Introduction

In 2009 Germany has become the nation with the most obese people in the whole of Europe. This statistic reveals that obesity with its comorbidities has developed into a widespread disease.

There are numerous conservative and operative strategies for the treatment of obesity. Plastic surgeons are increasingly confronted with the need for body contouring after massive weight loss through dietetic methods or bariatric surgery.^1–5

A few superobese patients, however, do not respond to the conventional treatment regimens. Then follows a vicious circle with reduced mobility and thus reduced calorie consumption. Reduced food intake alone is in this case often not sufficient to achieve an appropriate weight loss.

Patients with marked pannus usually have, in addition to significant medical comorbidities such as metabolic syndrome and premature arthritis, massive problems of hygiene in the lower abdominal fold, with recurrent furuncles, abscesses, and fistulas. In addition, distinct functional problems exist such as immobility, with the development of secondary lymphedema, chronic ulceration on the extremities, and pressure sores. Some patients with high body mass index show severe elephantiasis in the entire abdominal wall. Quite often there are additional problems in micturition, especially in male patients whose genitalia are completely obstructed⁶ (Fig. 27.1).

FIG. 27.1 (A, B) Patient with a pannus morbidus, presenting a permanent lymphedema of the abdominal wall. Secondary lymphedema on right leg due to compression of the inguinal region.

Current European guidelines recommend bariatric surgery in those patients with a body mass index of 40 and in those with an index of 35 accompanied by significant comorbidities. For patients with a body mass index higher than 60, the surgical treatment is often difficult, because the abdominal wall is very fat, and what can be achieved with the instruments is often limited. The parallel existing immobility is often an additional postoperative risk.

Historically, panniculectomy was done only in selected cases, when there was complete immobility, or patients were not suitable for bariatric surgery. The aim of such intervention was to interrupt the vicious circle of lack of mobility and insufficient calorie consumption. This was usually followed by a successful conservative weight reduction or bariatric surgery.^11–15

Today, such procedures are often performed together with bariatric surgery.^5–7 The plastic surgeon performs the panniculectomy, thus the general surgeon gains access to the abdominal wall and then laparoscopically places the gastric banding or performs a gastric bypass or sleeve.

The subsequent weight loss leads to an immediate increase in mobility. If the process of losing weight is completed and there is weight maintenance of about 1 year, subsequent plastic-reconstructive surgical operations are possible to complete the surgical treatment.⁸

Preoperative Preparation

Patients eligible for panniculectomy should be chosen carefully. Operations on such a patient population are always risky, since metabolic syndrome and the long-lasting cardiovascular stress tend to result in severe complications. Besides the increased general risks, however, there exist significantly increased surgical complication rates, with increased blood loss, excessive seroma formation, wound healing problems and necrosis. In the few publications related to this issue, complication rates are more than 50%; even serious events stated to be 2.5% seem not be substantially increased. Blood loss is given in the literature as significant (from 800 to 2500 ml with decrease of hemoglobin and a consequent transfusion requirement in more than 20%). Hernias were found in about 20% of patients and were treated mostly within the same session. The infection rate given in the literature is on average about 15%, due to poor preoperative hygiene.^9–11

For these reasons, strict indications and improved operational procedures are required. We have in the past sought for approaches to address the above-mentioned high complication rates. In the following, therefore, we present our concept, which has been derived from more than 20 years of experience with over 100 patients. The excision weight of our patients ranged between 10 and 65 kg.

Regarding the case history it is important to find out how many serious attempts to diet have been undertaken and whether there are exclusion criteria for bariatric surgery. The normal course of the survey includes, first of all, a classification of the pannus in the degree classification according to Igwe:¹²

FIG. 27.2 Igwe grade 1 deformity: coverage of the pubic hair.

FIG. 27.3 Igwe grade 2 deformity: coverage of the mons pubis.

FIG. 27.4 Igwe grade 3 deformity: coverage of the upper third of the thigh.

FIG. 27.5 Igwe grade 4 deformity: coverage of the top half of the thigh.

