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Abdominal Wall

Pfannenstiel Incision

Maylard Incision


Incisional Hernia

Abdominal Wound
Dehiscence and

Massive Closure
of the Abdominal
Wall With a One-Knot
Loop Suture

Hemorrhage Control Following Laceration
of Inferior Upper
Epigastric Vessels


A large abdominal panniculus after weight reduction in a patient who has had excessive obesity can be associated with excoriation and breakdown of the underside of the panniculus. In these cases, panniculectomy is indicated.

The purpose of panniculectomy is to remove the large abdominal panniculus.

Physiologic Changes.  Large panniculi will frequently contain 500-700 mL of blood within the mass of tissue. Therefore, this procedure can be associated with excessive blood loss. Postoperative hypovolemia and its clinical sequelae may result.

Points of Caution. The patient should be evaluated in both the standing and the supine position prior to the operation to design an incision that will prevent the "dog ears" that frequently occur after a panniculectomy in the area of the anterior iliac spine.

One assistant must be constantly available to keep traction on the panniculus.

Meticulous attention to hemostasis is essential. The wound should be drained with suction catheters.


The patient is placed in the dorsal supine position. Brilliant green surgical dye is used to design and mark off the lines of incision.

Large fishhooks are inserted into the panniculus and connected to an orthopedic frame erected over the operating table to elevate the panniculus. The inferior margin of the panniculus can be marked. A V-shaped incision over the mons pubis and Z-shaped incision at the lateral margins are made to prevent overlapping of the abdominal flaps and the "dog ear" protrusion of tissue at the iliac spines.

While the flap is held on traction with fishhooks, the incisions are carried down to the rectus fascia.

Unless meticulous hemostasis is maintained throughout the operation, blood loss will become excessive. The V-shaped incision in the mons pubis should be closed with interrupted 2-0 synthetic absorbable sutures.

The reconstruction of the mons pubis has been completed with placement of the subcutaneous row of interrupted 3-0 synthetic absorbable sutures.

Suction drains are placed in the wound and may be anchored to the rectus fascia with a 5-0 synthetic absorbable suture to prevent displacement. The skin stapler is used to close the edge of the wound.

The cephalad margin of the abdominal flap should be mobilized up to the umbilicus. If a great deal of mobilization is required, an elliptical incision can be made around the umbilicus, and a matching elliptical defect can be created cephalad to the umbilicus. Then, when the abdominal wall is completely mobilized and moved caudad to match the inferior margin of the incision, the elliptical umbilical incision can be closed, and the umbilicus can be sutured to the edges of the newly created abdominal defect. The abdominal incision should be closed with interrupted 2-0 synthetic absorbable sutures.

A second layer of subcutaneous sutures is placed with 3-0 synthetic absorbable sutures.

The remaining portions of the skin are approximated with stainless steel skin clips. The suction drains are connected to continuous suction. They are removed when they are no longer productive.


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