We get many requests asking what a Panniculectomy is and how it effects a Fobi Pouch procedure. So, here is the article that is in the June, 2001 issue of Hi Lites, Dr. Fobi’s Monthly newsletter.
INTRODUCTION
Abdominal Panniculectomy is the medical term for the surgical removal of excess abdominal panniculus which in lay term is called the "apron"; that redundant layer of fat tissue at the lowest portion of the abdominal wall. Because fat distribution is never even in all individuals, some people with obesity have significant deposit of fat at this most dependent part of the abdominal wall which further aggravates the various complications associated with obesity especially back and joint pain.
The "apron" (abdominal panniculus) in an obese individual may weigh as little as 5 pounds, or as much as 120 pounds. The largest abdominal panniculus removed at the Center for Surgical Treatment of Obesity weighed 110 pounds. The excess "apron" is part and parcel of the problem of obesity. The lay term for an abdominal panniculectomy is "TUMMY-TUCK surgery", which may unintentionally belittle the problem as merely cosmetic in nature.
This month, we will give you a concise overview of the abdominal panniculectomy including the surgical indication, complication, pictorial outlay and how it may impact the outcome of your surgery.
As the medical community and insurance companies come to realize that obesity is in fact a serious medical problem, which ultimately impacts negatively on quality of life and hence life span, it is also important that they understand that abdominal panniculectomy as part of the obesity surgery will aid in your recovery from surgery as you become a lighter active patient with less back and joint pain.
The abdominal panniculus can be graded as grades 1-5, which in most cases increases with the patient's weight. At higher grades, patients tend to have more problems with the various physical, medical and social limitations.
GRADING
GRADE 1: Panniculus barely covers the hairline and mons pubis but not the private part.
GRADE 2: Extends to cover the private part in the line with the upper thigh crease.
GRADE 3: Extends to cover the upper thigh
GRADE 4: Extends to cover the mid thigh.
GRADE 5: Extends to cover the knees or beyond. Some of the physical limitations associated with excess abdominal panniculus include: Difficulty getting in and out of bed; Standing and walking straight; Inability to bend over to tie one's shoes; Crossing one's legs; etc. There are also medical problems associated with excess abdominal panniculus such as personal hygiene due to excess pressure and moisture of the underlying skin, which leads to skin excoriation and breakdown. In some severe cases, the excess abdominal panniculus results in foul smelling infection (Panniculitis). This ultimately becomes a serious social problem, limiting social interactions in many ways you can imagine. Some panniculus become so big they outstrip their blood supply and gangrene ensues.
QUALIFICATIONS AND TIMING FOR SURGERY
Abdominal Panniculectomy can be performed:
a) Concurrently with the Fobi Pouch Operation for Obesity b) At least one year after the initial surgery when you should have attained a significant weight reduction leaving sometimes a redundant apron of loose skin
Option (a) is recommended for patients with Grades 2-5 panniculus. You will be marked the day before surgery or on the day of surgery. This allows us to estimate the extent of loose "apron" that needs to be removed. The New Bikini Cut" incision is only indicated in patients having the panniculectomy at the same time as the gastric bypass procedure. Old C-Section scars are usually removed at the same time of surgery. Some patients may need further cosmetic surgery on the abdomen after they have large amounts of weight loss. If you are marked the day before surgery (at final pre-op visit at the office), try not to scrub off the markings as you take the last shower before surgery. You should note that option (a) does not extend your hospital stay. If you are coming from out of town, especially out of state or country, you will be required to stay close to the area for a minimum period of 2˝ weeks after surgery. We need to watch the progress of your wound thereby preventing or treating any wound complication that may arise. The Fobi Pouch Operation for Obesity takes about 1˝-2˝ hours, but with the abdominal panniculectomy, this will add another 1˝-2˝ hours to the entire operation. This may seem too long for you, but in the real sense it may take longer in centers with less team approach. We take our time to control the blood vessels that may bleed, closing the wound in three layers, and use dissolving sutures. Patients with preexisting breathing problem (asthma, sleep apnea, etc.) or those coming out late from surgery may need overnight admission in the surgical intensive care unit for safety reasons. If the patient has a breathing tube, it is usually removed the following morning when the patient is fully awake and all the specialist are available to address any breathing problems that may arise. After extubation, the patient is placed back on the PCA pump (patient controlled analgesia) and transferred to the ward. The rest of the hospital post-operative course is similar to that of the patient that only had the gastric bypass procedure.
Option (b) is recommended for patients that have lost the weight but have significant loose skin "apron". At this time other reconstructive procedures can be done including: Hernia Repairs; Arm/thigh/hip Reduction; Breast Reduction and Mastopexy.