FIG. 27.6 Igwe grade 5 deformity: coverage of the knee and below.

In addition to this classification the presence of a permanent lymphedema of the abdominal wall (elephantiasis) needs to be documented. In this case it is called a pannus morbidus and recurrence after abdominal amputation in later courses of surgery is almost certain (Fig. 27.7).

FIG. 27.7 Pannus morbidus. (A) Preoperative (B) Postoperative (C, D) Postoperative

Furthermore, we look for secondary lymphedema in the extremities; carefully inspecting the abdominal fold, the umbilical region, and the external genitalia, especially for intertriginous inflammation, boils, or abscesses. The abdomen is carefully examined in the supine and standing positions for clinical hernia. In particular, the umbilical region is a predilection site. An exploratory ultrasound of the abdomen should be mandatory, because the clinical examination is often difficult. In most cases, we also request a CT scan of the entire abdomen for safe exclusion of a hernia, and a Doppler ultrasound of the deep venous system for the safe exclusion of thrombosis.¹³

Besides the usual laboratory tests, we look in particular at protein balance and wound healing parameters, such as zinc, vitamin C, and other trace elements.

Early involvement of anesthesiologists is advisable to optimize the preoperative situation in order to accomplish any therapeutic recommendations early enough. Breathing exercises should be initiated 1 month before the operation.

A preliminary cardiological examination should follow to check the resilience of the cardiovascular system. The substantial electrolyte and fluid shifts due to the large volume of excision are to be taken into account. If there is a lymphedema of the abdominal wall, the patient should be hospitalized for a few days before the operation to elevate the abdominal wall, to perform lymph drainage and forced diuresis, balancing the electrolytes in control of the renal parameters. On the preoperative day the patient should take only a liquid diet and reduce drug support. The abdominal fold should be treated at least a week before surgery with antiseptic soaps and the umbilical region with antiseptic ointment. Two hours before surgery the patient is preheated with prewarmed infusions and surgical table covers are provided. Antithrombosis stockings are applied.

A urinary catheter is applied, as well as a central venous catheter for measurement of the central venous pressure and an arterial cannula for continuous blood pressure measurement.

With initiation of anesthesia, an intravenous antibiotic treatment is given and the patient is well padded and supported with a Bear-Hugger blanket.

Surgical Technique

Immediately after the initiation of anesthesia the pannus is to be lifted (Fig. 27.8). To facilitate this procedure two to three conventional meat hooks are placed after stitch incisions at the apex of the abdominal wall (Fig. 27.9). Then, a patient lift, such as that found on most intensive care units, is pushed through the abdominal wall and iron chains suspended from the meat hooks. Slowly, and with continuous monitoring of the central venous pressure, the pannus is now lifted. This maneuver is carried out slowly, as there may be a significant relevant effect on the circulation due to interstitial and intravascular fluids. It follows an improvement in breathing resistance and a return blood flow in the sense of an autotransfusion (Fig. 27.10).^11,14,15

FIG. 27.8 Preparing the patient in a beach chair position.

FIG. 27.9 Elevating the pannus with hooks and hains using a patient lift.

FIG. 27.10 During prep and drape the pannus is elevated in terms of autotransfusion. After 20 min. the base of the pannus is infiltrated with tumescent fluid.

When the maximum height is reached the base of the area to be excised is infiltrated with tumescent solution to allow the most anemic preparation. Now the abdominal fold is meticulously disinfected and the bladder catheter is placed. Then the lifting crane is slightly released, so that the resection marks can be checked once more for tension-free closure. Afterwards the abdomen is scrubbed and sterile draped. The resection usually starts with two surgeons working in parallel. By using a Colorado needle for the incision it should be ensured that the lower incision is made strictly at 90° to the abdominal wall, so that no high tension on the skin occurs later. This follows the preparation to the upper resection marks, preserving Scarpa’s fascia in order to avoid seroma (Fig. 27.11). To prevent heat development and seroma we use an ultrasound cutting device, which shows significantly less fluid collection postoperatively.¹⁶ We avoid further preparation to prevent any unnecessary cavitation. In general, the umbilicus is resected, as an umbilical transposition would require further preparation that in turn would increase the likelihood of further cavitation. The voluminous periumbilical veins are either clipped or ligated.

