SSIs were detected in the outpatient setting following discharge. Of all preoperative and perioperative variables measured, increasing patient body mass index and intraoperative hypotension independently predicted incisional SSI. Although we could not measure statistically increased length of hospital stay associated with SSI, a representative population of patients with SSI accumulated a mean of $6200/patient of home health expenses related to wound care. Our rates of SSI were substantially higher than that reported generally in the literature, predicted by the National Nosocomial Infection System, or described by our own institutional surgical infection data base. The incidence of incisional SSI in patients undergoing elective colorectal resection in our cohort was substantially higher than generally reported in the literature, the NNIS or predicted by an institutional surgical infection complication registry. Although some of these differences may be attributable to patient population differences, we believe these discrepancies highlight the potential limitations of systematic outcomes measurement tools which are independent of the primary clinical care team. Accurate surgical complication documentation by the primary clinical team is critical to identify the true frequency and etiology of surgical complications such as incisional SSI, to rationally approach their reduction and decrease their associated costs to patients and the health care system.