Abdominal Apron Research Articles

EP568 - A rare case of necrotizing fasciitis caused by Streptococcus Anginosus and Staphylococcus Lugdunensis

Abstract Necrotizing fasciitis (NF) is a rare soft tissue infection involving the fascial planes, causing rapid and extensive tissue destruction. We present a unique case of NF in a patient with poor glycemic control caused by atypical pathogens. A 66-year-old female with a recent biopsy for a wart-like lesion developed a wound infection, with greenish-black exudate. Initial observations were: temperature: 39.4 degrees, heart rate: 105, GCS: 15/15. Physical examination revealed a grossly filiform lesion below her abdominal apron measuring 7cm in diameter. The patient was empirically treated with IV Co-Amoxiclav. Abnormal biochemistry results are shown below. Microbiological analysis revealed Streptococcus Anginosus, anaerobes and Staphylococcus Lugdunensis. CT abdomen revealed extensive inflammatory changes with gas and fluid collection and enlarged pelvic and inguinal lymph nodes. Two urgent surgical explorations and debridements, with meticulous wound care using negative pressure wound dressings (Prevena) were done. Intravenous Gentamicin, Benzylpenicillin, Clindamycin, Metronidazole and Flucloxacillin were administered for six weeks. The patient's clinical status gradually improved. Streptococcus Anginosus, that is part of the Streptococcus Milleri group and Staphylococcus Lugdunensis, a coagulase-negative Staphylococci (CoNS) are commensal organisms of the oral and gastrointestinal tracts. These organisms possess virulence factors that facilitate tissue invasion and destruction, causing an aggressive course of NF. This case highlights the importance of considering atypical pathogens, especially in patients with predisposing factors such as diabetes and obesity. Early recognition, prompt surgical intervention and a multidisciplinary approach are essential for improving outcomes in these cases.TestResultWhite Blood Cells (WBC)22,200 [WBCs per microliter]Sodium123 [mmol/L]Chloride88 [mmol/L]C-reactive protein (CRP)318 [mg/L]Blood Glucose19.3 [mmol/L]

Skin to origin of mesenteric artery study (STOMA): prospective study of distances between stoma location and proximal superior mesenteric artery.

Traditional siting of stomas, in the lower abdomen, has been guided by surgical dogma lacking evidence. In the lower abdomen, the combination of a thick and pendulous abdominal apron, can create a challenging and suboptimal site for a stoma. The anatomical determinant limiting delivery of a stoma to the abdominal skin is the distance of the SMA from the lower border of the pancreas. The aim of this cross-sectional study was to compare the distance between the traditional stoma site, and upper abdominal stoma sites, to both the superior mesenteric artery (SMA) origin and SMA at the inferior border of the pancreas on abdominal computed tomography (CT). A cross-sectional study at a single academic university hospital of adult patients who underwent abdominal CT in Australia. Two hundred and thirteen patients were included. Stoma sites in the upper abdomen were 57-76 mm shorter to the origin of the SMA and inferior border of the pancreas than those positioned at the traditional stoma site (P< 0.001). The mean panniculus thickness in the upper abdomen was 10 mm thinner than in the lower abdomen and increased with increasing BMI (P< 0.001). The ratio between the distance from the xiphisternum to umbilicus, and the umbilicus to pubic symphysis, was 1.10; this ratio increased with increasing BMI. The distance of the SMA to the skin is always shorter in the upper abdomen compared to the traditional stoma site. Consideration should be given to placing stomas in the upper abdomen, particularly in overweight or obese patients.

