Transcript
Abdominoplasty
Carly Winegar
Anatomy● Layers of the abdominal:
○ Subcutaneous fat ○ Scarpa’s Fascia○ External Oblique Muscle○ Internal Oblique Muscle○ Transversus Abdominus Muscle○ Transversalis Fascia
Physiology
● Subcutaneous fat composed of adipocytes○ Acts as padding for internal organs and energy reserve○ Thermoregulation (insulation)
Pathophysiology
● No disease or injury● Patient wants procedure for cosmetic purposes
Diagnostic Exams
● History and Physical● Direct Observation
Surgical Intervention
● Thinning the upper abdominal fat, tighten the abdominal muscles, and remove excess subcutaneous fat and skin from the mid- to lower abdomen, and creation of new belly button.
Special Considerations
● If patient is planning to bear children they should delay undergoing this procedure until all pregnancies are complete.
● Full abdominoplasty is considered a major surgery and can take 2-5 hours to complete.
● Test the fiberoptic retractors prior to patient arriving in the OR.
Anesthesia
● General
Positioning
● Supine
Skin Prep
● Pubic hair should be removed● Beginning at site of low abdominal
transverse incision, prep should extend to nipple line, to mid-thighs and bilaterally as far as possible.
Draping
● Entire abdomen outlined with 4 towels and laparotomy drape
Incision
● Low transverse incision○ Made low enough so the scar will be hidden
by the patient’s undergarment or bathing suit as well as regrowth of the pubic hair
● Umbilical incision
Supplies
● Sterile Umbilical Template (“cookie cutter”)● Large number of laparotomy sponges● Marking pen● Abdominal girdle● Bovie Scratch Pads
Equipment
● Closed wound drainage system (surgeon’s preference)● Fiberoptic retractor set● ESU pencil with long blade tip
Instrumentation
● Plastic Instrument set● Extra Crile hemostats and Kocher clamps● Several #10 knife blades
Procedural Steps
● Surgeon marks incision using the marking pen● A low transverse incision in the shape of a “W” is made down to the level of
the rectus sheath● A small inferior flap is created; bleeding controlled with cautery● Dissection begins on superior flap that extends beyond the level of the
umbilicus○ Much of initial dissection accomplished with electrocautery in cut or blend mode
Procedural Steps cont.
● Second incision is made around umbilicus using sterile template, commonly called the “cookie cutter” to ensure incision is a perfect circle
● Umbilicus is freed from the skin and subcutaneous tissue, allowing i to remain attached to its pedicle or base
● Flap dissection continues superiorly to the level of the outline of the ribs bilaterally (fiberoptic retractor may be used according to surgeon’s preference)
Procedural Steps cont.● The superior flap is retracted to reveal the rectus abdominis muscle ● The muscle and its fascia (sheath) is pulled together and sutured to firm the
abdominal wall and accentuate the waistline. ● The skin flap is then pulled down, the new location for the umbilicus is
marked, and the excess tissue is removed. ● An opening is created for the umbilicus using the “cookie cutter” template
and structure is sutured into position
Procedural Steps cont.
● The wound is then closed in layers ● One or two closed wound drainage systems may be placed, with the tubing
exteriorized through the lateral wound edges.● Staples may be used to close the skin layer● A small dressing is placed over the umbilicus and a pressure dressing over
the transverse incision.● Surgeon may request an abdominal girdle placed on patient.● https://youtu.be/KwRBAm8hIeU
Counts
● Initial Count● Closing Rectus Abdominis muscle and fascia● Closing Scarpa’s fascia● Closing Subcutaneous fat● Closing Skin● Final Count
Dressing Material
● Small dressing over umbilicus● Pressure dressing over transverse incision● Abdominal girdle
Specimen Care
● Removed adipose and skin sent to pathology
Prognosis
● Patient transported to the PACU● Patient’s bed should be slight flexed for comfort.● Patient will be hospitalized overnight● Hypodermic injections of narcotic pain medications are given for the first 24
hours● Although it will be difficult for the patient to stand erect, ambulation (walking
around) is encouraged as soon as possible
Prognosis: No Complications
● Drains remain in place for 2-3 weeks after patient is discharged from hospital. Patient education regarding wound and drain care is necessary.
● Patient should have an appointment with the surgeon approximately 1 week post-op to remove external sutures or staples and another week or two later for taking out the drains.
● It may take several weeks for the patient to return to normal activities.
Prognosis: Complications
● Postoperative SSI● Hemorrhage● Severe edema● Less-than-desired cosmetic results● Death
Wound Class/ Management
● Class I: Clean
Mini Abdominoplasty
Carly Winegar
Anatomy, Pathology, Physiology, Exams
● Same as total abdominoplasty
Surgical Intervention
● Tightening (by removing) of skin below the belly button
Special Considerations
● Very similar to full abdominoplasty but typically with shorter scar, and does not address skin above belly button, and new belly button not created.
Anesthesia
● General or Local
Positioning, Skin Prep, Draping
● Same as full abdominoplasty
Incision
● Low transverse Incision● Usually smaller than incision on full abdominoplasty, but it is surgeon/
patient specific.
Supplies, Equipment, Instrumentation
● Same as full abdominoplasty
Procedural Steps
● Surgeon marks incision using the marking pen● A low transverse incision is made down to the level of the rectus sheath● A small inferior flap is created; bleeding controlled with cautery● Dissection begins on skin and subcutaneous tissue to create flap
○ Much of initial dissection accomplished with electrocautery in cut or blend mode
Procedural Steps cont.
● The flap is retracted to reveal the rectus abdominis muscle ● The muscle and its fascia (sheath) is pulled together and sutured to firm the
abdominal wall. ● The skin flap is then pulled down, and the excess tissue is removed.● The wound is then closed in layers
Procedural Steps cont. ● One or two closed wound drainage systems may be placed, with the tubing
exteriorized through the lateral wound edges.● Staples may be used to close the skin layer● A small dressing is placed over the umbilicus and a pressure dressing over
the transverse incision.● Surgeon may request an abdominal girdle placed on patient.● https://youtu.be/soGg3Sn-3kE?t=1m58s
Counts
● Initial Count● Closing Rectus Abdominis muscle and fascia● Closing Scarpa’s fascia● Closing Subcutaneous fat● Closing Skin● Final Count
Dressings
● Pressure dressing over low transverse incision● Surgeon may request pelvic girdle
Specimen Care
● Removed adipose and skin sent to pathology
Prognosis
● Patient transported to the PACU● Patient’s bed should be slight flexed for comfort.● Although it will be difficult for the patient to stand erect, ambulation (walking
around) is encouraged as soon as possible● Patient should have an appointment with the surgeon post-operatively to
remove external sutures or staples or drains.● It will likely take much less time for a patient to return to regular activity
after a mini abdominoplasty than a full abdominoplasty
Complications
● Postoperative SSI● Hemorrhage● Severe edema● Less-than-desired cosmetic results● Asymmetry ● Death
Wound Class/ Management
● Class I: Clean
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