Contents:
»
Case Report
In cases of morbid obesity, excessive soft tissues in the abdomen form an apron-like deformity made worse by rapid weight loss caused by cancer.1
Figure 1. Preoperative examination for
planning with the surgeons, a plastic
surgeon, and the nurses who would manage
the patient's stoma care.
Figure 2. Preoperative design of W
technique. Resectable panniculus is in black.
The triangles («) were trimmed away as the
distal-end of the abdominal flap may
become necrotic.
Figure 3. Redundant panniculus in abdomen.
The triangles (*) were trimmed away as the
distal-end of the abdominal flap
(weight 2400 g).
Figure 4. Postoperative view.
Figure 5. Image of the patient three
months after surgery.
In patients who undergo laparotomy with stoma formation due to cancer resection, the apron-like deformity is an obstacle to stoma surgery and stoma care. In stoma surgery, obesity is a major risk factor of complications.2,3 Some studies have reported revision of stoma in excessive obesity patients.4 Abdominal dermolipectomy offers considerable advantages in stoma surgery and stoma care. This Case Report is of a morbid obesity patient who had an apron-like deformity in the abdomen. In this patient, at the time of laparotomy through an abdominal midline incision, an abdominal dermolipectomy to improve stoma surgery was performed.
A 60-year-old man was referred to us with melena. After colon fiberscope examination, cancer of the rectum (Rb, type 2) was present. He also had been obese for 15 years, had diabetes, and had lost 20 kg of weight within a month of consultation. After diagnosis, both abdomino-perineal resection of the rectum and abdominal dermolipectomy for stoma surgery were planned simultaneously to avoid the risk of stoma complications due to obesity. His height was 158 cm, weight was 102 kg, and body mass index (BMI) was 40.
Preoperatively, the surgeons, a plastic surgeon, and the nurses who would manage his stoma care examined the patient together (Fig. 1). During this examination, the surgeons initially drew an abdominal midline incision in the supine position. A plastic surgeon planned the expected volume of resectable panniculus in the abdomen, supine, and a standing position, because marked distortion between the abdominal skin and abdominal fascia in each position causes stoma obstruction and stenosis postoperatively. This resection is designed not for aesthetic reasons, but to reduce distortion in the abdominal wall. The W shaped incision was designed to remain low, just above the inguinal fold and central angle of the W, which enabled trimming away of the distal-end of the abdominal flap that could easily become necrotic. Considering the postoperative view of the shortened abdominal wall, nurses planned the stoma in supine and standing positions taking account of, for example, visibility by the patient himself, the waistband position, and the new umbilical position. On the day of surgery, a laparotomy through an abdominal midline incision was performed and the abdominal wall was closed in layers. In case of diastasis recti, the fascia of the recti muscles was treated by suturing with interrupted non-absorbent sutures; however, it was not necessary in this patient (Fig. 2).
In the dermolipectomy, the lower abdominal wall, as planned preoperatively, was initially incised down to the level of the fascia (V part in W design). The flap was elevated in this plane with electric cautery to the preoperatively designed upper abdominal line, taking great care with hemostasis and dissection of the umbilical stalk. Having confirmed that the abdomen would close the final volume of resectable panniculus in the abdomen was adjusted by additional dissection and resection (Fig. 3). At this juncture, it was necessary to not connect the dissected area to the stoma position. After the resection of excessive panniculus, the umbilicus was sutured in the new position at the center of the abdomen. Continuous suction drains were positioned in both sides of the abdomen and the wound was closed in layers. Finally, stoma surgery was performed (Fig. 4). Dressing was made under pressure except for the stoma region. Total operation time was 7 hours and 40 minutes. Total blood loss was 567 g. After surgery, slight steatolysis was present. The stoma could be cared for by the patient (Fig. 5).
Discussion
Previous articles related to stoma surgery have reported obesity as a major risk factor of stoma complications. One of the most frequent complications is necrosis. Leenen and Kuypers demonstrated a higher level of subsequent stoma necrosis in obese patients.2 The rate of complications was 47% in obese patients and 21% in the rate of necrosis as a complication of stoma surgery. This could be explained because the shortened and fatty mesentery makes mobilization of the bowel difficult. Additional traction is placed on both the mesentery and bowel wall, which result in further diminished blood flow because of the well-developed panniculus. In morbid obesity persons, excessive soft tissue in the abdomen forms an apron-like deformity because of rapid weight loss due to cancer. In this deformity, the panniculus is not only thick, but also is loose between the abdominal skin and fascia, and thus the abdominal skin moves in relation to body position. This situation causes stoma stricture, stenosis, and postoperative necrosis at a high rate. In addition, care by the patient is difficult due to the apron-like deformity of the abdomen. In this patient, at the time of laparotomy with stoma surgery, abdominal dermolipectomy for stoma stability and better postoperative care were performed.
In abdominal dermolipectomy, many different incisions have been proposed.5,6 The abdominal dermolipectomy selected was a combination of vertical and transverse abdominoplasty described as the W technique by Regnault in 1975.7 In this case design, the combination of an abdominal midline incision and lower abdominal transverse incision made the scar an inverted T type, but a lower scar can be hidden below underwear. Some studies have reported the safety of the inverted T incision.8,9 In aesthetic dermolipectomy, however, the rate of distal-end necrosis in the abdominal flap is 35% with the inverted T incision, as reported by Chaouat and colleagues in 2000.10 In our modification of the W technique, the transverse incision allowed us to trim away the distal-end of the abdominal flap that may become necrotic. Furthermore, the complication rate of lymphorrhea is 11% in abdominal dermolipectomy; however, limiting the area of dissection decreases the degree of lymphorrhea. In the case of stoma partial necrosis, infection under the flap can be caused by a connection between the dissected area and stoma position. The minimum dissection has the advantage of healing the stoma wound.
Conclusion
The authors encountered a case of morbid obesity that formed an apron-like deformity in the abdomen, and at the time of laparotomy through an abdominal midline incision performed abdominal dermolipectomy for stoma surgery. This abdominal dermolipectomy provided stoma stability, and allowed better postoperative care by the patient.
References
1. Haritopoulos KN, Labruzzo C, Papalois VE, et al. Abdominoplasty in a patient with severe obesity. Int Surg 2002;87:15-8.
2. Leenen LPH, Kuypers JHC. Some factors influencing the outcome of stoma surgery. Dis Colon Rectum 1989;32:500-4.
3. Duchesne JC, Wang YZ, Weintraub SL, et al. Stoma complications: A multivariate analysis. Am Surg 2002;68:961-6.
4. Evans JP, Brown MH, Wilkes GH, et al. Revising the troublesome stoma. Dis Colon Rectum 2003;46:122-6.
5. Baroudi R, Keppke EM, Netto FT. Abdominoplasty. Plast Reconstr Surg 1974;54:161-8.
6. O SJ, Thaller SR. Refinements in abdominoplasty. Clin Plast Surg 2002;29:95-109.
7. Regnault P. Abdominoplasty by the W technique. Plast Reconstr Srug 1975;55:265-74.
8. El-Khatib HA, Bener A. Abdominal dermolipectomy in an abdomen with pre-existing scars: A different concept. Plast Reconstr Surg 2004;114:992-7.
9. Gmur RU, Banic A, Erni D. Is it safe to combine abdominoplasty with other dermolipectomy procedures to correct skin excess after weight loss? Ann Plast Surg 2003;51:353-7.
10. Chaouat M, Levan P, Lalanne B, et al. Abdominal dermolipectomies: Early postoperative complications and long-term unfavorable results. Plastic Reconstr Surg 2000;106: 1614-8.