Combining abdominal contouring with hernia repair

Chapter 30 Combining abdominal contouring with hernia repair

• The optimal preoperative management that will improve outcomes and prevent complications is outlined.

• The technique of preoperative markings is described.

• The objectives of an excellent abdominoplasty are outlined.

• The technique of abdominal flap elevation is described.

• The methods of musculoaponeurotic abdominal wall repair are described.

• Postoperative management and treatment of complications are described.

Introduction

Patients requesting abdominal contouring to improve their appearance can present with defects of the skin/subcutaneous layer only, or external lamellar problems can be combined with musculoaponeurotic abdominal wall defects. These abdominal wall defects can vary from simple minor diastases of the recti muscles with weakness in the midline to frank midline hernias with significant separation and retraction of the recti muscle. In addition, between these two extremes, there is a spectrum of problems that requires attention.

Plastic surgeons should be prepared to repair these defects. The degree of confidence, previous training and the nature of the defect will dictate if these are repaired with or without the help of a general surgeon. The aim of this chapter is to describe the combined technique of abdominal wall contouring with the correction of abdominal wall bulges and/or hernias in the same operative setting.

Preoperative Preparation

The patient is prescribed Betadine showers and a routine antibiotic regime for gastrointestinal cleansing similar to that used for gastrointestinal surgery. This includes a clear liquid diet, laxatives, enemas, and antibiotics to decrease growth of the bacterial flora responsible for intestinal gas and stool production. Adequate intake of fluids and electrolytes during this process is recommended. In addition Reglan (chlorpropamide) 10 mg every 6 hours is prescribed to stimulate peristalsis in the early postoperative period.

This regimen aims to reduce intraabdominal pressure and prevent ileus paralyticus that is occasionally seen following major plications or myofascial advancements. This is more critical if the peritoneum is going to be invaded.

Increased intraabdominal pressure will produce increased tension on the myofascial line of closure and cause compression on the inferior vena cava. This, in turn, will produce stagnation of the venous return with the subsequent development of deep venous thrombosis (DVT). This bowel preparation seems to diminish postoperative abdominal pain and provides more comfort for the patient. Review of my cases has revealed that since we have routinely implemented this regimen, we have no reported cases of DVT despite lack of routine anticoagulant usage. There have also been no cases of ileus paralyticus or abdominal distention. The use of anticoagulants is not without significant side effects, mainly postoperative bleeding and large seroma formation.

Another important preoperative regimen is the patient wearing a progressively tighter abdominal binder or corset. This is particularly critical in those cases where you anticipate repair of large defects or significant tension and can preoperatively assess if the patient can tolerate large degrees of closure. The abdominal binder or corset is worn for a month at least but should ideally be worn for 3 months preoperatively. The abdominal binder also aims to prevent postoperative atelectasis and postoperative lung complications.

Prior to surgery the patient’s abdominal flaps are marked typically in a U-M pattern while they are standing (Figs 30.1 and 30.2). When the patient is lying down, all the reference points are lost and we cannot be precise in the degree of symmetry of the incisions. See references 1 and 2 for details of marking.^1,² These markings can be progressed to a grid type of pattern.³

FIG. 30.1 Reference landmarks and the U-M markings in a patient with a moderate abdominal pouch. The peaks of the M are moderate in height and located on the flanks. Closure of this wider gap will lift the anterolateral thigh skin. The mark on the pubis is 5 cm from the vulvar commissure.

FIG. 30.2 Observe the lateral extent of the markings as well as the general orientation and the peaks of the M.

Surgical Technique

The operation is performed under general anesthesia. Intermittent compression devices (ICD) are applied to the lower extremities. Tumescent solution is infiltrated in the interface between the fat layer and fascia/muscle, and less to the panniculus itself. The thick portions of the subcutaneous layer of the flap to be advanced inferiorly are suctioned with 2 or 3 mm cannulas. This should follow the orientation of the vascular supply to the flaps to prevent injuries of these arcades. To create the xiphoumbilical depression, the central portion of the flap is suctioned, starting from the position of the new umbilicus going up to the xiphoid process and suctioning up to the subdermal layer. This etching of the midline is not carried out below the new position of the umbilicus because this will compromise the blood supply and is not needed esthetically.

