Discussion

The present study provides a comprehensive experimental evaluation of the impact of obesity on forensic autopsy workflow, integrating procedural, anatomical, and cognitive dimensions under a standardized medico-legal setting. The observed prolongation of autopsy duration in obese decedents, together with the graded increase across obesity severity classes, confirms that obesity exerts a dose-dependent effect on the technical execution of post-mortem examinations, even when all other procedural variables are tightly controlled [18–20].

The difference in mean procedural time between obese and control cases, coupled with the persistence of a significant BMI–duration association across the full sample, supports the conclusion that once BMI reaches the obese range, the autopsy workflow undergoes a qualitative shift toward increased complexity and workload [21–23]. This finding is particularly relevant in contemporary forensic practice, given the rising prevalence of obesity in the general population and the consequent increase in obese decedents undergoing medico-legal examination.

A key contribution of the present study lies in the integration of cognitive performance assessment into the analysis of autopsy procedures. The use of the Mackworth Clock Test allowed quantification of vigilance decrement associated with prolonged and demanding dissections. While both obese and control cases showed some degree of post-autopsy attentional decline, the magnitude of vigilance decrement was greater in obese cases, closely paralleling the longer procedural duration. The observed association between longer procedural duration and increased missed stimuli is consistent with previous human-factors research on fatigue during prolonged tasks.

The morphometric observation that subcutaneous adipose tissue thickness exceeded 4 cm in all cases with BMI ≥ 35 kg/m² provides an objective anatomical correlate to the observed procedural difficulties. Increased adipose thickness at the thoracoabdominal incision site translated into deeper incision planes, delayed access to body cavities, and prolonged dissection times, particularly during exposure and mobilization of deep or adipose-surrounded organs such as the liver, pancreas, adrenal glands, and pelvic organs.

It should be noted that cardiac examination protocols may vary across forensic institutions, particularly with regard to the timing of dissection in relation to fixation. While in many centers the heart is dissected fresh during the autopsy, alternative approaches involving delayed detailed examination after fixation are also described. Such variability may influence both procedural workflow and total autopsy duration, as fresh dissection requires additional time during the active autopsy phase, whereas deferred examination may redistribute workload to subsequent steps. In the present study, a standardized approach including fresh cardiac dissection was adopted for all cases in order to ensure methodological consistency. Nevertheless, inter-institutional differences in cardiac examination protocols should be considered when comparing autopsy duration across different settings.

The present findings support the relevance of workload-related human factors in forensic autopsy practice. However, the vigilance-related component of the study should be interpreted as exploratory and hypothesis-generating, since cognitive assessment was not designed to evaluate diagnostic performance or autopsy accuracy.

The study has limitations that warrant consideration. Although the inclusion of a matched control group enhances interpretability, the overall sample size remains moderate. The qualitative assessment of technical difficulty, while supported by consistent morphometric observations, remains partly subjective and could be further refined through future studies incorporating objective metrics of physical effort or motion analysis. The assessment of operator vigilance was conducted within a fixed autopsy team, which may limit generalizability. This design introduces a potential risk of pseudo-replication, limits external generalizability, and does not allow separation of individual operator characteristics from workload-related effects.

In conclusion, this study suggests that obesity is associated with longer and technically more demanding forensic autopsies under standardized conditions. Obese decedents require longer and more technically demanding examinations than non-obese controls, and increasing obesity severity is associated with progressive procedural prolongation and increased vigilance decrement scores in operators. Further investigations involving multiple operator teams and larger cohorts are required to better characterize workload-related cognitive effects in forensic autopsy practice.