Is simultaneous panniculectomy an ideal approach to repair a ventral hernia: a general surgeon’s experience

The number of Australian patients undergoing ventral hernia repair has seen a significant increase in the last twenty years. With the obesity epidemic, the general surgeon is frequently seeing patients with hernias and significant abdominal aprons and is being asked to address this at the time of the hernia repair. This can be performed utilising a general surgery and plastic surgery team, but there may be some advantages to general surgeon being able incorporate this into their practice. We present our approach to patients undergoing ventral hernia repair and simultaneous panniculectomy (VHR + PAN) by a single general surgeon. Data were analysed from a single surgeon's experience performing VHR + PAN at the same operation. Data were collected prospectively from 2009 to 2020. 146 cases of patients undergoing VHR + PAN were identified and included in this study. The mean age of patients undergoing VHR + PAN was 58years. The mean BMI was 35, with 59% of patients losing weight loss prior to surgery. 66% of patients had a hernia repair with biosynthetic mesh and 91% of patients had retro-rectus or pre-peritoneal mesh approach to the repair. 42% of patients had a post-operative complication with 80.6% of these being related to surgical-site occurrences. Other complications included gastrointestinal (14%), respiratory (13%) and venous thromboembolism, such as a deep vein thrombus or pulmonary embolism (6%). There were 2 deaths in the series (1.3%). The hernia recurrence rate was 6%. Simultaneous PAN is possible in patients with an abdominal apron who are undergoing VHR, with an acceptable risk of SSOs and other complications. This technique provides excellent exposure and with appropriate training is well within the remit of the general surgeon. This may save further operative management in the future and can offer patients improved self-esteem, mobility, and independence. Patient optimisation is key, paying careful attention to pre-operative weight loss, diabetic control, smoking cessation and respiratory function. VHR + PAN is an important technique that should be in the repertoire of all abdominal wall reconstruction units.

The Challenging Groin: Femoral Access Technique in TAVR

A 72-year-old with severe symptomatic aortic stenosis was admitted for transcatheter aortic valve replacement (TAVR). Medical history was notable for morbid obesity (body mass index = 47) with a large abdominal apron and para-umbilical hernia ([Figure 1][1]). Transthoracic echocardiography showed

How to repair parastomal hernias involving the abdominal apron: to move or not to move

How to repair parastomal hernias involving the abdominal apron: to move or not to move

Sleeve Gastrectomy with Concomitant Abdominoplasty: A Novel Procedure

Background: Obesity is a major health problem and bariatric surgery has been shown to be the most effective approach in the management of obesity. Abdominoplasty is a common aesthetic procedure for divarication recti with abdominal apron and it has a wide appeal. The aim of this study is to determine the usefulness of laparoscopic sleeve gastrectomy with concomitant abdominoplasty.Subjects/methods: This is a retrospective study over a 7 - year period from 2009 to 2015, conducted on 82 patients who underwent sleeve gastrectomy and simultaneous abdominoplasty at Sunrise Group of Hospitals, Kochi and Dubai. A classical Pfannenstiel incision was made and the skin flap raised, laparoscopic sleeve gastrectomy carried out with the usual port placement directly on the sheath. Ventral hernia (if present) repaired, neoumbilicus created, redundant skin and fat excised and the flap sutured in layers over suction drains. Patients were followed up indefinitely.Results: Eighty two patients underwent combined laparoscopic bariatric surgery and abdominoplasty. Of these, 68 (82.93%) had ventral hernia repair carried out and 14 (17.07%) underwent abdominoplasty alone. The median length of stay was 4 days. 6 patients developed postoperative seroma, and 1 patient had surgical site cellulitis; whereas 3 patients developed surgical site infection. To date, one patient required a revision abdominoplasty.Conclusion: Considering the advantages, comparable hospital stay and the low rate of complications, it would be safe to conclude that LSG with concomitant abdominoplasty is a beneficial procedure in patients of obesity and abdominal apron.

Comment on "Panniculectomy Combined with Bariatric Surgery by Laparotomy: An Analysis of 325 Cases".

