The rectus abdominis and the internal, external, and transverse oblique musculature contribute to the support and contour of the anterior abdominal wall (Fig. 12-1).

The perforating vasculature to the adipocutaneous component of the anterior abdominal wall emanates from the intramuscular vascular network (Fig. 12-2). The majority of significant perforators arise from the deep inferior epigastric system. Other blood vessels contributing to the perforating system include the superficial inferior epigastric artery, superficial circumflex iliac artery, and the deep circumflex iliac artery. All of these perforators converge at the dermis, forming the subdermal plexus.

The aponeurotic layers of the anterior abdominal wall include the linea alba, anterior rectus sheath, posterior rectus sheath, and the external oblique fascia (Fig. 12-3).

Perforating vessels pierce the anterior rectus sheath and external oblique fascia as they course through the adipose layer, until contributing to the subdermal plexus of vessels (Figs. 12-4 and 12-5).

Preoperative imaging is important when considering panniculectomy. Computed tomography (CT) or magnetic resonance imaging (MRI) delineate the size of the hernia defect and provide information regarding the thickness of the abdominal pannus (Fig. 12-6). The abdominal musculature also is appreciated. MRI also permits visualization of the larger arteries and veins that course through the pannus.

There are several design patterns for abdominal panniculectomy. These include the horizontal incision; vertical incision; and a horizontal and vertical incision, also known as a fleur-de-lis pattern (Fig. 12-7). The specific pattern depends on the location of excess tissue and the location of prior incisions. Most patients with abdominal hernias will have a prior vertical midline incision. Incorporating this into the excision pattern is useful and does not usually result in additional scars.

In patients with abdominal hernias and excess abdominal skin and fat, some degree of soft tissue undermining is usually necessary in order to adequately close and contour the abdominal wall. The undermining is always at the junction of the fascia and fat. All of the perforators supplying the skin and fat pierce the fascia (see Fig. 12-5). Preservation of one or more perforators improves the vascularity of the adipocutaneous layer and minimizes the incidence of delayed healing or skin necrosis.

Preoperative markings are important. With the patient in the standing position, the amount of excess skin is approximated by grasping and elevating the pannus (Fig. 12-8). The markings typically include the incision for the hernia repair and the incisions for the panniculectomy (Fig. 12-9).

Once the hernia repair is complete, the soft tissues are further undermined off of the anterior rectus sheath, and the amount of excess skin and fat is determined (Fig. 12-10). The degree of undermining depends on the thickness of the adipocutaneous tissues, location of scars, and assessment of skin vascularity. Vertical skin excisions are performed by elevating the adipocutaneous flaps and redraping one side over the other (Fig. 12-11). The overlapping areas are marked before excision (Fig. 12-12). Vertical and horizontal skin excisions proceed, incorporating the vertical and horizontal incisions (Fig. 12-13). It is important to excise any abnormal or thickened skin. The vascularity of the remaining skin flaps is based superolaterally. In patients with a very large or thick pannus, it is important to avoid extensive undermining that may compromise vascularity.

An alternative technique for skin pattern design and excision is the “Mercedes” approach (Figs. 12-14 and 12-15). This technique is indicated in patients in whom a vertical and horizontal skin excision is necessary. The advantage of this pattern is that it will preserve vascularized tissue at the trifurcation point and potentially minimize the delayed healing and skin necrosis that often occurs there. In preparation for this technique, the vertical midline and transverse horizontal patterns are delineated much like the standard techniques. The unique feature of this design is that an equilateral triangular pattern is delineated just below the umbilicus extending to the horizontal markings. The lengths of these triangular limbs are usually 15 to 20 cm and vary, based on body habitus and the dimensions of the pannus. This triangular skin is not excised with the panniculectomy. It is preserved as a caudally based flap that is advanced in the cephalad direction following the central and lateral skin excisions.

In some cases, the incision is not closed completely and a negative pressure wound therapy device is applied (Fig. 12-16). The reasoning for this is to minimize potential fluid collections and soft tissue edema. Once stable, this device can be removed and the wound closed secondarily.

Length of stay: The length of hospital stay is variable and depends on various factors. These include but are not limited to return of bowel function, development of complications, and patient compliance. Reid and Dumanian (2005) have determined that the average length of stay in patients who have component separation repair of an abdominal hernia with panniculectomy was 7.7 days.