What are the preoperative and postoperative considerations for an adult patient undergoing abdominal body contouring surgery with supra and infra panicular incisions?

Perioperative Considerations for Abdominal Body Contouring with Supra and Infrapanicular Incisions

For adult patients undergoing abdominal body contouring surgery with supra and infrapanicular incisions, prioritize preoperative weight optimization, meticulous surgical site infection prevention with prophylactic closed-incision negative-pressure wound therapy (cINPT), and aggressive postoperative wound monitoring given the substantially elevated risk of surgical site complications in this population.

Preoperative Considerations

Weight Management and Optimization

• Implement a supervised low-calorie diet preoperatively, as preoperative weight loss correlates positively with postoperative outcomes and reduces surgical complications 1.
• A low-carbohydrate diet is more effective than low-fat approaches for short-term weight loss and improving insulin sensitivity, particularly beneficial in patients with metabolic syndrome 1.
• Preoperative weight loss of approximately 9.5% significantly reduces postoperative complications including anastomotic leakage, deep infection/abscess, and wound complications, with even greater benefit in patients with BMI >45 1.
• Avoid very-low-calorie diets (<800 kcal/day) as sole method for multiple weeks as this may induce a catabolic state that impairs postoperative recovery 1.

Surgical Site Infection Risk Assessment

• Recognize that obesity is an independent risk factor for SSI following all surgical procedures, with particularly high rates in abdominal contouring 2.
• Patients with large dependent panniculi and central obesity face increased risk of wound maceration and failure of spontaneous wound closure 2.
• Plan for prophylactic measures in all high-risk patients rather than reactive treatment 1.

Preoperative Skin Preparation

• Perform preoperative skin antisepsis with either povidone-iodine or chlorhexidine solutions 1.
• If hair removal is necessary, use clipping only—never shaving, as shaving increases SSI risk and should not be part of routine practice 1.
• Remove nail polish and rings as part of standard preoperative preparation 1.

Intraoperative Considerations

Incision Planning

• Avoid midline incisions when possible for extraction sites or primary access, as midline incisions have significantly higher incisional hernia rates compared to transverse, oblique, or paramedian approaches 1, 3.
• Transverse incisions demonstrate lower rates of wound dehiscence, burst abdomen, and postoperative pain compared to midline laparotomy 1.
• For panniculectomy procedures specifically, the supraumbilical vertical midline incision provides reasonable peritoneal access with acceptable complication rates 4.

Infection Prevention Protocol

• Administer broad-spectrum intravenous antibiotics within 60 minutes before incision covering staphylococcal and Gram-negative bacteria 1.
• Maintain perioperative normothermia using active cutaneous warming (preferably circulating-water garments over forced-air systems) to reduce wound infections, cardiac complications, and bleeding 1.
• Extend systemic warming 2 hours before and after surgery for additional benefit 1.

Surgical Technique

• Use continuous suture technique for fascial closure as it reduces operative time without increasing hernia or dehiscence rates compared to interrupted sutures 1.
• Avoid routine prophylactic intra-abdominal drain placement in clean and clean-contaminated cases due to lack of evidence for benefit 1.

Postoperative Considerations

Wound Management Strategy

• Apply prophylactic closed-incision negative-pressure wound therapy (cINPT) immediately postoperatively in all high-risk patients, as this represents the single most effective intervention for reducing SSI 1.
• The PICO single-use NPWT system specifically demonstrates a 58% reduction in SSI rates (from 12.5% to 5.2%), 29% reduction in wound dehiscence, and 0.47-day reduction in hospital length of stay across pooled data 1.
• Maintain cINPT for the manufacturer-recommended duration (typically 5-7 days) for optimal benefit 1.

Subcutaneous Drain Management

• Place subcutaneous closed-suction drains uniformly in panniculectomy patients, as this practice significantly reduces wound breakdown incidence and shortens hospital stay 4.
• Continue drains until output is minimal (typically <30 mL/24 hours).

Monitoring and Early Intervention

• Conduct daily wound assessments for signs of infection, dehiscence, seroma, or hematoma during initial hospitalization 5.
• Recognize that wound complications requiring treatment occur in approximately 22% of patients even without frank SSI 6.
• In panniculectomy patients, expect higher rates of postoperative infections and wound breakdowns compared to supraumbilical incisions alone (though modern drain protocols have reduced this disparity) 4.

Glycemic Control

• Maintain postoperative blood glucose <12 mmol/L to avoid glucosuria and hypovolemia while minimizing hypoglycemia risk 1.
• Avoid aggressive insulin protocols in ward settings due to hypoglycemia risk 1.

Postoperative Nausea and Vomiting (PONV) Management

• Administer multimodal PONV prophylaxis with dexamethasone at induction plus serotonin receptor antagonist (ondansetron) at surgery end for patients with ≥2 risk factors 1.
• Risk factors include female sex, non-smoking status, history of motion sickness/PONV, and postoperative opioid administration 1.

Nasogastric Tube Management

• Avoid routine nasogastric decompression, as it increases fever, atelectasis, and pneumonia while delaying return of bowel function 1.

Fluid Management

• Restrict perioperative intravenous fluids to avoid excessive salt and water overload, which increases complication rates and delays recovery 1.
• Avoid weight gain exceeding 3 kg postoperatively 1.

Management of Complications

Deep Surgical Site Infection

• If deep SSI develops and fails conservative management (antibiotics, dressings, bedside debridement), consider panniculectomy as a definitive surgical option for patients with large abdominal panniculus, as this provides effective source control with good cosmetic outcomes 2.
• This approach is particularly indicated when wound maceration from central obesity prevents spontaneous closure 2.

Long-term Considerations

• Integrate dietary and psychological management as part of comprehensive postoperative care to address underlying obesity and prevent recurrence 2.
• Monitor for late complications including incisional hernia formation, which occurs at higher rates with open incisions in obese patients 1.