Intraabdominal pressure in abdominoplasty patients

Is There a Direct Effect Between the Plication of the Myoaponeurotic Layer and the Force of Inspiratory and Expiratory Muscles After Abdominoplasty?

OBJECTIVE

Abdominoplasty may generate an increase in the intra-abdominal pressure (IAP) and consequently an alteration in the pulmonary ventilation. The purpose of this study was to evaluate the potential alterations in the maximal static inspiratory pressure (MIP) and maximal static expiratory pressure (MEP) after abdominoplasty.

METHODS

Thirty-three female patients, aged between 18 and 60, with type III/B Nahas abdominal deformity that underwent abdominoplasty with plication of the anterior rectus and external oblique aponeurosis were selected. The MIP and MEP were measured using a mouthpiece. This is a simple way to indirectly gauge inspiratory and expiratory muscle strength. Measurements were performed before surgery and on the 2nd, 7th, 15th, and 180th postoperative day. In addition, IAP was measured before abdominoplasty and after the placement of compression garment. The MIP and MEP were compared using analysis of variance, followed by the Bonferroni multiple comparison test pairing the different points in time. Paired Student's t test was used for comparing IAP measurements. Pearson's correlation test was used to compare MIP and MEP variations with IAP variation. Results were considered statistically significant when P ≤ 0.05.

RESULTS

A decrease was observed in MEP on the 2nd day, with a return close to normal values on the 15th day. In opposition MIP had a surprisingly increase on the 15th postoperative day (129 cmH2O), normalizing 180 days after the operation. A leap in IAP values was revealed at the end of the surgical procedure. It was not possible to establish a positive correlation between the increase of IAP and the alterations of MIP and MEP.

CONCLUSIONS

There is a decrease in maximum expiratory pressure on the very early postoperative day (2nd postoperative day) and an increase in maximum inspiratory pressure on the 15th postoperative day in patients who underwent abdominoplasty. There was no correlation between the IAP and maximum respiratory pressure variations, both inspiratory and expiratory.

Intra-abdominal pressure increases peri-operatively in patients undergoing deep inferior epigastric perforator flap reconstruction: A prospective study linking high intra-abdominal pressure to non-fatal lung embolism within one patient

BACKGROUND

The deep inferior epigastric perforator (DIEP) flap is the gold standard for autologous breast reconstruction. The procedure and peri-operative period are associated with the risk of severe post-operative complications, like venous thromboembolic events (VTE) and lung embolism. Whether the intra-abdominal pressure (IAP) increases after the closure of the abdominal defect, thereby potentially affecting the venous backflow and the risk of VTE, is currently not known.

AIM

The primary aim is to test if the closure of the abdominal donor site increases the IAP in women undergoing secondary DIEP flap breast reconstruction.

MATERIALS AND METHOD

By using a Unometer, we measured the intravesical pressure as a surrogate marker for the IAP, at baseline, immediately after, and 24 h after abdominal skin closure, for 13 patients.

RESULTS

The mean IAP increased from 6.1 mmHg (95% CI 4.6-7.7) at baseline to 9.0 mmHg (95% CI 8.0-10.0) immediately after skin closure [mean diff. 2.9 (95% CI 1.0-4.8) (p = 0.007)] and further up to 11.7 mmHg (95% CI 9.0-14.5) 24 h after closure [mean diff. 5.3 (95% CI 1.4-9.1) (p = 0.012)]. We found that IAP varies among the patients, regardless of the tightness of abdominal closure or rectus plication (n = 3). Immediately after closure, none of the isolated patients showed abnormal levels of IAP (>12 mmHg), while eight out of 12 isolated patients (67%) showed IAP levels above the normal range after 24 h. One patient developed a non-fatal lung embolism.

CONCLUSION

The mean IAP increases significantly over the post-operative period after DIEP flap reconstruction, although abnormal IAP values are only seen 24 h after the closure of the skin.

