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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_884_Библиотеки_им_академика_М_И_Перельмана
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Fig. 9.3
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Fig. 9.4
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Duplicate Patient Information
The patient is first given comprehensive information about the objectives and risks ofthe procedure on the day of the first cons ultation.
A written record is kept of this.
One day before the surgical procedure, the patient is again given comprehensive information on two separate occasions: once by the surgeon
and once by the surgical resident. All the risks are set down in writing
at this time.
Severe blood loss requiring a transfusion of blood or blood components occurs rarely. An auto logo us blood donation may be very sensible for obese patients and for extensive reconstructions of the abdominal wall.
It is possible to avoid damaging the internal abdominal organs by carrying out an ultrasound examination before the operation and by ruling out hernias. Otherwise, if there is an umbilical hernia, the abdominal cavity may be opened up during the dissection of the navel. As the
wound surface is large, the patient must be made aware that postoperative bleeding, hematomas, and wound-healing disturbances may occur
following the operation. Therefore, the operation must be performed in
the hospital, careful postoperative wound checks must be carried out,
and thrombosis and antibiotic prophylaxis must be given.
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If thescars are taut, theymay enlarge and thismay result inthick,
distended, discolored, painful scars.
Preliminary Examinations
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Current preoperative routine laboratory tests, ECG, chest X-ray
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Clinical examination of thepatientwith ultrasound findings
to rule out hernias
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Possibly two autologous blood donations
Photographic Documentation
Overview image: Whole abdomen
Borders: Cranial: two finger-breadths above the xiphoid process
Caudal: 15 cm below the inguinal ligament
Medial/lateral: lateral sides of the hips
Surgical Planning
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Tightening of the abdominal wall is indicated if the skin no longer
shrinks following substantial weight loss, or after a pregnancy that has
overstretched the abdominal skin and, as a result of this, the elastic
fibers of the skin have been destroyed (cellulite) or the abdominal muscles have been strained and have moved away from one another in the
center , which has resulted in divarification with a midline hernia.
Retracted and painful scars following a gynecological operation (caesarian section) can also be a reason for tightening the abdominal wall.
If the patient is severely overweight, weight loss before the operation is
necessary. In rare cases, tightening of the abdominal wall may be combined with liposuction.
The operation is performed under general anesthesia. The type of
incision depends on the type and amount of surplus skin.
On the day before the operation, the surgeon has a discussion with the
patient about the changes requested by him/her and the performance of
the opera tion itself.
The incision is marked precisely on the patient, who should be in a
standing position. When doing this, it should be ensured that a median
line runs from the xiphoid process over the navel to the mons pubis
and that there are no differences in the sides when drawing the line. A
vertical incision is to be avoided. If there is not too much surplus skin,
it is better to site the incision slightly more cranially.
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The incision line is usually to be marked through the layer of fat and
the surplus skin. A good estimation of how high the incision must be to
avoid the necessity of a vertical incision can be made before the operation. This is the surgeon ’s art.
Whether the incision line is horizontal or W-shaped is not important.
The important factor is the patient’s individual anatomical characteristics, and the individual incision line should be adapted to these.
Thrombosis prophylaxis with s.c. fractionated heparin given once daily
should be started the day before the operation. This thrombosis prophylaxis should be continued for 10 days after the operation, as one of
the main risks in tightening of the abdominal wall is the danger of
thrombosis and embolism.
Intraoperative infection prophylaxis with cefaclor 2 g.
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Postoperative Treatment
In order to relieve the pressure on the sutures, it is necessary to position the bed in a specific way for the first 3 days after the operation.
The knees should be at an angle and the upper body slightly raised. The
patient should be mobilized as early as the first day after the operation
to prevent blood clots forming. Initially, there should be no extension
of the upper body, so that wound healing is not impaired. Frequent
movementofthelegsisgood,asthispromotesthereturnbloodflow.
On the second day after the operation, the Redon drains are remov ed,
the dressing is changed, and a special compression girdle is fitted.
Thrombosis prophylaxis (fractionated heparin s.c.) and antibiotic
protection (oral cefaclor) should be carried out for 10 days after the
operation.
The compression girdle should be worn for 4 weeks; then intensive care
should be taken of the scar with silicone gel and/or silicone plasters.
It is possible to resume sports activities after 8 weeks.
Typical Findings: Indications for Tightening the Abdominal Wall
The limit of the indications for liposuction in the area of the abdomen/
hips is exceeded if either the skin is slack and cracked (severe cellulite)
following pregnancies or all the skin of the lower abdomen is slackened
as a result of the aging process or extreme weight loss.
Theincisionlineismarkedthroughthesurplusskinandshouldnotbe
extended beyond this laterally and cranially in the bikini region.
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Fig. 9.5
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Marking the Individual Incision Line (Fig. 9.6)
Before the operation, the midline from the xiphoid process to the mons
pubis and the W-shaped or arched horizontal incision line will be
marked on the patient, who should be standing. The horizontal incision
line should be marked in the pubic hair boundary to approxima t ely
3–4 cm caudal to the anterior superior iliac spine on both sides or
steeper/straighter according to the requirements and the patient’s
characteristics. Therefore, the most wide-ranging incision variations
are possible, depending on the individual findings for the patient. It is
important that the incision line is marked in the relaxed skin tension
lines, preferably does not extend beyond the bikini region, and is
selected in such a way that a vertical incision is not required. It may
also be useful to mark the course of the costal arch for orientation.
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Fig. 9.6 a: Lower border of the incision edge
b: Lower boundary of the navel
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Positioning, Disinfection
The operation is performed with the patient in a supine position. The
upper body is raised by 30° and the hips and knee are slightly flexed. It
should be ensured that the extremities are well padded and positioned.
An indwelling catheter is inserted that should be left in place for 24 h.
Tumescence (Fig. 9.7)
Following disinfection and sterile draping, the incision is tumefied
with 500 ml tumescence solution (0.9% NaCl 500 ml, 1% prilocaine
250 mg = 25 ml, epinephrine 0.5 mg, 8.4% NaHCO
5mEq).The
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tumescence solution (500 ml) should not be injected more than twice,
and this will not be necessary. Larger quantities of tumescence solution
given under general anesthesia may increase the danger of thrombosis
and cause hypervolemia and even pulmonary edema.
Incision (Fig. 9.8)
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Following the individually marked incision line, a sharp incision is
made with the size 10 scalpel as far as the rectus fascia. The scalpel
should be introduced at an angle of 30° so that the resection edges can
be brought together later, section by section, without the formation of
cavities below and depressions above. The subsequent scar is a sign of a
well-performed abdominoplasty.
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Fig. 9.7
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Fig. 9.8
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