How to treat panniculitis associated with a fat-containing hernia?

Treatment of Panniculitis from Fat-Containing Hernia

Surgical repair of the hernia is the definitive treatment for panniculitis associated with fat-containing hernias, as addressing the underlying mechanical cause resolves the inflammatory process in the subcutaneous fat.

Immediate Assessment and Surgical Planning

Determine Urgency of Intervention

• Assess for signs of incarceration or strangulation including elevated white blood cell count, fever, and guarding on examination, which are moderately predictive of bowel compromise 1
• Emergency surgery is indicated if there is evidence of bowel strangulation, peritonitis, or inability to reduce the hernia 1
• Elective repair can be considered for reducible hernias without signs of complications, though the panniculitis will persist until definitive repair 1

Evaluate Hernia Characteristics

• Determine hernia size and location as this guides the surgical approach and repair technique 1
• Assess for bowel involvement through clinical examination and imaging if needed 1
• Check for signs of fat necrosis or ischemia in the herniated adipose tissue, which may present as the panniculitis 1

Surgical Approach Selection

For Stable Patients Without Strangulation

• Laparoscopic repair is preferred when there is no evidence of bowel strangulation or need for resection, as it provides lower wound infection rates without higher recurrence 1
• Open pre-peritoneal approach is preferable if there is suspicion of bowel compromise requiring resection 1
• Local anesthesia can be used for inguinal hernias in the absence of bowel gangrene, providing effective anesthesia with fewer postoperative complications, shorter hospital stay, and faster recovery 1

For Unstable Patients or Complicated Cases

• Laparotomy approach is indicated in unstable patients or when bowel resection is anticipated 1
• General anesthesia should be used when bowel gangrene is suspected or intestinal resection is needed 1

Hernia Repair Technique

Primary Repair Considerations

• Attempt primary closure with non-absorbable sutures when the defect can be closed without excessive tension 1
• Use interrupted non-absorbable 2-0 or 1-0 monofilament or braided sutures in two layers for optimal strength 1
• Avoid primary closure if the distance between the defect edge and chest wall exceeds 3-4 cm as this leads to excessive tension and high recurrence rates up to 42% 1

Mesh Reinforcement

• Use mesh for defects larger than 3 cm or when primary closure cannot be achieved without tension 1
• Biosynthetic, biologic, or composite meshes are preferred due to lower hernia recurrence rates, higher resistance to infections, and lower risk of displacement compared to synthetic meshes 1
• Ensure 5-cm mesh overlap for successful clinical outcomes in ventral hernias 1

Management of Hernial Sac and Fat

• Excision of the hernial sac is controversial but may reduce tissue trauma, fluid collection, and recurrence, particularly when colon or stomach is contained within the sac 1
• Remove as much omentum as possible during laparoscopic repair of large irreducible hernias, using a small groin incision if needed to excise adherent omentum from the distal sac 1
• The inflamed panniculitic fat will typically resolve once the mechanical cause (herniation) is corrected through definitive repair 2

Antimicrobial Management

Prophylaxis Based on Contamination

• Short-term prophylaxis for clean cases (CDC wound class I) with intestinal incarceration but no ischemia or bowel resection 1
• 48-hour antimicrobial prophylaxis for cases with intestinal strangulation and/or bowel resection (CDC wound classes II and III) 1
• Full antimicrobial therapy for patients with peritonitis (CDC wound class IV) 1

Adjunctive Panniculitis Management

If Panniculitis Persists Post-Operatively

• Obtain deep excisional biopsy with adequate tissue for histopathological evaluation if the panniculitis does not resolve after hernia repair, as superficial biopsies may miss the pathology 3, 4
• Test for alpha-1 antitrypsin deficiency in all cases of biopsy-proven severe panniculitis that persists, particularly in necrotizing cases 3, 4
• Consider immunosuppressive therapy such as cyclosporin-A, corticosteroids, or other agents only if the panniculitis is confirmed to be independent of the hernia rather than secondary to it 5, 6

Critical Pitfalls to Avoid

• Do not delay hernia repair in favor of treating the panniculitis medically, as the mechanical cause must be addressed for resolution 2
• Avoid inadequate tissue resection of necrotic or severely inflamed fat during hernia repair, as this can lead to persistent inflammation and wound complications 2
• Do not perform superficial biopsies if panniculitis persists post-repair, as deep excisional specimens are required for accurate diagnosis 3, 4
• Recognize that massive panniculus with herniation presents considerable technical challenges requiring careful adhesiolysis and wound management 2