We would be happy to comment on the study by Dr. Colabianchi et al. on the role of synchronic panniculectomy and bariatric surgery when performed by laparotomy. As the authors mention in the article, bariatric surgery can be combined with panniculectomy during the first stage. Although controversial, the authors present the experience of 325 cases [1]. Interestingly, there are few reports that mention this approach compared to performing a regular panniculectomy separately from bariatric surgery and only after the weight loss of the patient has been stabilized. This last approach could be better in order to perform an optimal and maximal panniculectomy with a better esthetical result. However, most of the patients will not reach a perfect aesthetic result. In fact, it is not the goal for bariatric surgery. The goal is improving quality of life and reducing the comorbidities associated with the severe obesity [2]. For this purpose, the initial panniculectomy can be more interesting avoiding a second surgery to the patient, with acceptable final results and leading to a better quality of life since the early beginning after bariatric surgery [3]. As we have read, the authors do not report any special complication in the postoperative period once the bariatric surgery is combined with the panniculectomy specially when the technique is perfectly reproduced. Thus, it can be encouraged as far as the procedure is performed open. A clear way to perform the technique, including a specific training or learning curve, should however be included in the protocol before attempting massive panniculectomy to patients simultaneously with bariatric surgery. Another comment that appears is regarding the approach to perform the bariatric surgery. Interestingly, the authors mention a series belonging to some years ago. Regarding the role of laparoscopy nowadays, the index of penetration of laparoscopy in bariatric surgery has increased in a tremendous way much more even compared to colorectal surgery [4]. This surgical approach would suggest that the panniculectomy cannot be done in the same way, but this still should be demonstrated. When we think of minimally invasive surgery, we do not see a maximal panniculectomy; however, a special focus should be done while differentiating the two procedures although some of the benefits for the laparoscopic surgery in terms of pain control, hospital stay, or wound complications will not be achieved. As the readers know, a cholecystectomy can be performed laparoscopically on a second surgery combined with a panniculectomy after the weight loss of the patient has been stabilized. More rarely, but not uncommon, a combined panniculectomy during the bariatric laparoscopic surgery has been performed in order to allow pneumoperitoneum and performing the procedure. This combined approach is sometimes necessary to perform a laparoscopic approach. As the authors mention, further studies combining panniculectomy with laparoscopic bariatric surgery are necessary for comparison of results obtained by the different techniques. We would like to encourage multidisciplinary teams to analyse the benefit of the combined procedure including immediate reduction of the abdominal apron, prevention of lymphedema of the abdominal wall, improved personal hygiene and quality of life and self-esteem, satisfactory results with no need for revision surgery, and weight loss compared to standard laparoscopic procedure with associated panniculectomy after the weight loss of the patient. A very interesting data would be to combine in a randomized control trial patients who undergo bariatric surgery alone and combined and evaluate these issues according to grades, according to Igwe Jr. et al. [5]. More interesting is to know whether it is important to estimate the degree of satisfaction before and after any type of the proposed treatment. There is a clear need for the appropriate management of expectations before surgery is mandatory [6]. We believe that any intervention related to an obese patient must be optimal. The costs and benefits of any intervention should be stressed and it is important to define which is more cost effective the one-stage or two-stage procedure according to the final results and perioperative complications, even combining laparoscopic approach [7]. We can conclude that bariatric surgery can be combined with abdominal panniculectomy; however, a clear and accurate technique is needed in order to improve the patient's quality of life soon after surgery and during the weight loss period.

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

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.

Massive panniculectomy results in improved functional outcome

BackgroundPanniculus morbidus is a large abdominal apron found in morbidly obese patients. This condition creates a vicious cycle of weight gain and functional incapacity. Our study assessed the functional improvement in patients undergoing massive panniculectomy. MethodsA retrospective review of panniculectomies performed from 1994 to 2012 was conducted. Twenty-seven patients with resections >20 lbs were selected. Data on demographics, operative details, complications, and pre- and postoperative functional capacity (using the Steinbrocker Functional Classification) were collected. ResultsThe preoperative mean body mass index was 58 kg/m2, with a mean resection weight of 33 lbs. The overall complication rate was 74%. A statistically significant improvement in functional capacity (preop mean 3.7 vs postop mean 2.0; P < .0001) was identified. ConclusionsPanniculus morbidus is a functionally debilitating condition and massive panniculectomy is often the only treatment available. Our data suggest that massive panniculectomy is a viable option for patients functionally incapacitated by panniculus morbidus.