Abdominal Hypertension after Abdominal Plication in Postbariatric Patients: The Consequence in the Postoperative Recovery

Background  Abdominoplasty with abdominal plication increases intra-abdominal pressure (IAP) and has been previously associated with limited diaphragmatic excursion and respiratory dysfunctions. Many factors found in abdominoplasties and among postbariatric patients predispose them to a higher occurrence. This study aims to evaluate the impact of abdominal plication among postbariatric patients, assess whether the plication increases their IAP, and analyze how these IAP correlate to their postoperative outcome. Methods  This prospective study was performed on all patients who underwent circumferential Fleur-De-Lis abdominoplasty. For this intended study, the IAP was measured by an intravesical minimally invasive approach in three stages: after the initiation of general anesthesia, after a 10-cm abdominal wall plication and skin closure, and 24 hours after the procedure. Results  We included 46 patients, of which 41 were female and 5 were male. Before the bariatric procedure, these patients had an average maximum weight of 121.4 kg and an average maximum body mass index of 45.78 kg/m 2 ; 7 were grade I obese patients, 10 were grade II, and 29 were grade III. Only three patients were operated on with a gastric sleeve and 43 with gastric bypass. We presented six patients with transitory intra-abdominal hypertension in the first 24 hours, all of them from the grade I obesity group, the highest presented was 14.3 mm Hg. We presented 15% (7/46) of complication rates, which were only four seroma and five dehiscence; two patients presented both seroma and wound dehiscence. Conclusion  Performing a 10-cm abdominal wall plication or greater represents a higher risk for intra-abdominal hypertension, slower general recovery, and possibly higher complication rate in patients who presented a lower degree of obesity (grade I) at the moment of the bariatric surgery.

Preaponeurotic endoscopic repair (REPA) of diastasis recti: a single surgeon's experience

BACKGROUND

Diastasis recti is a pathology that affects not only the abdominal wall but also the stability of lumbopelvic muscles, consequently altering urinary and digestive functionality. Preaponeurotic endoscopic repair (REPA) is an endoscopic alternative to tummy tuck for the treatment of diastasis. In this study, the outcomes of REPA application by a single surgeon are presented.

METHODS

A total of 172 patients underwent REPA for the treatment of diastasis recti between August 2017 and December 2019. One hundred twenty-four patients were followed for at least one year. Sixty-three patients responded to a survey on satisfaction and quality of life 12 months after surgery.

RESULTS

Three (2.4%) recurrences occurred, of which two occurred in the same patient. The main postoperative complications observed were 12 (9.7%) seromas, 3 (2.4%) haematomas, a single wound infection, 3 (2.4%) cases of skin fold formation, and a case of trophic skin lesion that required negative pressure therapy. Quality of life after surgery, as reported by 63 patients who responded to the survey, was satisfactory.

CONCLUSIONS

REPA is a safe and effective technique for diastasis recti treatment, representing a valid alternative to abdominoplasty. Since there is no need to access the peritoneal cavity and the mesh is onlay, there are no risks of bowel damage or adhesions between the intestine and prosthesis.

Preoperative Respiratory Physiotherapy in Abdominoplasty Patients

BACKGROUND

After abdominoplasty, patients experience decreased ventilatory function and increased intra-abdominal pressure (IAP). Breathing exercises are used during the pre- and postoperative periods of several abdominal surgeries to prevent or minimize postoperative complications.

OBJECTIVES

The aim of this study was to assess the effect of preoperative respiratory physiotherapy on the outcome of abdominoplasty patients.

METHODS

Thirty-three patients were divided into 2 groups. The control group (n = 18) received no preoperative intervention. The intervention group (n = 15) performed breathing exercises during the preoperative period, including incentive spirometry, diaphragmatic breathing, shortened expiration, and sustained maximal inspiration. Respiratory physiotherapy started one week before surgery. Breathing exercises were performed daily. They were performed 3 times weekly in the presence of a physiotherapist and patients were instructed to carry on the exercises at home on days without physiotherapy sessions for three sets of 20 repetitions each. Patients were assessed by spirometry and IAP measurements.

