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oncurrent panniculectomy and ventral hernia repair has been shown to safely reduce
pannus size, wound-healing morbidity (e.g.,
infection, hematoma, seroma, and dehiscence)
rates, and hernia recurrence rates in obese hernia
patients.15 Infraumbilical hernias can often be
repaired through horizontal panniculectomy incisions, with no need for vertical incisions. However, extensive undermining of the skin flap to
access the upper abdomen causes additional dead
space and may increase the risk of wound-healing
complications.2 Therefore, vertical incisions are
useful for hernias that extend to near the xiphoid
and for when high laparotomy incisions are
needed for additional intraoperative procedures.
T-point necrosis and wound dehiscence are
common wound-healing complications associated
with concurrent horizontal and vertical incisions.6 9
In one study, all patients who underwent supraumbilical hernia repair with panniculectomy and inverted-T closure developed complications, including abscesses and dehiscence.10 To reduce T-point
necrosis, improve distal flap vascularity, and reduce
complication risks, we propose an alternative incision design that allows horizontal and vertical panniculectomy and simultaneous ventral hernia repair
with component separation and inlay mesh.
TECHNIQUE
The Mercedes panniculectomy includes a horizontal and vertical skin and fat resection in a fleurde-lis pattern (Figs. 1 through 5). The lower border
of the horizontal component is marked with a curvilinear line, 2 cm cephalad and parallel to the groin
crease between the anterior axillary lines. An equilateral triangle (each side, 15 to 20 cm) is drawn with
its base along the center of this line and tip just
caudal to the umbilicus (Figs. 1 and 2). This triangle
From the Department of Plastic Surgery, University of Texas
M. D. Anderson Cancer Center.
Received for publication August 25, 2009; accepted October
2, 2009.
Copyright 2010 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181cb641d
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www.PRSJournal.com
Fig. 3. A 46-year-old woman presented with advanced endometrial and ovarian cancer. She had a massive ventral hernia and
left upper quadrant colostomy site hernia after sigmoid colon
resection; she had undergone a diverting colostomy for diverticular abscess and subsequent colostomy takedown, both complicated by wound infection and dehiscence that required secondary intention healing. Four previous mesh ventral hernia repairs
had failed, and she presented for tumor debulking and recurrent
ventral and stomal site hernia repair. (Above) The previous
polypropylene mesh was removed, component separation was
performed, and acellular dermal matrix was inset into the ventral
hernia defects as an inlay reinforcement. The inferior triangular
flap was elevated inferiorly to the pubis for laparotomy access.
(Below) Using minimally invasive access to the semilunar lines
through the horizontal component of the panniculectomy
wound, we performed a bilateral component separation to allow
primary fascial midline closure.
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Fig. 4. (Left) The inferior triangular flap was retracted superiorly, and the horizontal components of the panniculectomy specimens were removed. The inferomedial aspects of the upper
skin flaps were subsequently resected and the triangular flap was advanced and inset into the
defect with a Mercedes closure pattern. (Right) Anterior photograph obtained 5 months postoperatively. The redundant suprapubic tissue just below the triangular flap allowed for undermining and advancement of the triangular flap superiorly in the event of a midline woundhealing complication.
Fig. 5. Preoperative (left) and 6-month postoperative (right) lateral views of the same patient. There was a considerable reduction in pannus size and amount of protuberance over
the groin crease.
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DISCUSSION
This modified panniculectomy technique appeared to be beneficial for vertical incisions, particularly for upper abdominal hernia repairs using
minimally invasive component separation. Preservation of the rectus perforating vessels and resecting the most distal, least vascularized tips of the
upper flaps improved vascularity and, in combination with the triangular flap, distributed inset
tension more evenly at the trifurcation point.
This technique is indicated for ventral hernia
repairs with panniculectomies that require vertical
incisions. We prefer to remove the umbilicus, as its
subsequent position would be located more cranially
after the triangular flap has been elevated and advanced. The triangular flap is elevated caudally as far
as required to extend the vertical midline fascial
incision; in some cases, it requires no elevation, particularly if the fascial incision is limited to the upper
abdomen. This technique is safe in patients with
previous vertical incisions extending inferiorly to the
pubis because it does not interfere with the inferiorbased vascularity of the triangular flap. However, we
feel that this technique is contraindicated in patients
with long Pfannenstiel incisions that could cause
ischemia of the triangular flap, particularly if it is
elevated far inferiorly.
The Mercedes panniculectomy technique has
other advantages. The trifurcation point is moved
cranially, away from the pubis and groin crease,
where it is less likely to be irritated by clothing or
be located in a skin fold, possibly resulting in skin
maceration. Resection of both vertical and horizontal components has been shown to result in
improved aesthetic outcomes.1214 Ostomy sites
can be resected in panniculectomy incisions and
re-sited through upper flaps without vascular compromise (Fig. 4). The triangular flap provides an
effective lifeboat for wound complications at the
trifurcation point: if debridement is needed because of necrosis or dehiscence, sufficient suprapubic tissue exists to advance the flap superiorly,
as a V-Y flap, into the resulting defect.
SUMMARY
The Mercedes panniculectomy technique is
simple and allows simultaneous supraumbilical
hernia repair and horizontal and vertical panniculectomy, with access to the semilunar line for component separation; it may reduce wound-healing
complication rates, particularly at the trifurcation
point. Further prospective studies are needed to
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CODING PERSPECTIVE
This information prepared by Dr. Raymond
Janevicius is intended to provide coding
guidance.
15734
15734-51
49560-51
15830-51
49568
Use the muscle flap code, 15734, for component separation. Each side is reported
separately.
Even though 15734 is performed bilaterally, the bilateral modifier, 50, is not used,
as many payers, including Medicare, do
not recognize 15734 as a bilateral procedure. Use the multiple procedure modifier, 51.
Panniculectomy is reported with code
15830. Many insurance companies will not
reimburse for this procedure, so preauthorization in writing is necessary prior
to performing the procedure.
Code 49568 is an add-on code and does
not take the multiple procedure modifier, 51.
If the hernia is recurrent, report code
49565.
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