Introduction

Body mass index (BMI) represents one of the most extensively validated anthropometric parameters for the classification of overweight and obesity and is widely employed in clinical, epidemiological, and public health research [1]. Defined as the ratio between body weight and the square of height, BMI provides a standardized and reproducible surrogate of overall adiposity that enables interindividual and population-level comparisons. Despite its limitations, BMI remains the reference metric for stratifying obesity-related risk [1, 2]. In clinical medicine, elevated BMI has been consistently associated with increased incidence of cardiovascular disease, metabolic syndrome, type 2 diabetes, thromboembolic events, and sudden cardiac death, while in forensic pathology a growing body of autopsy-based literature has confirmed its correlation with structural cardiac alterations, coronary atherosclerosis, epicardial adipose tissue expansion, pulmonary thromboembolism, and obesity-related cardiomyopathy [1–3]. Despite this consolidated pathogenic relevance, BMI is still largely treated in routine forensic practice as a descriptive variable rather than as an active determinant capable of influencing the autopsy process itself.

From an anatomical and procedural standpoint, obesity profoundly modifies the internal landscape encountered during autopsy. Obesity may reduce the visibility of anatomical structures and complicate in situ evaluation due to excessive visceral and subcutaneous adipose tissue. These modifications are particularly evident in the thoracoabdominal compartment, where adipose infiltration affects not only the abdominal wall but also the mesentery, retroperitoneum, and perivisceral spaces, thereby complicating organ exposure, mobilization, and removal. In addition to the thoracoabdominal and retroperitoneal regions, the cervical district represents a critical area in forensic investigations. In obese subjects, increased adipose tissue in the neck may obscure anatomical landmarks and complicate dissection. Autopsy-based morphometric studies have further demonstrated that increased BMI correlates with increased thickness of subcutaneous adipose tissue, augmented epicardial and perivascular fat, and greater visceral adiposity, all of which contribute to increased resistance during dissection and prolongation of operative steps [1–3]. In this context, BMI may be conceptualized as a biomechanical modifier that directly impacts the physical workload required to complete a forensic autopsy.

Despite this expanding evidence, the procedural consequences of elevated BMI on autopsy workflow remain largely unexplored in the forensic literature. In particular, no systematic investigation has yet addressed whether BMI influences autopsy duration, technical execution, or the cognitive performance of operators engaged in prolonged dissections. This gap is particularly relevant when considering that forensic autopsies are complex, physically demanding procedures that require sustained attention, fine motor control, and continuous situational awareness over extended periods of time. Forensic autopsies require sustained attention and procedural precision throughout the examination [4–9].

Human-factors research has shown that prolonged and demanding tasks may contribute to fatigue and vigilance decline [10–12]. The Mackworth Clock Test is a validated tool for assessing sustained attention, although its application in forensic pathology has been limited. In the context of obesity, it is reasonable to hypothesize that increased procedural duration and technical complexity may exacerbate cognitive fatigue and reduce vigilance. Longer dissections may increase procedural workload and operator fatigue during autopsy performance. The present study was therefore designed to investigate BMI not merely as a pathological correlate but as an independent procedural and cognitive modifier within forensic autopsy practice. By integrating objective measurements of autopsy duration, standardized assessment of operator vigilance, and qualitative evaluation of technical difficulty, this experimental investigation aims to provide a systematic analysis of how BMI influences the dynamics of medico-legal autopsy execution.