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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_731_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 12 • Panniculectomy and Abdominal Wall Reconstruction 211
Figure 12-7.
212 Section V • Other Abdominal Wall Procedures
2. Technique of Perforator Sparing
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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.
Undermining can be performed using electrocautery or blunt dissection techniques. A
blunt, tapered-point surgical scissor or clamp can be used to separate the perforator from
the surrounding fat. An alternative approach is to use a low-voltage electrocautery device
with a fine-tip surgical clamp.
In general, smaller perforators (<1 mm) are usually cauterized. Larger perforators (1.0 to
2.5 mm) can be preserved. The presence of a palpable pulse in the perforator is recommended when considering preservation.
The number of perforators to be spared is also variable and depends on the body habitus
and the thickness of the abdominal pannus. Personal experience has demonstrated that
preservation of a single perforating vessel on each side of the hemiabdomen is usually adequate. Surgeons also should be aware that in some patients with multiple hernia repairs,
perforating vessels may no longer be present.
3. Technique of Skin/Fat Excision
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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).
Before the operative incisions, measures to control and limit blood loss may be considered.
One such maneuver is to place tumescent fluid into the soft tissues of the pannus. The
typical tumescent solution consists of 1 ml of 1:1000 epinephrine solution per liter of lactated Ringer solution.
Typically, the panniculectomy is performed after the hernia has been completed. This is
important in order to better assess the exact amount of skin and fat to be excised. In cases
where an open component separation has been performed, it is important to preserve perforators when possible to optimize skin perfusion.
Once the hernia repair is complete, the soft tissues are further undermined off of the ante-
rior 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
Chapter 12 • Panniculectomy and Abdominal Wall Reconstruction 213
Figure 12-8.
Figure 12-9.
Figure 12-10.
214 Section V • Other Abdominal Wall Procedures
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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.
In cases where the hernia is extremely large and associated with a loss of domain in which the
hernia sac is lining the deep fat layer, the sac or scar is excised because it may be a nidus for
infection. The skin flaps are then elevated and redraped in order to determine how much will
be excised. Skin excision is performed sharply to minimize any thermal damage to the edges.
Chapter 12 • Panniculectomy and Abdominal Wall Reconstruction 215
Figure 12-11.
Figure 12-12.
Figure 12-13.
216 Section V • Other Abdominal Wall Procedures
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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.
Chapter 12 • Panniculectomy and Abdominal Wall Reconstruction 217
Bilateral costal
margin incisions
Anterior
axillary lines
“Mercedes”
skin incision
Figure 12-14.
Equilateral triangle flap
(length 15-20 cm)
Groin
2 cm
Lower border of
horizontal component
Trifurcation point
Figure 12-15.
Advanced inferior
triangle flap
Large caliber,
closed suction
drainage catheters
218 Section V • Other Abdominal Wall Procedures
4. Closure Techniques
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Before skin closure, the wounds are copiously irrigated with an antibiotic solution. Closed
In some cases, the incision is not closed completely and a negative pressure wound therapy
4. Postoperative Care
1. Hospital Care
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Antibiotics: Postoperatively, patients are continued on intravenous antibiotic. In some
Drains: The duration of the drains is variable and based on quantity of fluid and the need
Venous thromboembolism (VTE): All patients following hernia repair and panniculec-
Nutrition: Nutritional status is assessed and diets are advanced as tolerated once bowel
Length of stay: The length of hospital stay is variable and depends on various factors.
suction drains are placed in the lateral gutters and as needed for the hernia repair. These
drains are usually large caliber and can be inserted through the incision or via a remote
skin site. The closure is completed in layers using absorbable sutures in the Scarpa layer
and the dermis. The cutaneous closure can be performed using staples or sutures, depending on the perceived risks of infection, delayed healing, and incisional dehiscence.
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.
centers, antibiotic coverage is delivered during the perioperative period (24 hours). However, personal experience has been favorable with a 1-week duration. This may be prolonged in the setting of a postoperative infection.
for prolonged suction to promote tissue adherence. Typically, drains are removed when the
output is <30 mL/drain/day and usually left in place for 1 to 2 weeks.
tomy will require VTE prophylaxis in the form of pneumatic compression devices and
chemoprevention using pharmaceutical agents such as Lovenox or subcutaneous heparin.
Pulmonary consideration may be relevant because the added pressure on the diaphragm
from the hernia repair and the panniculectomy may increase airway resistance. Incentive spirometry and early ambulation are encouraged to improve pulmonary status and
circulation.
function has returned. In some situations when enteral feeding is not possible early, parenteral feeding is advised.
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.
Chapter 12 • Panniculectomy and Abdominal Wall Reconstruction 219
Figure 12-16.
220 Section V • Other Abdominal Wall Procedures
2. Home Care
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Following hernia repair and panniculectomy, patients are instructed to minimize strenu-
ous activities for 6 weeks. The use of an abdominal binder is appropriate once it is known
that tissue viability is certain. Patients may shower and get the incision wet on day 3 following surgery, if possible. Most patients will require a convalescence period of 1 to 2
months following surgery.
5. Management of Complications
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When performing panniculectomies in patients with abdominal hernias, one should not
be surprised in the event of complications. In the majority of cases, complications are
infection, soft tissue necrosis, and delayed healing or incisional dehiscence. Studies have
demonstrated that the incidence of a major postoperative wound complication in increased
sixfold when the BMI is greater than 35, and that those patients are 5 times more likely to
undergo reoperation.
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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.
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Soft tissue necrosis: Impaired vascular circulation, increased tension, or soft tissue infec-
tion 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.
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Incisional dehiscence: Dehiscence can occur because of tension or abnormal forces being
placed upon the incision. In the event of a pure dehiscence, secondary closure may be
indicated, However, in the event of contamination, local wound measures may be indicated for a period of time, followed by delayed secondary closure.