Caesarean delivery and celiotomy using panniculus retraction in the morbidly obese patient.

Abstract

One of the most challenging and least desirable surgical procedures is a Caesarean delivery in a morbidly obese patient, especially in an emergent situation. Because these patients have a substantial panniculus that extends well below the symphysis pubis even when the patient is positioned in a supine position, the operation is technically difficult, time-consuming, and associated with increased postoperative morbidity. Wound infection with dehiscence is a major postoperative complication in the morbidly endomorphic patient. Pitkin 1 reported a 29% wound complication rate in obese surgical patients compared with a 4% wound complication rate in nonobese patients. The type of skin incision for the extremely obese gravid patient remains controversial. There have been several reported surgical techniques with modifications specifically designed for the abdominal incision in the morbidly obese patient. 2,3 Although there have been anecdotal experiences of panniculus retraction in obese women, an extensive Medline review of the published medical and surgical literature failed to produce a single article describing a reliable, atraumatic approach to this increasingly common surgical dilemma. In an obese patient the area directly above the symphysis pubis is usually flat and firm. Unless the panniculus is retracted cephalad exposing this ideal incision site, the obese patient is a poor candidate for a Pfannenstiel or low transverse incision. Although early investigators concluded that the subpanniculus fold is the “worst place to make an incision,” 4 more recent studies on obese gravidas have reported good outcomes after Caesarean delivery using the Pfannenstiel incision. 5 Pfannenstiel incisions were not associated with increased blood loss, wound infection, or prolonged incision-todelivery time. Advantages of the Pfannenstiel incision are: less subcutaneous adipose tissue, a more secure closure because the abdominal muscles tend to pull the incision together with less postoperative pain, and earlier ambulation. 6 Transverse incisions are common in gynecologic surgery. Obese patients with uterine myomata or those who are undergoing an operation for an unruptured ectopic pregnancy or other benign uterine or adnexal disease are candidates for transverse incisions. While providing adequate access to the pelvis, the Pfannenstiel or transverse incision is associated with less risk of incisional hernias compared with vertical incisions. In the past, various makeshift techniques have been used for panniculus retraction, ranging from placing large retaining sutures in the skin or grasping the redundant skin with towel clamps and then attaching the instruments to intravenous poles, securing the panniculus with tape to an anesthesia screen, or having an additional assistant retract the panniculus throughout the operation. These techniques are not only awkward, but are also unstable, cumbersome, and potentially dangerous.