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25 Abdominoplasty inVentral Hernia
247
Table 25.1 Case selection
BMI<35 with abdominal skin redundancy
Young, motivated patients
Psychologically stable
HbA1c <7.4 (in diabetics)
No major systemic insufciency
Acceptable lung function
Smokers to stop 3weeks before and after surgery
laxis with low-molecular-weight heparin is
started the day prior to surgery.
Optimization for other systemic illnesses is
the same as that before any other abdominal surgery under general anesthesia.
25.3 Surgical Technique
(Table25.2)
Markings are performed preoperatively after taking clinical photographs in the standing and sitting positions. It helps delineate the hernial sac,
liposuction areas, and skin redundancy in the
abdomen.
After anesthetic induction, the patient is catheterized aseptically and pneumatic compression
devices are started for DVT prevention.
Tumescent liposuction of the anks and surrounding abdominal skin allow the skin aps to
become pliable while preserving the skin perforators and cutaneous nerve branches. 1:10,00,000
Adrenaline solution of Ringer’s lactate with local
anesthetic is inltrated in the areas of liposuction
15–20 min prior to the liposuction. It reduces
bleeding and permits hydro dissection in the
deeper fat planes, preserving Sub-Scarpa lymphatics and musculocutaneous perforators and
nerves (Fig.25.3). No liposuction is performed in
the hernia sac area, marked prior to anesthesia.
Following liposuction, the redundant skin is
excised and the hernia sac is visible. The amount
and location of redundancy dictate the choice of
skin resection pattern. In large ventral hernias
involving the supraumbilical abdomen, “anchor”
abdominoplasty [3] or Fleur de Lis abdominoplasty is usually necessary (Figs. 25.4 and 25.5).
When the laxity is limited to the lower abdomen,
Table 25.2 Surgical steps
Markings
Tumescent liposuction
Excision of redundant skin and fat
Hernial sac dissection
Hernioplasty
Midline recti approximation/bridging
Quilting of skin aps
Umbilicoplasty
Skin closure in layers
Fig. 25.3 Honeycomb appearance post-liposuction,
showing Scarpa’s fascia
traditional infraumbilical skin resection [1, 2] is
performed (Fig.25.6).
During infraumbilical skin resection, subScarpa lymphatics are preserved and diathermy
use is limited to attain hemostasis only. This
helps reduce seroma formation postoperatively
[5, 6].
Hernial sac dissection and hernioplasty are
performed by the Hernia team. Rectus muscles
are approximated over a sublay [7], macroporous
Polypropylene mesh (Fig.25.5g–i).
Prior to denitive skin closure, hemostasis is
ensured and “tailor tacking” is done by bringing
the skin aps together with skin staplers from lateral to medial, sequentially reducing the tension
at the midline closure. This step helps to trim
residual redundant skin and prevent dog ears,
both of which can be extremely dissatisfying for
the patient and a cause for unnecessary complaint
postoperatively [3].
248
R. Tondon and A. K. Agarwal
a
d
b
e
c
f
gh
Fig. 25.4 33-years-old female patient with BMI 29, underwent umbilical hernioplasty and Fleur de Lis abdominoplasty with primary umbilical reconstruction. (a, b)
Preoperative. (c, d) Preoperative abdominal CECT images.
(e) Preoperative markings. (f) Panniculectomy specimen. (g,
h) 8months postoperative
25 Abdominoplasty inVentral Hernia
249
a
c
b
d
e
Fig. 25.5 56-years-old female with BMI 33 underwent
ventral hernioplasty and Fleur de Lis abdominoplasty. (a,
b) Preoperative. (c, d) Preoperative abdominal CECT
images. (e) Preoperative markings. (f) Panniculectomy
f
g
specimen. (g) Hernia sac exposed. (h) Retrorectus mesh
placement. (i) Midline recti closure. (j) Abdominoplasty
closure. (k, l) 3months postoperative
250
R. Tondon and A. K. Agarwal
h
j
i
k
l
Fig. 25.5 (continued)
ac
25 Abdominoplasty inVentral Hernia
251
b
d
e
f
Fig. 25.6 29-year-old female patient with BMI 26 Kg/m2 underwent ventral hernioplasty and abdominoplasty with
primary umbilical reconstruction. (a–c) Preoperative. (d–f) 5months postoperative
Umbilicus inset is performed in the skin ap,
resecting a narrow kite-shaped skin (2×1cm) at
the designated position, defatting the skin marginally for umbilical inset, creating a natural
reducing the tension on the midline closure. The
skin is closed with 3-0 polydioxanone continuous
barbed dermal suture, followed by adhesive skin
closure bandages across the scar.
depression at the scar [8].
Sequential “quilting” of the thinned skin ap
is done in the midline, anchoring the umbilical
25.4 Postoperative Care
dermis to the fascia at 12 and 6 o’clock positions
with 3-0 PDS sutures. This reduces the dead
space [9] and tension on the scar and helps create
the slight midline depression, which is desirable
[1, 2].