FIG. 27.11 (A) Starting the resection from both sides using clips for hemostasis of the large vessels. (B) Care must be taken not to run into hernia especially around the area of the umbilicus. (C) The patient lifter enables you to manage the huge weight of the pannus.

In this region the surgeon has to watch out for hernias as they can occultly occur around the navel (Fig. 27.12).

FIG. 27.12 The resected pannus is weighed with a lot of edema is inside.

Then the pannus is cut off and weighed. In the upper section of the incision line a 90° angle is essential in order to achieve good adaptation to the lower cut line (Fig. 27.13).

FIG. 27.13 Primary closure can easily be achieved without undermining to prevent seroma. Baroudi stitches may be helpful to close the existing dead space.

If a bariatric surgery is planned in the same session, the general surgeon is now involved and usually performs the intervention laparoscopically. Because of the removal of fat it is now easier to use the instruments. In case of high intraabdominal pressure it is possible to switch to an open procedure.

Finally, the entire wound is again checked for bleeding and rinsed carefully and thoroughly with sodium chloride. The wound is closed in multiple layers, and multiple Baroudi sutures are applied to reduce the cavities. In particular, Scarpa’s fascia is adapted exactly to minimize the tension of the skin. We insert multiple drains and plug them in a vacuum pump with continuous pressure. The closure of the skin is done atraumatically intracutaneously, with additional application of PRINEO-topical skin adhesive to prevent local wound infections (Fig. 27.14).

FIG. 27.14 Wound closure in multiple layers using several drains and a permanent vacuum pump.

Case studies are shown in Figs 27.15–27.22.

FIG. 27.15 Patient after Roux-en-Y bypass and weight loss of 180 kg. He presents with a double pannus grade 5 and a hernia of the umbilicus.

FIG. 27.16 Elevating the abdominal pannus shows the elephantiasis of the mons pubis.

FIG. 27.17 Functional problems.

FIG. 27.18 Frontal view demonstrating the mons pubis.

FIG. 27.19 Elevating the abdominal pannus and the mons pubis, demonstrating the hidden penis and scrotum.

FIG. 27.20 After complete resection of the abdominal pannus and mons pubis, hernia repair and umbilicus transection and excavating the penis, lateral view.

FIG. 27.21 After complete resection of the abdominal pannus and mons pubis, hernia repair and umbilicus transection and excavating the penis, frontal view.

FIG. 27.22 Same patient wearing his old clothes.

Optimizing Outcomes

The surgical concept is developed to avoid major complications such as blood loss, seroma, and wound healing problems.

To prevent blood loss, we start the operation directly with the autotransfusion, use the tumescent infiltration solution, and finally incise the skin with the Colorado needle to avoid microbleeding. In this way the transfusion rate can be reduced to 11%.

Most complications can be attributed to wound fluid retention. Therefore, the prevention of fluid loss has highest priority. We showed in an evidence-based study level I that the use of an ultrasonic scalpel results in less blood loss and lower seroma rates.¹⁶ Furthermore, a preparation preserving Scarpa’s fascia has also the advantage of not damaging the underlying lymphatic network. Thus less seroma occurs. The insertion of drains in abdominoplasty is also evidence based. In this case we insert multiple drains and connect them to a continuous vacuum system. The significant advantage is that not only are the liquids aspirated, but a continuous negative pressure causes the wound surfaces to stick together more effectively. The use of Baroudi sutures is also evidence based and leads to a reduction of the cavities, as well as progressive tension sutures, which reduce the tension of the wound surface.

Studies have not yet shown a significant reduction of seroma using fibrin glue.

Wound healing in this patient population occurs very often and is not an exception. First, most patients have significant endocrinological comorbidities as well as nutritional deficiency.

