Abdominoplasty & Hernia Repair

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Abdominoplasty is a procedure where excess skin and fat is removed from the abdomen. This can be performed at the same time as an open abdominal hernia repair.  A hernia is a weakness in the abdominal wall that allows abdominal contents to protrude.  Henias may be due to a congenital weakness (congenital hernia), or due to previous surgery (incisional hernia). Hernias of the anterior abdominal wall are referred to as ventral hernias.

The benefit of doing an abdominoplasty at the same time as a hernia repair, is that it allows excellent exposure for repair of the hernia, as well as improved cosmesis, allowing excess skin and fat to be removed with a single incision below the bikini line.

Transverse (Pfannenstiel) incisions below the bikini line occupy a single dermatome so are also much less painful that vertical midline incisions.  This results in improved recovery after surgery with less pain, and easier mobilization and deep breathing and coughing.  It may also reduce the risk of an incisional hernia recurrence [1-2]

Figure 1.  a. abdominal hernia with excess abdominal skin and fat; b. hernia repaired; c abdominoplasty performed with excision of excess skin and fat; d end result with flat abdomen, new belly button and incision bellow the bikini line.

During this procedure. The excess skin and fat is mobilized off the abdominal wall via a pfannenstiel incision placed below the bikini line. In very large fatty aprons this also includes removal of any moist intertriginous skin folds that are prone to infection (ie. intertriginous candidiasis) or enlarged scars (keloid) from previous abdominal surgery.

This allows exposure of the abdominal wall and hernial defect, which is repaired.  This typically involves excising the weakened abdominal wall (hernia sac), and then closing the strong fascia of the abdominal wall with sutures.  The repair of the hernial defect may also require mesh reinforcement, and this mesh can be placed superficial to the peritoneum but deep to the rectus sheath and fascia (extra-peritoneal sublay repair), or superficial to the anterior rectus sheath fascia (onlay repair).

The abdominoplasty is them performed with an elliptical excision of all excess skin and fat, allowing the abdominal wall skin to be pulled down tight.  If a very large amount of skin is excised, then the belly button (umbilicus) will need repositioning (supra-umbilical abdominoplasty).  If very little skin is excised, the belly button is not altered (infra-umbilical abdominoplasty).  Once this is done, a suction drain is placed deep to the fat of the raised flap and a special glue (Tisseel® glue) is sprayed to allow the space to between abdominal wall fascia and fat of the flap to seal so that a collection of sterile fluid (seroma) does not develop within this space.  Dressings are then applied (either steri-strips or Prineo® tape and Dermabond® glue), and an abdominal binder applied.  The abdominal binder helps to splint the abdomen, as well as ensure that constant pressure is applied to the flap, to prevent the development of a seroma.

WHAT TO EXPECT POST OPERATIVELY AFTER HERNIA REPAIR AND ABDOMINOPLASTY SURGERY
Open hernia repair with adbominoplasty can be performed as a day stay procedure, although usually requires admission overnight. Typically one or two drains are left under the repair, to allow for “vacuum seal” of the repair, and to prevent the formation of fluid collection (seroma) under the abdominoplasty skin flap.  This drain typically stay in place for 4-7 days.  Following your surgery, you will recover for an hour until the effects of the sedatives have worn off. If your surgery is being performed as a day-stay procedure, you will be allowed to leave several hours after your anaesthetic has worn off. You should not drive yourself home after your procedure and should have someone organised (a friend or relative) to accompany you.
Whilst return to light activities is possible within a few days, no heavy lifting (>10kg) should occur for at least 6 weeks following your surgery to avoid a recurrence of your hernia. You will require a combination of simple over the counter analgesia and stronger analgesia for pain in the first few days following your surgery. Your drains are usually removed day 3-4 after your operation and outer (Comfeel®) dressings can be removed 7 days after your surgery. You should follow up with your surgeon within 1-2 weeks, and again as required or instructed. Occasionally a sterile collection of fluid (seroma) will develop and will require a needled drainage in the rooms.

Reference

1. DeSouza A1, Domajnko B, Park J, Marecik S, Prasad L, Abcarian H.  Incisional hernia, midline versus low transverse incision: what is the ideal incision for specimen extraction and hand-assisted laparoscopy? Surg Endosc. 2011 Apr;25(4):1031-6. doi: 10.1007/s00464-010-1309-2. Epub 2010 Aug 25.
2. Bosanquet DC1, Ansell J1, Abdelrahman T2, Cornish J1, Harries R3, Stimpson A4, Davies L1, Glasbey JC5, Frewer KA5, Frewer NC5, Russell D6, Russell I6, Torkington J1. Systematic Review and Meta-Regression of Factors Affecting Midline Incisional Hernia Rates: Analysis of 14,618 Patients. PLoS One. 2015 Sep 21;10(9):e0138745. doi: 10.1371/journal.pone.0138745. eCollection 2015.

 

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