RESULTS

No significant difference in spirometry was found between groups. However, patients in the intervention group had lower IAP at the start of surgery and at all time points (P = 0.010) compared with controls.

CONCLUSIONS

Preoperative respiratory physiotherapy had no impact on spirometry, but may have contributed to reduce IAP intraoperatively.

LEVEL OF EVIDENCE 2

Effect of Switching between Pressure-controlled and Volume-controlled Ventilation on Respiratory Mechanics and Hemodynamics in Obese Patients during Abdominoplasty

Background:

The ideal intraoperative ventilation strategy in obese patients remains obscure. This prospective, randomized study was designed to evaluate the effect of pressure-controlled ventilation (PCV) before or after volume-controlled ventilation (VCV) on lung mechanics and hemodynamics variables in obese patients subjected to abdominoplasty operation.

Patients and Methods:

The study included forty patients with body mass index 30–45 kg/m² subjected to abdominoplasty. All patients were randomly allocated in two groups after the induction of general anesthesia (twenty patients each), according to intraoperative ventilatory strategy. Group I (P-V): started with PCV until the plication of rectus muscle changes into VCV till the end of surgery. Group II (V-P): started with VCV until the plication of rectus muscle changes into PCV till the end of surgery. Lung mechanics, hemodynamics variables (heart rate and mean blood pressure), and arterial blood gases (ABGs) were recorded.

Results:

No significant difference in the hemodynamics and ABGs were recorded between the studied groups. The use of PCV after VCV induced the improvement of lung mechanics.

Conclusion:

Switching from VCV to PCV is preferred to improve intraoperative oxygenation and lung compliance without adverse hemodynamic effects in obese patients.

Thromboprophylaxis in Abdominoplasty: Efficacy and Safety of a Complete Perioperative Protocol

BACKGROUND

Venous thromboembolism, a spectrum of diseases ranging from deep venous thrombosis to pulmonary embolism, is a major source of morbidity and mortality. The majority of cases described in plastic surgery involve abdominoplasty. Risk assessment and prophylaxis are paramount in such patients. General recommendations were recently developed, but the evidence in the literature was insufficient to prepare exhaustive guidelines regarding the medication, dosage, timing, or length of the prophylaxis.

METHODS

A thromboprophylaxis protocol was developed for patients undergoing abdominoplasty. The protocol consisted of preoperative, intraoperative, and postoperative measures. Enoxaparin was administered as chemoprophylaxis in selected patients. The study involved 253 patients. The patients were analyzed for age, body mass index, enoxaparin dosage, risk factors, and complications.

RESULTS

Deep venous thrombosis was documented in two cases (0.8%). No pulmonary embolism occurred. Three patients (1.2%) presented mild subcutaneous abdominal hematoma within the first postoperative week that spontaneously resorbed with neither aesthetic nor functional complications. Two patients (0.8%) presented severe hematoma requiring surgical re-intervention for drainage and hemostasis revision. Statistical analysis showed no significant correlation between enoxaparin dosage and hematoma (P=0.18) or deep venous thrombosis (P=0.61).

CONCLUSIONS

The described thromboprophylaxis protocol proved to be effective in the prevention of thrombotic events, with an acceptable risk of hemorrhagic complications. Furthermore, it provides new evidence regarding the currently debated variables of chemoprophylaxis, namely type, dosage, timing, and length.

Improvements in Vertebral-Column Angles and Psychological Metrics After Abdominoplasty With Rectus Plication

BACKGROUND

Substantial fluctuations in body weight can result in diastasis recti and weakening of the connections between the lateral abdominal muscles and the rectus sheath.

OBJECTIVES

The authors sought to determine the postural and psychological effects of abdominoplasty with vertical rectus plication.

