Panniculectomy and Abdominal Wall Reconstruction

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Relevant General Anatomy

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  When considering panniculectomy in the setting of abdominal hernia repair, important anatomic considerations include the underlying musculature, aponeurotic layers, and adipocutaneous structures. These components are interrelated and should be addressed systematically to optimize outcomes after panniculectomy.

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Relevant Muscular Anatomy

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  The support and contour of the anterior abdominal wall are derived from the rectus abdominis and the internal, external, and transverse oblique musculature ( Fig. 13.1 ).

  

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  The perforating vasculature to the adipocutaneous component of the anterior abdominal wall or pannus emanates from the intramuscular vascular network ( Fig. 13.2 ). Most perforators arise from the deep inferior epigastric system. Other vascular contributions include the superficial inferior epigastric artery, superficial circumflex iliac artery, and deep circumflex iliac artery. All of these perforators converge at the dermis, forming the subdermal plexus.

  

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  Prior abdominal operations can disrupt this perforating vascular network. However, over time, angiogenesis re-establishes a vascular network to maintain perfusion to the adipocutaneous layer.

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Relevant Aponeurotic Anatomy

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  The aponeurotic layers of the anterior abdominal wall include the linea alba, anterior rectus sheath, posterior rectus sheath, and external oblique fascia ( Fig. 13.3 ).

  

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  The anterior rectus sheath and linea alba are composed of collagen fibers arranged in lattice configuration. The width and thickness of these structures fluctuate at various regions of the anterior abdominal wall and are assessed based on the distance from the umbilicus. The width of the linea alba ranges from 11 to 21 mm between the xiphoid process and the umbilicus and decreases from 11 to 2 mm from the umbilicus to the pubic symphysis. The thickness of the linea alba ranges from 900 to 1200 μm between the xiphoid and the umbilicus and increases from 1700 to 2400 μm from the umbilicus to the pubic symphysis. The thickness of the anterior rectus sheath ranges from 370 to 500 μm from the xiphoid to the umbilicus and increases to 500–700 μm from the umbilicus to the pubic symphysis. The posterior rectus sheath is slightly thicker than the anterior rectus sheath above the umbilicus, ranging from 450 to 600 μm and decreases from 250 to 100 μm from the umbilicus to the arcuate line.

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  Perforating vessels that originate from the deep inferior epigastric artery and vein pierce the anterior rectus sheath and external oblique fascia as they course through the adipose layer, until contributing to the subdermal plexus of vessels ( Fig. 13.4 ) and ( Fig. 13.5 ).

  
  

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Relevant Adipocutaneous Anatomy

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  In a patient with an abdominal pannus, the overlying skin may be thickened and indurated.

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  Ulcerations may be present with associated infections.

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  The thickness of the pannus is variable and depends on body habitus and body mass index (BMI). The adipose component may be edematous with very large fatty lobular tissue.

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