Dermolipectomy is done by initially incising on the “U” landmark. Large vessels are ligated or hemoclips applied. Smaller vessels are electrocoagulated. I prefer bipolar coagulation to prevent thermal damage to the vascular trees of the vessels being coagulated. Monopolar cautery will compromise the vascular supply of the flaps.

When the dissection approaches the navel, this is cored out after a heart-shaped incision is made. Early coring out of the navel will prevent its accidental transection during flap elevation, especially on very thick flaps. Dissection extends up to the costal margins and the xiphoid area. After a trial of advancement of the flap and changing the operative table to about 45°, the previously marked M component is re-assessed by matching it against the lower incision line. Any discrepancies are adjusted at this point. Trimming of the flap is made initially by incision perpendicular to the skin and then very quickly the knife is turned up to 45° in order to remove as much as possible of the deep fat layer of the upper flap (Figs 30.3 and 30.4).

FIG. 30.3 The deep fat of the upper abdominal flap is resected by an initial 45° tangential incision and then axial excision.

FIG. 30.4 Observe in the center of the screen the fatty defect of the navel. For comparison the height of the resected fat is almost of the same height as the skin flap.

This deep fat layer is between the Scarpa’s fascia (deep) and Camper’s fascia (superficial). In the middle and upper abdominal skin (to be advanced inferiorly) these two layers are well defined and easy to recognize. This is an excellent way to thin out the advanced flap. Scarpa’s fascia is left attached to the abdominal myofascial layer. In previous publications it has been noted that this maneuver decreases postoperative seroma formation.⁴

Abdominal Wall Weakness and/or Hernia Repair

This is done after the skin flap is elevated. A well-executed musculoaponeurotic repair will provide a significant improvement of the abdominal contour (Figs 30.5 and 30.6). There are different variations of repair according to the anatomical problem. If the problem is generalized weakness of the abdomen without any definite bulging or there is a large rectus diastasis, this is repaired after the myofascial release previously described.²

FIG. 30.5 The recti fascia partition extends from xiphoid to pubis. The ellipse has its widest dimension above the navel area.

FIG. 30.6 The recti myofascial advancement will redefine the waistline and will tighten the entire abdominal wall.

An elliptical shaped marking from xiphoid to pubis on the anterior rectus sheath is done with the widest portion around the waistline, which usually is above the navel. The navel is usually located at the level of the iliac crest. This ellipse varies from 6 to 18 cm in its largest width, with an average of 10.5 cm. The myofascial release is done initially by making 1 cm incisions every 3 to 4 cm on the anterior rectus sheath using a cold knife. The hemostat is introduced and the fascia elevated and in between the blades of the open hemostat incisions are made with electrocautery. During this process, the areas of the tendinous insertions are avoided. I do not recommend making a direct incision into the fascia with the electrocautery device as the muscle tends to contract and jump, which will potentially make the incision deeper, with bleeding in the muscle. After the myofascial incision is completed, the repair is done by application of inverted figure-of-eight 2-0 nylon sutures applied to the lateral edge of the rectus sheath incision (at the border at the myofascial incision). The suture bites should include muscle layer. The muscle will work as a pledget to the fascia and prevent its disruption. Two key sutures are applied initially, one above the navel and one below the navel. This will set an easy closure because immediately you will see a drop of the muscle below the level of the rectus repair line (Figs 30.7 and 30.8). Since this will significantly bury the navel it is important to tag the navel with 3-0 nylon sutures to retrieve it later. The rest of the myofascial repair is completed from xiphoid to pubis.

FIG. 30.7 Axial view of the repair. The recti fascia is partitioned to perform the so-called “myofascial release”. The released recti muscle will push itself toward the midline. This will enable closure of the muscle/fascia layer with lesser tension.

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Jul 23, 2016 | Posted by admin in Aesthetic plastic surgery | Comments Off

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