Massive panniculectomy and hernioplasty as a salvage procedure

Background Salvage panniculectomy is sometimes the only solution to remove a massive pannus or abdominal apron, which is the source of many physical, social, and emotional problems for the patient. Often, the panniculus morbidus prevents weight loss, as the patient cannot exercise and can lead to hygiene and chronic pain issues, including intertrigo, chronic infections, ulcerations, and low-back pains. The heavier the panniculus, the more marked the symptoms.

Integrated concept of treatment for reduction of morbidity after resection of panniculus morbidus associated with lymphoedema

A subgroup of grossly obese patients may develop a large hanging abdominal apron, panniculus morbidus, which can contain an element of lymphoedema. This hinders normal activities and prevents adequate hygiene. We reviewed published reports and found that the complications that result from resection of a panniculus had been well described, but the presence of lymphoedema and the possible benefit of appropriate physiotherapy was not addressed. Our first aim was to assess our overall morbidity. Secondly we assessed whether perioperative complex decongestive physical therapy had the potential to reduce the incidence of commonly encountered complications. We retrospectively reviewed the casenotes of all massively obese patients who had panniculectomies between 1998 and 2008. We identified two groups of patients, in the first of which were 38 patients who were given perioperative complex decongestive physical therapy (CDP). In the second group were 18 patients who had no additional treatment perioperatively. We then compared the differences between the groups in the incidence of complications, reoperation rate, duration of hospital stay, and wound complications. All the patients not given perioperative treatment developed a postoperative complication. Only 6 patients in the treated group had minor wound problems. The rates and severity of complications associated with this type of operation can be improved if the patient has access to additional care in a specialised rehabilitation centre during the perioperative period.

Are Pfannenstiel Scars a Boon or a Curse for DIEP Flap Breast Reconstructions?

Abdominal incisions and their subsequent scarring alter the vascular architecture of the abdominal pannus. This is of significance when reconstructing the breast with the deep inferior epigastric perforator (DIEP) flap. This study aimed to objectively investigate the impact of the lower abdominal Pfannenstiel scar in utilizing the DIEP flap. A retrospective study of breast reconstruction with DIEP flaps was conducted on patients who had a Pfannenstiel scar (n = 36) compared with patients who did not (n = 36). Computed tomography angiograms were analyzed for the numbers, positions, and dimensions of perforator vessels. Influence of the scar on the reconstructive outcome was assessed. The number of perforators was greater in the control group (mean, 9.14) compared with the study group (mean, 8.3) but was not significant, with marginal significance (p = 0.09). The percentage of found perforators with 4 mm or greater was significantly higher in the study group than in the control group (21.7 percent compared with 14.3 percent, respectively; p = 0.04). The position of perforators was more or less the same, and complications were also comparable in both groups. Pfannenstiel incisions result in undermining of the lower abdominal apron and, in most cases, division of the superficial epigastric vessels. This results in "ischemic preconditioning" of the flap, as has been evidenced by the increased dimensions of the perforators. Hence, flaps raised from these abdomens are not only safe but may even be better vascularized. Therapeutic, III.

“Uro-Abdominoplasty”

The aim of this study was to describe the indications, surgical technique and outcomes of abdominoplasty as a novel tool for revising complicated urostomies. Four patients (3 female, 1 male; mean body mass index = 32 kg/m; mean age = 56 years) who underwent abdominoplasty for urostomy revision 2007-2009 were identified. Ileal conduits had been performed following ablative or diversion surgery for cervical carcinoma, bladder carcinoma, interstitial cystitis, and neuropathic bladder. A postal questionnaire was used to establish pre- and postabdominoplasty stoma function. Patients were referred to the reconstructive team with problems fitting their urostomy-appliance leading to urinary leakage, skin irritation, and social embarrassment. Uro-abdominoplasty indications included multiple abdominal scars (n = 2), large abdominal apron (n = 4), and deep skin creases (n = 2). Three patients had undergone previous failed urostomy repositioning or peristomal liposuction. The joint plastic surgical-urological operations lasted a mean of 3 hours, with no major postoperative complications. Patients were discharged 8 days later. Of 4 patients, 3 reported improved appliance fitting and reduced urinary leakage (>50%) and the remaining patient had intermittent leakage due to a persistent abdominal fold superiorly, and has since undergone reverse abdominoplasty. Two patients complained of long-term lower abdominal numbness, but all 4 were satisfied with the aesthetic improvement. Abdominoplasty has been successfully used in our center for the purpose of improving urostomy dysfunction of intractable mechanical leakage by creating a flatter surface for appliance fitting. Uro-abdominoplasty widens the reconstructive repertoire of plastic surgeons and can be considered in those who have exhausted conservative or simpler surgical solutions.