METHODS

Forty women with substantial back and lumbar pain owing to abdominal lipodystrophy were evaluated in a prospective study. Preoperatively and 6 months postoperatively, patients underwent bidirectional radiography of the thoracic and lumbar regions. A visual analog scale (VAS), the Beck Depression Inventory (BDI), and the Nottingham Health Profile (NHP) were applied to assess physical, psychological, and quality-of-life changes following surgery.

RESULTS

Significant improvements in posture, assessed in terms of lumbar lordosis, thoracic kyphosis, and the lumbosacral angle, were observed 6 months after abdominoplasty with rectus plication. Results of the VAS and BDI indicated significant improvements in pain and quality of life, respectively. Results of the NHP indicated significant postoperative improvements in fatigue, pain, and sleep.

CONCLUSIONS

Abdominoplasty with rectus plication improves posture by tightening the thoracolumbar fascia. In selected patients, abdominoplasty can reduce back and lumbar pain, thereby improving quality of life.

Failed pneumoperitoneum for laparoscopic surgery following autologous Deep Inferior Epigastric Perforator (DIEP) flap breast reconstruction: a case report

Background

Laparoscopic abdominal surgery may prove difficult in patients who have undergone previous abdominal procedures. No reports in the medical literature have presented an aborted laparoscopic procedure for failed pneumoperitoneum following autologous flap-based breast reconstruction.

Case presentation

A 55-year-old woman presented with recurrent invasive lobular carcinoma of the right breast as well as a history of ductal carcinoma in situ of the left breast. The patient desired to proceed with bilateral skin- and nipple-sparing mastectomies with right axillary lymph node biopsy, followed by immediate bilateral autologous deep inferior epigastric perforator (DIEP) flap-based breast reconstruction. Preoperatively, a computerized tomography angiogram was obtained for reconstructive preparation, which revealed a left adrenal mass. Ensuing work-up diagnosed a pheochromocytoma. Given the concern for breast cancer progression, the patient elected to proceed first with breast cancer surgery and reconstruction prior to addressing the adrenal tumor. Subsequently, 3 months later the patient was brought to the operating room for a laparoscopic left adrenalectomy for the pheochromocytoma. With complete pharmacologic abdominal relaxation, the abdomen proved too tight to accommodate sufficient pneumoperitoneum and the laparoscopy was aborted. The patient was evaluated in the outpatient setting for assessment of abdominal wall compliance at regular intervals. Five months later, the patient was taken back to the operating room where pneumoperitoneum was established without difficulty and the laparoscopic left adrenalectomy was performed without complications.

Conclusion

Pneumoperitoneum for laparoscopic surgery subsequent to autologous DIEP flap-based breast reconstruction may prove difficult as a result of loss of abdominal wall compliance. Prior to performing laparoscopy in such patients, surgeons should consider the details of the patient’s previous reconstructive procedure and assess potential risk factors for difficulty with insufflation. Lastly, careful abdominal examination should be performed to indicate whether laparoscopy for elective procedures should be delayed until abdominal wall compliance normalizes.

Does Diastasis Width Influence the Variation of the Intra-Abdominal Pressure After Correction of Rectus Diastasis?

BACKGROUND

It has been demonstrated that there is an increase of intra-abdominal pressure (IAP) after correction of rectus diastasis.

OBJECTIVE

To evaluate the correlation between the diastasis width and IAP variation after the plication of the anterior rectus sheath.

METHODS

Seventeen patients met the inclusion criteria and were selected. The diastasis width was measured at three levels: 3 cm above the umbilicus, 2 cm above the umbilicus, and 2 cm below the umbilicus. Rectus sheath plication was performed in two layers: the first layer with separate stitches, and the second with continuous suture. The IAP was measured at two stages: before and after the correction of rectus diastasis. The distance between the iliac spines (IS) and that between the xiphoid process and pubic symphysis (XP) were measured. The abdominal surface index (ASI) was calculated using the formula: ASI = (IS × XP)/2. This index was used to determine the individual abdominal surface. The relative diastasis coefficient (RDC) was calculated using the formula: RDC = diastasis/ASI. These measurements were correlated to the IAP variation. The results of the IAP measurements obtained in each stage and the RDC values were compared, using the Pearson's linear correlation coefficient.