These are usually done at least one year after the initial Fobi Pouch Operation for Obesity. Not everyone that undergoes obesity surgery needs an abdominal panniculectomy. However, we have observed that abdominal panniculectomy done concurrently with the gastric bypass procedure may give you a head start to losing the weight by psychologically motivating you to use the tool properly. As we have said again and again, the Fobi Pouch Operation for Obesity is a tool. The outcome is the weight loss which you can attain by following the doctors instructions closely. The most important adjuncts to surgery are vitamins and exercise. When you consistently take the vitamins, it primes your energy bank which propels you to engage in calorie burning activities and exercise. And always remember that the calorie you burn is not from the foods you consume following your surgery, but the excess fat you have stored all these years. In other words, the body as a well primed pump now uses fat calories more efficiently. Remember that the obese patient does not eat more than usual per se, but has a highly efficient system that stores fat rather than burn it.
A formula to remember: Fobi Pouch Operation for Obesity With or Without Panniculectomy + Vitamins, Exercise and Correct Nutrition = Weight Loss and Maintenance.
COMPLICATIONS
This like any other major surgery can result in some major or minor complications in spite of all the precautions taken. However, in most cases, these risks and complications are less than complications of remaining obese.
PAIN: Pain; by itself is not a complication but an expected event from surgical trauma, which is experienced differently depending among other things on ones threshold for pain. With an abdominal panniculectomy, the length of your surgical incision is doubled that with just the Fobi Pouch. This may double the pain and decrease your ability to move. Post-operatively, you are provided with the PCA pump until a point when pain pills or shots will suffice.
SEROMA (DRAINAGE): Surgery on fat tissue creates trauma, and along with old blood in the area, the body reacts by producing body fluid which further mixes with irrigation fluid used to wash clean the raw tissue surface during surgery. This collection in the wound is called seroma. In anticipation of seroma, two drainage tubes may be placed on either side of the abdominal panniculectomy wound, and usually removed on the third post operative day when the output is scant and non-bloody. On occasions, the drainage tubes may be left longer and removed at a subsequent post-operative office visit. Most wounds remain swollen for up to 4 weeks. This usually goes down as the body absorbs the remaining body fluid. However, sometimes the rate of fluid production exceeds the rate of absorption resulting in body fluid drainage through the surgical incision. The quantity of drainage at times can be voluminous, and should that occur, please do not panic, but call the office immediately. This problem does not necessarily signify acute bleeding or infection but needs to be appropriately addressed.
WOUND SEPARATION / DEHISCENCE: This may occur up to four weeks following surgery for various reasons, but more commonly as a result of unequal tension along the incision following a sudden change in body position - as may occur during lifting, pulling or pushing action or when adopting a sitting or standing position. It is therefore recommended that you refrain from any physical activities that may endanger your wound healing, including: avoid lifting more than 15 pounds for six weeks, driving for 4 weeks and sex for 6 weeks.
BLEEDING: This may occur in 1-3 percent of cases in spite of the time we spend in controlling every exposed blood vessel. When this occurs following surgery, you may require observation or blood transfusion, or another surgery to explore the wound and control the bleeding. Remind the doctor if you are taking aspirin, or any other blood thinner on a regular basis as it may adversely affect your surgery.
INFECTION: The incidence of wound problems from the midline incision for the Fobi Pouch procedure is about 8.5 percent which may double with the longer incision required for abdominal panniculectomy. In anticipation of this problem, patients are sent home with antibiotics for at least 10 days, with at least bi-weekly wound evaluation at the office. Infected wounds may require daily cleansing and packing with gauze dressings along with additional antibiotics.
SKIN BREAK-DOWN: In rare occasions you may have sloughing off of part of the wound especially if there is a nearby scar from pervious abdominal surgery, hereby compromising blood flow to surrounding tissues. This may be managed with daily wound care, and rarely will require skin grafting. Finally, as hard as we try to preserve the umbillicus (belly-button) you may lose that during surgery or it may slough off subsequently if blood supply is not enough to sustain it. This may happen if there is an associated umbilical hernia, or scar tissue from previous surgery around the umbillicus which limits its blood supply. Preserving an umbilicus with poor blood supply due to associated hernia or scar tissue exposes the patient to more serious wound infection.
NUMBNESS / DYSESTHESIA: Because the nerves cut during surgery may not grow back exactly to their original form, they recover at different rates and some may not recover, leaving areas of decreased sensation and those of exquisite sensation even to the slightest touch. It takes up to six to eighteen months for nerves to show appreciable recovery.
BLOOD CLOTS: Blood clots can occur with the Fobi Pouch procedure with or without the abdominal panniculectomy, just as in any other major surgery. The most common symptom is pain in the calf muscles or groin, which should not be ignored. The major concern is when the blood clot in the lower legs travel to the lungs, which can be dangerous. Notify your nurse as soon as you notice a persistent pain in your calf so that the doctor can evaluate you immediately and order the necessary test. If the test demonstrates blood clots in the leg veins you will require intravenous blood thinners and this may prolong your hospital stay by about 3 days. Bloods clots can occur up to a month following surgery especially after a prolonged sitting position. Therefore, continue to move your legs and to ambulate as much as you can.