Massive paraumbilical hernia: not all is as it seems

We discuss the management of an otherwise healthy obese patient who presented with a massive paraumbilical hernia extending into a large lymphoedematous abdominal apron. After anaesthetic assessment and abdominal computed tomography (CT), the patient underwent an elective operation. The hernia was dissected free of the heavy lymphoedematous apron with the aid of orthopaedic pins and a motorised patient lifter. Despite the size of the hernia, the primary defect was found to be relatively small and easy to reduce. The defect was repaired with a sublay Proceed(®) mesh and skin closure was achieved primarily. The patient had an uneventful post-operative course and gained significant improvement in her mobility.

Dealing with the Mass: A New Approach to Facilitate Panniculectomy in Patients with Very Large Abdominal Aprons

Panniculectomy surgery is performed to remove a massive pannus, or abdominal apron, which frequently contributes to a number of health concerns. The resection of such a massive abdominal panniculus is technically difficult due to the weight of the tissue and the difficulty in handling it during surgery. We performed a retrospective review on 20 morbidly obese patients (14 male, six female) who underwent a panniculectomy with a resection weight of >6 kg between November 2003 and November 2007 at our department. The patients' weight ranged from 90 to 240 kg, with a mean weight of 157.6 kg. The redundant pannus weighed from 6.8 to 60.0 kg. Uncomplicated healing occurred in 55% of cases. Further complications were not observed. The treatment of a massive panniculus requires a multitask management considering optimal conditions for the surgeon and patient. Based on our experience from 20 patients over 4 years, we are able to present our standardized and improved technique using a mechanical lift and a tumescent solution to facilitate this procedure.

Pseudotumors after Primary Abdominal Lipectomy as a New Sequela in Patients with Abdominal Apron

Malnutrition and overweight is a common problem in modern societies. Primary abdominal lipectomy is a standard surgical tool in patients with these problems. However, unknown secondary problems result from recent advances in obesity surgery. Plication of the anterior musculoaponeurotic wall is a widely and commonly used operative technique during abdominoplasty. Many different plication techniques have been published. So far no common standard and long-term effectiveness is proven. In addition, there is no sufficient literature dealing with the postoperative risks of plication of the musculoaponeurotic wall. Four patients with development of pseudotumors were reviewed. All four patients received 12 months in advance a primary abdominal lipectomy including a vertical plication of the musculoaponeurotic wall. All four patients were females with mean age of 61 years and mean body mass index (BMI) of 37 kg/m(2). All four patients had developed a pseudotumor of the abdomen as a long-term complication more than 12 months after primary abdominal lipectomy including a vertical plication of the anterior rectus sheath. One should be aware of the potential long-term risk of secondary postoperative hematoma formation, with or without partial necrosis of the anterior rectus sheath after vertical plication of the anterior musculoaponeurotic wall. Viewed clinically and radiologically, such sequelas may appear as pseudotumor like masses and require immediate revision.

Abdominoplasty after Weight Loss in Morbidly Obese Patients: A 4-Year Clinical Experience

Morbid obesity is associated with various co-morbidities. With the significant weight loss, new dysfunctions arise, and prior body contour disorders start to severely affect the patient's quality of life. The abdominal apron is generally the greater and the first disturbance faced by the post-bariatric patient. The authors retrospectively reviewed their clinical experience in the treatment of those disorders through abdominoplasty. The benefits in terms of relief of said disorders and drawbacks in terms of surgical complications are described. 117 abdominoplasties were performed from January 2002 to December 2005 on patients who had lost significant weight. The tissue removed ranged from 400 g to 10,500 g of adipose-cutaneous tissue (mean 2,276.5 g). Mean duration of the procedure was 4 hours and 25 minutes, with a maximum of 7 and a minimum of 2 and 40. Complication rate was 50.43%. Abdominoplasty in the post-obese patient is an apparently simple procedure, which in fact causes a high rate of surgical complications. The complication rate is higher than that of cosmetic abdominoplasties. Nevertheless, the improvement in quality of life following such a procedure renders it a fundamental step in the rehabilitation of the formerly obese patient.

