Panniculectomy and Abdominal Wall Reconstruction

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Chapter 12 Panniculectomy and Abdominal Wall Reconstruction image

1 Clinical Anatomy of the Anterior Abdominal Wall

3 Relevant Aponeurotic Anatomy

2 Preoperative Considerations

3 Operative Steps

1 Design Patterns for Panniculectomy

image 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.

3 Technique of Skin/Fat Excision

image 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.
image 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.

4 Postoperative Care

1 Hospital Care

image 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.

5 Management of Complications

image Infection: Postoperative wound infections typically manifest within a few days and may present with cellulitis or drainage (Fig. 12-17). Appropriate cultures and sensitivities are obtained. Infectious disease consultation is recommended and based on surgeon comfort and extent of disease. Causative organisms are variable and may include staphylococcus, streptococcus, Escherichia coli, and others. Surgical incision and drainage procedures may be necessary.
image Soft tissue necrosis: Impaired vascular circulation, increased tension, or soft tissue infection may result in tissue necrosis (see Fig. 12-17). Surgical debridement is necessary. The debridement must include all necrotic tissue and extend to viable, bleeding tissue. Closure immediately following debridement is usually not performed. Local wound measures are implemented and may include wet to dry dressings or enzymatic measures. Secondary closure is considered when all signs of infection and necrosis are cleared.

6 Pearls and Pitfalls

Selected References

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Axer H., v. Keyserlingk D.G., Prescher A. Collagen fibers in linea alba and rectus sheaths II. Variability and biomechanical aspects. Journal of Surgical Research. 2001;96:239-245.

Borud L.J., Grunwaldt L., Janz B., Mun E., Slavin S.A. Components separation combined with abdominal wall plication for repair of large abdominal wall hernias following bariatric surgery. Plast Reconstr Surg. 2007;119:1792.

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Korenkov M., Beckers A., Koebke J., et al. Biomechanical and morphological types of the linea alba and its possible role in the pathogenesis of midline incisional hernia. Eur J Surg. 2001;167:909-914.

Nahabedian M.Y., Manson P.N. Contour abnormalities of the abdomen following TRAM Flap breast reconstruction: A Multifactorial Analysis. Plast Reconstr Surg. 2002;109:81-87.

Nahabedian M.Y., Dooley W., Singh N., Manson P.N. Contour Abnormalities of the abdomen following breast reconstruction with abdominal flaps: The role of muscle preservation. Plast Reconstr Surg. 2002;109:91-101.

Reid R.R., Dumanian G.A. Panniculectomy and the separation-of-parts hernia repair: A solution for the large infraumbillical hernia in the obese patient. Plast Reconstr Surg. 2005;116:1006.

Saulis A.S., Dumanian G.A. Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in “separation of parts” hernia repairs. Plast Reconstr Surg. 2002;109:2275.