The umbilical inset is done by four to six 4-0
poliglecaprone dermal sutures, keeping the
umbilical scar hidden. The supercial fascial
(Scarpa’s) layer is closed from lateral to medial
with interrupted 2-0 polydioxanone sutures,
Patient is nursed in Fowler’s position for 2days.
Pneumatic compression stockings are used until
the patient is mobile. Ambulation is started the
day after surgery. DVT chemoprophylaxis
(Enoxaparin) is started 12 h following the surgery and given for 2days only or until the patient
starts ambulating. Daily showers are started from
postoperative Day 2. The patient is discharged on
postoperative Day 3 or 4 after reviewing the
252
R. Tondon and A. K. Agarwal
scars. Light pressure elastic garments are prescribed for 3–6weeks to reduce edema.
The patient is instructed to walk at home and
perform light activities and is followed up every
week for 3weeks and then, every 3months for a
year, and annually thereafter. Heavy exercises
and exertional activities are permitted after
3weeks, once the scars have healed well.
25.5 Complications (Table25.3)
25.5.1 Local Complications
Bleeding and hematoma are commonly due to
inadequate hemostasis and unstable blood pres-
Table 25.3 Complications
Local Systemic
Bleeding and hematoma DVT with pulmonary
embolism
Seroma Abdominal compartment
Skin ap necrosis and
dehiscence
Scar stretching and
hypertrophy
Deformed umbilicus
Dog ears
Local sepsis
Dysesthesias
syndrome
sure in the immediate postoperative period. Small
hematomas may resorb spontaneously.
Hematomas >30 mL need ultrasound-guided
aspiration after they have hemolysed. Large
hematomas with skin bruising, although rare,
may need surgical drainage [3].
Seromas following abdominoplasty can be
prevented by adjunct liposuction, retaining the
sub-Scarpa lymphatic vessels and minimizing
dead space formation by quilting sutures. Small
seromas may resorb over a period of time, while
those larger than 25 mL may need serial
ultrasound- guided aspiration and local steroid
injection. Rarely, encapsulated and persistent
seromas will need surgical drainage [6].
Skin ap necrosis and dehiscence (especially
in the suprapubic area) are usually attributed to
over-exuberant resection, smoking, and excessive tension at closure [3, 4]. This can be prevented by meticulous preoperative marking and
planning. Marginal skin necrosis usually heals
over 3–4 weeks by secondary intention
(Fig.25.7).
Wider areas of skin necrosis require surgical
debridement, negative pressure dressings, and
secondary closure (Fig.25.8).
Scar stretching and hypertrophy are usually
related to marginal necrosis and healing by secondary intention.
a
Fig. 25.7 (a) Marginal skin necrosis. (b) Healed by conservative care in 4weeks
b
25 Abdominoplasty inVentral Hernia
253
a
b
c
Fig. 25.8 (a) Marginal ap necrosis with slough at 3weeks postoperative (BMI 39). (b) 2weeks post-debridement and
NPWT dressings. (c) 2weeks post-secondary suture
Dog ears at the edges of the scar are best prevented. They rarely improve with time and ultimately need surgical revision [3].
Umbilical deformities are usually related to
malpositioning and excessive visible scarring.
Often, the umbilical cicatrization is due to a
poorly perfused umbilicus [2, 8].
Dysaethesia is transient in the areas of liposuction and can last for 4–6weeks.
lipoabdominoplasty as compared to truncal liposuction. Therefore, prophylactic measures (SCD
pumps and LMWH) are very important in all
patients undergoing abdominoplasty [4].
Abdominal compartment syndrome (ACS)
results from a tight midline approximation of the
Recti muscles. Therefore, a tight closure should
be avoided and measures should be taken to
reduce postoperative bowel edema and ileus. In
the event of impending ACS, early detection and
decompression are the key to gut survival and
25.5.2 Systemic Complications
preventing mortality. Negative pressure wound
therapy for 5–7days may be used as a “bridge” to
The incidence of deep vein thrombosis and pulmonary embolism are 8–10 times more following
help the gut and parietal edema to subside before
secondary closure is attempted.
254
R. Tondon and A. K. Agarwal
25.6 Summary
A complete understanding of the altered anterior
abdominal wall anatomy in presence of ventral
hernia as well as the vascularity of the musculature and skin is imperative for planning abdominoplasty in hernia patients. Further, CECT of the
abdomen helps in illustrating the expected musculoaponeurotic defect and the hernia
characteristics.
Abdominoplasty in ventral hernia is a gratifying surgical procedure, provided proper case
selection, meticulous planning, and skillful execution are carried out.
Abdominoplasty in well-selected and prepared patients leads to improvement in quality of
life, activity levels, and self-esteem; without
increased morbidity [10].
The outcomes are excellent if a good coordination exists between the hernia surgeon and
plastic surgeon.
References
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