Introduction

In 2009 Germany has become the nation with the most obese people in the whole of Europe. This statistic reveals that obesity with its comorbidities has developed into a widespread disease.

There are numerous conservative and operative strategies for the treatment of obesity. Plastic surgeons are increasingly confronted with the need for body contouring after massive weight loss through dietetic methods or bariatric surgery.^1–5

A few superobese patients, however, do not respond to the conventional treatment regimens. Then follows a vicious circle with reduced mobility and thus reduced calorie consumption. Reduced food intake alone is in this case often not sufficient to achieve an appropriate weight loss.

Patients with marked pannus usually have, in addition to significant medical comorbidities such as metabolic syndrome and premature arthritis, massive problems of hygiene in the lower abdominal fold, with recurrent furuncles, abscesses, and fistulas. In addition, distinct functional problems exist such as immobility, with the development of secondary lymphedema, chronic ulceration on the extremities, and pressure sores. Some patients with high body mass index show severe elephantiasis in the entire abdominal wall. Quite often there are additional problems in micturition, especially in male patients whose genitalia are completely obstructed⁶ (Fig. 27.1).

FIG. 27.1 (A, B) Patient with a pannus morbidus, presenting a permanent lymphedema of the abdominal wall. Secondary lymphedema on right leg due to compression of the inguinal region.

Current European guidelines recommend bariatric surgery in those patients with a body mass index of 40 and in those with an index of 35 accompanied by significant comorbidities. For patients with a body mass index higher than 60, the surgical treatment is often difficult, because the abdominal wall is very fat, and what can be achieved with the instruments is often limited. The parallel existing immobility is often an additional postoperative risk.

Historically, panniculectomy was done only in selected cases, when there was complete immobility, or patients were not suitable for bariatric surgery. The aim of such intervention was to interrupt the vicious circle of lack of mobility and insufficient calorie consumption. This was usually followed by a successful conservative weight reduction or bariatric surgery.^11–15

Today, such procedures are often performed together with bariatric surgery.^5–7 The plastic surgeon performs the panniculectomy, thus the general surgeon gains access to the abdominal wall and then laparoscopically places the gastric banding or performs a gastric bypass or sleeve.

The subsequent weight loss leads to an immediate increase in mobility. If the process of losing weight is completed and there is weight maintenance of about 1 year, subsequent plastic-reconstructive surgical operations are possible to complete the surgical treatment.⁸

Preoperative Preparation

Patients eligible for panniculectomy should be chosen carefully. Operations on such a patient population are always risky, since metabolic syndrome and the long-lasting cardiovascular stress tend to result in severe complications. Besides the increased general risks, however, there exist significantly increased surgical complication rates, with increased blood loss, excessive seroma formation, wound healing problems and necrosis. In the few publications related to this issue, complication rates are more than 50%; even serious events stated to be 2.5% seem not be substantially increased. Blood loss is given in the literature as significant (from 800 to 2500 ml with decrease of hemoglobin and a consequent transfusion requirement in more than 20%). Hernias were found in about 20% of patients and were treated mostly within the same session. The infection rate given in the literature is on average about 15%, due to poor preoperative hygiene.^9–11

For these reasons, strict indications and improved operational procedures are required. We have in the past sought for approaches to address the above-mentioned high complication rates. In the following, therefore, we present our concept, which has been derived from more than 20 years of experience with over 100 patients. The excision weight of our patients ranged between 10 and 65 kg.

Regarding the case history it is important to find out how many serious attempts to diet have been undertaken and whether there are exclusion criteria for bariatric surgery. The normal course of the survey includes, first of all, a classification of the pannus in the degree classification according to Igwe:¹²

FIG. 27.2 Igwe grade 1 deformity: coverage of the pubic hair.

FIG. 27.3 Igwe grade 2 deformity: coverage of the mons pubis.

FIG. 27.4 Igwe grade 3 deformity: coverage of the upper third of the thigh.

FIG. 27.5 Igwe grade 4 deformity: coverage of the top half of the thigh.

FIG. 27.6 Igwe grade 5 deformity: coverage of the knee and below.

In addition to this classification the presence of a permanent lymphedema of the abdominal wall (elephantiasis) needs to be documented. In this case it is called a pannus morbidus and recurrence after abdominal amputation in later courses of surgery is almost certain (Fig. 27.7).

FIG. 27.7 Pannus morbidus. (A) Preoperative (B) Postoperative (C, D) Postoperative

Furthermore, we look for secondary lymphedema in the extremities; carefully inspecting the abdominal fold, the umbilical region, and the external genitalia, especially for intertriginous inflammation, boils, or abscesses. The abdomen is carefully examined in the supine and standing positions for clinical hernia. In particular, the umbilical region is a predilection site. An exploratory ultrasound of the abdomen should be mandatory, because the clinical examination is often difficult. In most cases, we also request a CT scan of the entire abdomen for safe exclusion of a hernia, and a Doppler ultrasound of the deep venous system for the safe exclusion of thrombosis.¹³

Besides the usual laboratory tests, we look in particular at protein balance and wound healing parameters, such as zinc, vitamin C, and other trace elements.

Early involvement of anesthesiologists is advisable to optimize the preoperative situation in order to accomplish any therapeutic recommendations early enough. Breathing exercises should be initiated 1 month before the operation.

A preliminary cardiological examination should follow to check the resilience of the cardiovascular system. The substantial electrolyte and fluid shifts due to the large volume of excision are to be taken into account. If there is a lymphedema of the abdominal wall, the patient should be hospitalized for a few days before the operation to elevate the abdominal wall, to perform lymph drainage and forced diuresis, balancing the electrolytes in control of the renal parameters. On the preoperative day the patient should take only a liquid diet and reduce drug support. The abdominal fold should be treated at least a week before surgery with antiseptic soaps and the umbilical region with antiseptic ointment. Two hours before surgery the patient is preheated with prewarmed infusions and surgical table covers are provided. Antithrombosis stockings are applied.

A urinary catheter is applied, as well as a central venous catheter for measurement of the central venous pressure and an arterial cannula for continuous blood pressure measurement.

With initiation of anesthesia, an intravenous antibiotic treatment is given and the patient is well padded and supported with a Bear-Hugger blanket.