I live and practice medicine in SE Asia. It's very rare that I encounter morbidly obese patients, and they're usually in the 100kg-150kg (220 lbs to 330 lbs) range. And yet, even for these patients considered "smallfats" by FAs, there are still difficulties during surgery...
Anaesthesia. All right, I'm not an anaesthesiologist, and part of the reason why I decided on a surgical field is because pharmacology was one of my worst subjects in medical school, but obesity makes induction difficult because one, if you're using general aneasthesia obese patients are harder to intubate. There's more stuff in the way, same reason why a lot of obese patients get obstructive sleep apnea. There are also people who are harder to intubate because of the size of their necks and mouths and what not. It's not like the anaesthesiologist is shitlording it over patients with these variations in anatomy as well. Two, it's harder to calculate the right dose that will properly anaesthesise an obese patient without killing them. It's not prejudice. It's not because every single anaesthesiologist hates fat people. It's pharmakokinetics, pharmacodynamics, and physiology.
Landmarks and incision. Surgery will go smoothly if you're properly oriented from the start. That means knowing where to cut, cutting in the right place. In orthopaedics, our landmarks for making the incision are bony landmarks. If these are, for any reason, difficult to palpate, it's also more difficult to make the incision in the right place. I've had to operate on patients wherein the area in question was severely swollen, and thus it also took longer for me to mark where to cut. Does this mean that I'm prejudiced against people with swollen limbs? Am I oedema-phobic? Were we supposed to practice on more bloated cadavers in medical school? Swelling fucks up the expected anatomy in different ways from patient to patient. So does fat.
Superficial dissection. After making the skin incision, we have to go through the subcutaneous layer; basically, fat. An important part of surgery is haemostasis (controlling the bleeding). Even if it's a surgery that uses a tourniquet, bleeding still happens. Guess what tissue contains a lot of bleeders? Fat. You cut through more fat, you get more bleeding. You get more bleeding, you spend more time cauterising, you prolong your overall operative time. The longer the surgery, the riskier it is for the patient. Yet you can't afford to be haphazard about your haemostasis because you don't want ongoing blood loss during the surgery nor do you want to develop haematomas (pockets of blood) post-surgery. Despite what FAs claim, practice and training more and studying harder will not make this part go any faster. The more bleeding, the more haemostasis needs to be done, the more time you will spend in the OR.
Deep dissection. You've cut through the fat, now you have to keep it out of the way so you can see the muscles you're dissecting through. Again, it's not shitlording. It's physics. If you have more fat, the more effort and equipment you have to use to keep it out of the way so the surgery can be done properly. No surgeon is going to cut something they can't see. Seriously, do you want someone hacking away at your body blindly?
The main part. Depending on the surgery, this could be fracture reduction and fixation, joint replacement, reconstructing a tendon or a ligament...lots of things. Whatever it is, if it involves manipulating a limb, well, the heavier a body part is, the harder it is to lift and maneouvre properly. FAs may have a point here in that we should train harder and practice more on heavier bodies. I got into powerlifting because I was sick of feeling like I got beaten up after I would assist on knee replacements for obese patients. But I don't expect all my colleagues or the scrub nurses to get into lifting just to be able to deal with this...
Closing time. Again with the haemostasis; there are thicker layers to suture, you're gonna use more sutures, it's going to take a longer time. And more likely than not the incision made was bigger than what would have been made on a thinner patient, because you need it for a better exposure. Bigger incision takes longer to sew up.
Overall, a longer operative time increases risks for complications such as infection, bad reaction to anaesthesia, more post-operative pain. For the same procedure, a fat person will take longer to operate on than a thin person, because it's more difficult to decide where to start, there's more to cut through, there's more adipose tissue that will bleed, there's more stuff you have to push out of the way, there's more stuff you have to sew up in the end. No amount of training or practice or additional equipment will change that.
Post-operative care. Morbidly obese patients have poorer wound healing, especially if they have co-morbidities such as diabetes. Also, my experience with obese patients is that they are less compliant with post-operative rehab. I tell all my patients, regardless of size, once the surgery is over, that we doctors have done our part. From this point forward any healing is all on them, as long as they do their rehab and push themselves hard. I do my best, together with the anaesthesiologist, to relieve their pain post-operatively so that they can do the physical therapy exercises as much as they can. Unfortunately, if pre-operatively they were never motivated to care for themselves or push themselves hard toward a goal, there's not much I can do about that. All I can do is educate them about the risks and benefits. To be fair, there are thin patients who aren't compliant as well so this part isn't exclusively a fat person problem. It's just my experience with fat patients overall is that they don't push themselves to do the rehab as much.
