Massive panniculectomy: a novel method of treatment of postlaparotomy wound dehiscence in morbid obesity

Abstract

It was with interest that we read the article “High-concentration oxygen and surgical site infections in abdominal surgery: a meta-analysis.”1 Massive liposuction and body contouring procedures are no longer primary therapeutic options for the treatment of morbid obesity owing to their complications and suboptimal results. The obvious paradigm shift has been noted to favour bariatric procedures since the advent of laparoscopic approaches over last 2 decades. Panniculectomy is a cosmetic procedure that involves the removal of excess skin and fat from the affected organ. We performed massive panniculectomy for the treatment of postlaparotomy wound dehiscence in a morbidly obese patient. A 60-year-old woman with body mass index (BMI) of 41.7 underwent a total abdominal hysterectomy for dysfunctional uterine bleeding. A surgical site infection and dehiscence involving skin and subcutaneous layers across the complete length of incision developed in the immediate postoperative period. The initial treatment at the primary centre involved drainage, debridement and regular dressings. The patient was referred to our centre for further management in postoperative week 4. Upon clinical examination, we observed that the abdomen skin fold was thick and large, and it was difficult to examine the dehiscence suture line in the recumbent position (Fig. 1A). The bacteriological study of culture and sensitivity from the abdominal wound was unremarkable; blood work was essentially normal. After counselling the patient and her relatives, a decision was made to repair the wound with massive panniculectomy to remove excessive skin and subcutaneous tissue from the abdomen. The excessive abdominal skin complex incorporating the suture line and the umbilicus was removed (weighing 8.5 kg) and the procedure was completed. The duration of the surgery was 180 minutes; blood loss was minimal (100 mL). The postoperative period was uneventful and the wound healed well, with no excessive abdominal fold. The patient was able to resume her normal activities 14 days after the procedure (Fig. 1B). Fig. 1 (A) Clinical picture showing laparotomy wound dehiscence. (B) Postoperative picture of the suture line shows good healing after massive panniculectomy surgery. Management of morbid obesity involves a trial of strict diet and exercise, followed, if unsuccessful, by one of the various bariatric surgical procedures. Plastic surgical intervention usually comprises massive liposuction and body contouring with or without lumpectomies after achieving weight loss. Panniculectomy is a procedure that involves the removal of excess skin and fat from any part of the body. This procedure is different from abdominoplasty, which involves tightening of the muscles. Panniculectomy is done routinely after massive weight loss (e.g., after bariatric surgeries), where excessive skin and subcutaneous fat are removed to enhance appearance and improve confidence. When more than 10 lbs of tissue is removed, the procedure is known as massive panniculectomy.2,3 Abdominal wall hernia repair is treated with mesh repairs, component separation technique and pedicled fascia lata flap. In our case, excess bulk of the abdominal wall mass was dragging in multiple directions, thereby stretching the operative wound and preventing it from closing. During the procedure, the previous vertical wound was excised en masse with the excess abdominal apron and umbilicus using a supra pubic Pfannensteil incision; the postexcision wound was closed transversely corresponding to the relaxed skin tension lines. Therefore, a reduced abdominal wall mass and a new suture line along the relaxed skin tension lines enabled us to have good wound healing and increased patient satisfaction. We conclude that panniculectomy, which is primarily a cosmetic method of excess skin and fatty tissue removal, can be used to treat postsurgical wound dehiscence in morbidly obese patients.