RESULTS

There was no statistically significant correlation between the IAP variation and the RDC values at the three levels studied.

CONCLUSIONS

The diastasis width does not interfere with the increase of the IAP when a plication of the anterior aponeurosis is performed.

LEVEL OF EVIDENCE

3 Diagnostic.

Abdominal compartment syndrome following abdominoplasty: A case report and review

Abdominoplasty is among the most commonly performed aesthetic procedures in plastic surgery. Despite high complication rate, abdominal contouring procedures are expected to rise in popularity with the advent of bariatric surgery. Patients with a history of gastric bypass surgery have an elevated incidence of small bowel obstruction from internal herniation, which is associated with non-specific upper abdominal pain, nausea, and a decrease in appetite. Internal hernias, when subjected to elevated intra-abdominal pressures, have a high-risk of developing ischemic bowel. We present a case report of patient with previous laparoscopic Roux-en-y gastric bypass who developed acute ischemic bowel leading to abdominal compartment syndrome following abdominoplasty. To the best of our knowledge, this is the first reported case in the literature. We herein emphasise on the subtle symptoms and signs that warrant further investigations in prospective patients for an abdominal contouring procedure with a prior history of gastric bypass surgery.

A novel approach to abdominoplasty: TULUA modifications (transverse plication, no undermining, full liposuction, neoumbilicoplasty, and low transverse abdominal scar)

BACKGROUND

Lipoabdominoplasty can be associated with complications, particularly tissue necrosis, wound dehiscence, epigastric bulging, high transverse scar, low positioning of the umbilicus, and seroma.

METHODS

Modified abdominoplasty characterized by (1) transverse elliptical plication of the lower abdominal wall, (2) no undermining of the flap above the navel, (3) unrestricted liposuction, (4) umbilical amputation and neoumbilicoplasty by skin graft, and (5) low transversely placed abdominal scar (TULUA) was performed for 42 patients. These procedures were elective and performed primarily to remedy epigastric skin redundancy associated with obesity or when supraumbilical undermining was considered inappropriate.

RESULTS

The results were objectively scored as excellent for 20 patients, good for 21 patients, and fair for 1 patient. A normal-appearing umbilicus was attained in all cases except one. The lower transverse scars were generally concealable (6.3 ± 1.4 cm from the anterior vulvar commissure), and epigastric bulging was avoided. Although four patients experienced seromas at the tail ends of incisions, no skin necrosis, wound dehiscence, or other major complications such as venothromboembolism occurred, and there were no fatalities. In four patients, postoperative magnetic resonance imaging demonstrated measurable and significant changes attributable to plicature compared with equivalent control points (p < 0.000001), which persisted over time.

CONCLUSIONS

The TULUA procedure offers potential advantages in terms of vascular safety, sensory recovery, position and quality of the umbilicus, and transverse scar location, with aesthetic outcomes that generally eliminate epigastric bulging. A sizeable patient population stands to benefit from this approach, especially when obesity, smoking, secondary revisions, umbilical or hypogastric hernias, and massive weight loss are clinical considerations for abdominoplasty.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Ventilatory function and intra-abdominal pressure in patients who underwent abdominoplasty with plication of the external oblique aponeurosis

BACKGROUND

After correction of rectus diastasis there is a change in the values obtained by spirometry in the first few postoperative days. In specific cases, a plication of the external oblique aponeurosis in addition to plication of the anterior rectus sheath is indicated. Therefore, the aim of this study was to evaluate ventilatory function and intra-abdominal pressure (IAP) in patients who underwent abdominoplasty with the plication of the anterior rectus sheath, associated with an "L-shaped" plication of the external oblique aponeurosis.

