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Approximately 30% of the general surgical population presents with obesity, and the perioperative implications remain concerning. This review provides recent insights regarding morbid obesity and perioperative complications.Cardiovascular risk including cardiac arrest and myocardial infarction varies by type of surgery and is not always correlated with BMI. Functional status rather than associated comorbidities is an important component for risk assessment of obese patients undergoing noncardiac surgery. Just as for cardiac complications, pulmonary outcomes are influenced by the concurrence of obesity and the metabolic syndrome and/or sleep apnea rather than by BMI alone. New evidence suggests that continuous positive airway pressure treatment before surgery may reduce postoperative complications. Clinical Practice Guidelines for thromboembolic prophylaxis in bariatric patients are available. A comprehensive understanding of the obesity survival paradox has remained elusive. Postoperative surgical infections remain a leading problem related to obesity.Further research and evidence are needed for the development of accepted perioperative pathways to address obesity and related comorbidities including sleep disordered breathing and metabolic syndrome as well as evidence-based strategies to reduce surgical infections. Rather than BMI alone, an improved index for obesity risk assessment is needed.