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Chief editor
Abdulrazak Abyad MD, MPH, MBA, AGSF, AFCHSE
Editorial office:
Abyad Medical Centre & Middle East Longevity Institute
Azmi Street, Abdo Centre
PO Box 618
Tripoli, Lebanon
Tel: 961 6 443 684
Fax: 961 6 443 685
aabyad@cyberia.net.lb
Publisher
Lesley Pocock
medi+WORLD International
572 Burwood Road,
Hawthorn 3122, VIC
Australia
Tel: +61 3 9819 1224
Fax: +61 3 98193269
Lesleypocock@mediworld.com.au
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While all efforts have been
made to ensure the accuracy of the information in this journal,
opinions expressed are those of the authors and do not necessarily
reflect the views of The Publishers, Editor or the Editorial
Board. The publishers, Editor and Editorial Board cannot be
held responsible for errors or any consequences arising from
the use of information contained in this journal; or the views
and opinions expressed. Publication of any advertisements
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The contents of this journal
are copyright. Apart from any fair dealing for purposes of
private study, research, criticism or review, as permitted
under the Australian Copyright Act, no part of this program
may be reproduced without the permission of the publisher.
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October
2008, Volume
5 - Issue 5
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Surgery - Combined Incisional Hernia
Repair and Abdominoplasty ("Tummy-tuck")
Mr Charles Leinkram
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INTRODUCTION
An incisional hernia is a weakness
which has developed in part of the muscle layer of the
abdominal wall at the site of a previous abdominal operation.
It produces the bulging out of loops of bowel contained
within a sac which is covered only by the skin and the
underlying layer of subcutaneous fat. An incisional
hernia often causes the patient varying intensity of
pain, can appear unsightly and has the potential of
producing obstruction or strangulation of its contents.
Causes of an incisional hernia
are usually multifactorial but very often it is associated
with some degree of obesity. Thus, in addition to the
bulging hernia, the patient may also have an associated
unsightly overhang of redundant abdominal skin and subcutaneous
fat.
Rationale for the combined operation
Repair of the incisional hernia
may be indicated on clinical grounds. If it is, and
if there is also a significant associated overhang,
it may be prudent to incorporate an abdominoplasty with
the hernia repair. The advantages of the combined operation
are:
- By lifting up the entire
abdominal skin and subcutaneous fat, the margins of
the incisional hernia can be very clearly defined
and the repair can be carried out with precision.
- There is a marked improvement
in the patient's cosmetic appearance. The combined
operation removes a large amount of redundant skin
and underlying fat, usually also incorporating the
previous scar, thus producing a very significant cosmetic
improvement.
Key
points of the operation
- The incision is transverse
across the lower abdomen, below the bikini line.
- The entire skin and subcutaneous
fat layer of the abdominal wall is raised, up to the
level of the rib cage, except for the umbilicus itself,
which is left in situ as a small island, in its normal
position.
- If an incisional hernia is
present, it is now repaired using a large sheet of
prolene mesh. The rest of the abdominal wall is also
tightened using non-absorbable nylon sutures.
- The redundant overhang of
skin and subcutaneous fat is trimmed off and the residual
flap is pulled down to the transverse incision line.
Before closing the transverse incision, a small opening
is made in the flap to allow the undisturbed umbilicus
to emerge in its normal position. This is sutured
into place.
- The wound is closed under
some tension, giving the tummy a taut appearance.
The lines of tension are designed so that they are
directed inwards, thus creating a new and more attractive
waistline.
Post-operative
considerations
- In the immediate post-operative
period a special corset is worn by the patient in
order to apply firm and constant pressure on the abdomen.
Pillows are placed under the thighs so as to minimise
the tension on the wound.
- Physiotherapy is an important
element in the post-operative management. Thus respiratory
problems are minimized, as is the risk of calf thrombosis
(DVT).
- There is a small risk of
a wound infection, or of fluid accumulation under
the abdominal skin flap.
There is also a very low risk
of loss of viability of the umbilicus.
It should be noted than an abdominoplasty is not recommended
in a patient who is grossly obese. It is largely ineffective
in improving the cosmetic appearance in such a patient
and would also be associated with a much higher risk
of post-operative complications.
Cost
of Surgery
Because both an abdominoplasty
and incisional hernia repair have MBS item numbers ascribed
to them, they are claimable from both Medicare and the
patient's own private health insurance. These would
cover a significant portion of the cost of the surgery,
although there will still be a residual out-of-pocket
sum left to pay. This would be discussed at the time
of the initial consultation.
SUMMARY
Mr. Leinkram has much experience
in performing abdominoplasties both with and without
an associated incisional hernia. Being a General Surgeon
with a special interest in hernias, he would be able
to deal with all kinds of incisional hernias, irrespective
of their complexity. Patients who request the operation
would first need to see Mr. Leinkram and undergo a full
clinical assessment. Any associated medical conditions
and any medications being taken by the patients would
be noted. The operation and any potential complications
of surgery would be full discussed, as would the cost
of the surgery.
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