METHODS

Eighteen female patients, classified as Nahas type III or B, were selected. Spirometry was performed preoperatively and on the 2nd, 7th, and 15th days after surgery. Intraoperatively, the IAP was measured at five points in the surgical procedure: (1) before skin incision, (2) after the plication of the rectus abdominis muscle, (3) after the L-plication of the aponeurosis of the external oblique, (4) after skin closure, and (5) after the use of a compressive garment.

RESULTS

There was a significant reduction in spirometry values after surgery. There was no correlation between body mass index (BMI), pain, the increase of IAP, and the width of diastasis and changes in spirometry (p ≤ 0.05) in any of the postoperative evaluations.

CONCLUSION

Spirometric parameters change on the 2nd and 7th postoperative days and tend to normalize on the 15th day. Postoperative pain, BMI, and increased IAP are not related to these changes. The use of compressive garments increases the IAP.

One-year follow-up after incisional hernia treatment: results of a prospective randomized study

BACKGROUND

The incidence of incisional hernia after midline laparotomies ranges from 10 to 20%. The recurrence rate after this hernia surgery varies from 25 to 52% using autogenous tissue. The use of prosthetic meshes can decrease the postoperative hernia recurrence by up to 10%. The aim of this prospective randomized clinical study was to analyze and compare the results of three different incisional hernia surgical techniques.

MATERIALS AND METHODS

One hundred and sixty-one patients who underwent incisional hernia surgery were randomized into three groups. The Keel technique was used in the first group, the "Onlay" technique (prosthetic mesh is fixed on the external abdominal muscle slip) in the second group, and the "Sublay" technique (prosthetic mesh is placed on the posterior abdominal muscle sheath) in the third group. Age, sex, hospitalization time, body mass index (BMI), intraabdominal pressure, postoperative complications, postoperative pain, normal physical activity recovery time, and recurrence rate were compared between the groups. The postoperative follow-up period was 12 months.

RESULTS

Fifty-four patients in the Keel group, 57 patients in the "Onlay" group, and 50 patients in the "Sublay" group were operated. Age, hospitalization time, and BMI were similar in all of the groups. The operative time was significantly longer in the prosthetic mesh groups compared with the Keel group. The intraabdominal pressure changes before and after surgery was significantly higher in the Keel group compared with the prosthetic mesh groups (5.66 ± 2.5 mmHg vs. 1.88 ± 1 mmHg vs. 1.76 ± 1 mmHg; P < 0.05). The postoperative wound complications rate was significantly higher in the "Onlay" technique group compared with the Keel and "Sublay" technique groups (49.1% vs. 22.2% vs. 24%; P < 0.05). Postoperative pain (VAS score) was significantly lower in the "Onlay" and "Sublay" groups (5.53 ± 1.59 vs. 3.96 ± 1.56 vs. 3.78 ± 1.97; P < 0.05). All of the patients in "Sublay" group recovered to normal physical activity during the 6 months follow-up period compared with 94.4% of patients in the Keel group and 98.3% of patients in the "Onlay" group. The recurrence rate was 22.2% in the Keel group, 10.5% in the "Onlay" group, and 2% in the "Sublay" group during the follow-up period. The general complications rate after hernia surgery was 5.6%. Postoperative pneumonia was the most frequent complication, which appeared in 4.3% of patients. There was no postoperative death in our prospective study.

CONCLUSIONS

Mesh repair is the first-choice technique for incisional hernia treatment. The results of the "Sublay" technique are better than the "Onlay" technique.

Esophageal stricture and metaplasia following abdominoplasty

Numerous complications have been reported following abdominoplasty. In this report, the case of a 48-year-old woman who developed an esophageal stricture, and subsequently Barrett's esophagus, secondary to increased intra-abdominal pressure following abdominoplasty is presented.