Bilateral breast reconstruction with the deep inferior epigastric perforator (DIEP) flap: an experience with 280 flaps.

Bilateral prophylactic mastectomy can reduce the incidence of breast cancer by 87 to 93% in high-risk individuals and is an appealing option for many patients if reconstruction can be provided with acceptable morbidity and outstanding esthetic results. Autogenous breast reconstruction techniques have evolved over the last 20 years to meet this goal. Familiarity with the deep inferior epigastric perforator (DIEP) flap led us to carry out simultaneous bilateral breast reconstruction with acceptable morbidity and superior esthetic outcome in 3 patient groups: (1) after bilateral prophylactic mastectomy, (2) after therapeutic and contralateral prophylactic mastectomy, and (3) after explantation of bilateral implant failures. A retrospective review of our experience with 280 flaps in 140 patients was performed. Average operating times, including time for implant removal or mastectomy and reconstruction, was 7.3 hours. Average hospitalization was 3.9 days. Significant perioperative complications occurred in 9 patients (6.4%); all returned to the operating room. This included 7 microvascular complications, 1 hematoma, 1 seroma, and 1 DVT. Less significant complications were divided into early and late. The early complications included 1.8% partial flap necrosis, 4.2% abdominal apron necrosis greater than 5 cm2, 2.9% seromas that required intervention, and 5.7% partial breast flap dehiscence. Late complications included 12.5% fat necrosis of any size and 2.1% hernia formation. Smoking, obesity, age, history of chest wall radiation, and flap size were evaluated as risk factors for increased morbidity.

Obesity, panniculitis, panniculectomy, and wound care: Understanding the challenges

Sixty-one percent of Americans are overweight, and 20% are considered obese. The number of obese adults has doubled since 1960, and the number of overweight teenagers has tripled. In many overweight people, skin and wound conditions develop over the abdominal area, largely because of the consequences related to a large abdominal apron or panniculus. Panniculectomy surgery is performed to remove a massive pannus, or abdominal apron, which frequently contributes to a number of health concerns and threatens quality of life. Some patients are candidates for surgical removal of the pannus, and some are not candidates for this surgery. Occasionally cellulitis develops over the panniculus, leading to panniculitis. Panniculitis can lead to skin and wound problems; likewise, skin injury can lead to panniculitis. Additionally, in obese patients who require general surgery in the abdominal area, skin and wound complications may develop simply as a result of having a large panniculus. In this article, local wound care and preoperative and postoperative nursing care are discussed and case studies are presented.

Panniculectomy, documentation, reimbursement, and the WOC nurse

Panniculectomy surgery is a reconstructive procedure performed to remove a panniculus, sometimes referred to as a pannus or abdominal apron. The pannus frequently contributes to a number of health concerns, including chronic wounds. Panniculectomy surgery becomes necessary for many patients who have had massive weight loss as a result of successful bariatric weight-loss surgery. Bariatric weight-loss surgery is one of the fastest growing specialties in America, and therefore, nurses can expect to care for increasing numbers of patients who require this reconstructive procedure. Despite the medical necessity of panniculectomy surgery, barriers to reimbursement exist. An update on the demographics of obesity, nationally and worldwide, are presented, especially as this information relates to the growing interest in panniculectomy surgery following massive weight loss. Bariatric weight-loss surgery and panniculectomy surgery are described and barriers to reimbursement are explained. The importance of wound care documentation in making the case for reimbursement is described, and a sample letter of appeal is provided. (J WOCN 2003;30:72-7.)