Important factors such as zinc and vitamin C may be evaluated preoperatively and if necessary supplemented. A protein deficiency can also be easily compensated before surgery. Intensified hygiene with antiseptic soaps may also lead to an improvement of the local wound healing. The topical skin glue PRINEO also effectively prevents any secondary bacterial infection.

The operation time plays an important role in respect of the complication rate. Usually two surgeons operate simultaneously, so that the operation time does not exceed 90 minutes (Fig. 27.23).

FIG. 27.23 (A, B) Clamps may be helpful to get a better overview during preparation.

Postoperative Treatment

In the early recovery phase the patient lies in the beach-chair position covered with Bear-Hugger blankets. In rare cases postoperative ventilation is useful; however, a stay in the intensive care unit is recommended. Because of the potential electrolyte and fluid imbalance in particular, this approach has been established in our department.

Directly after surgery, we start with the injection of weight-adjusted low molecular weight heparin and a calf muscle pump. The breathing exercises begin 2 weeks prior and right after surgery.

In general, patients are carefully mobilized on the first postoperative day to prevent thrombosis. An abdominal compression garment, specially made for this patient, is applied. The perioperative administration of a single-shot antibiotic treatment is evidence based in abdominoplasty.

We do not deliver continuous antibiotics and regularly monitor the inflammatory markers. On the fifth postoperative day, we replace the vacuum pump by suction bottles and remove the drains if less than 30 ml per day is produced.

The wounds are disinfected twice daily and the dressing is done under aseptic conditions. Patients are showered with drains in place to reduce any local bacterial infection.

Complications and Their Treatment

With the concept presented here we managed to reduce the complication rate to an acceptable range for this patient group. Nevertheless, minor complications often occur and require special attention.

Early complications include hematoma, which should be aspirated early, sucked, or surgically removed because they encourage bacterial growth. Other complications include local inflammation and dehiscent wounds. Wound healing problems are treated by keeping the wound moist and closing early by secondary sutures. Larger wound-healing problems are treated with vacuum-assisted closure therapy. Hemoglobin decline is tolerated to a clinical relevance and a transfusion is provided if hemoglobin declines to less than 8 mg/dl.

In case of bariatric surgery at the same time blood glucose should be checked. Amazingly, the blood glucose returns to a normal level after bypass surgery within a very short time, so that insulin-dependent diabetic patients can easily become hypoglycemic.

In general, patients continue to receive reduced-calorie soft food, to keep the intraabdominal pressure as low as possible. Flatulent food should be avoided and drugs should be applied for prevention of meteorism.

To improve the microcirculation for the first 4 days the patients receive 2500 ml Ringer’s solution given intravenously. They are additionally encouraged to drink at least 3 liters per day. The preoperative drink containing protein, vitamins, and minerals is continued until wound healing is completed.

Seromas occurring after removing the drains are to be aspirated under sterile conditions. If necessary they can be drained and antibiotic injections can be used. Formation of a pseudo bursa needs to be excised.

Conclusion

Surgery in super obese patients with a high body mass index is always a precarious treatment. Due to the metabolic comorbidities and restricted blood flow and healing of the fat tissue, operations in these patients are carried out unwillingly. For the treatment of obesity physical exercise is part of the therapy. Mobility is restricted and often followed by a complete immobility due to the mechanical problems caused by the excess pannus.

The panniculectomy, once considered a last resort, can interrupt the existing vicious circle. By regaining mobility, the calorie consumption is increased and dietary approaches can be pursued. Clinical experience shows that this particular group of patients can rarely be managed without bariatric surgery. The simultaneous combination of surgical intervention and panniculectomy has been established as a useful concept.

The planning of the operation requires strict indications and extensive preparation to make the postoperative complications as few as possible. Special emphasis should be given to the specific metabolic situation.

The operation is preferably done by two surgeons simultaneously to ensure rapid progress. Criteria for the prevention of seroma and bleeding need to be taken into account. The postoperative course is characterized by early mobilization and prevention and treatment of wound healing problems.

In case of a positive clinical course, great weight loss and weight maintenance patients will be prepared for further plastic reconstructive interventions.