This document summarizes a study of 100 consecutive lipoabdominoplasty procedures performed between 2007-2010. Key findings include:
- Lipoabdominoplasty combines aggressive liposuction, excision of redundant skin/tissue, and plication of the rectus muscles without extensive undermining of the abdominal flap.
- There were no cases of DVT or death. Minor complications included 1 small bowel injury during liposuction and 5 hematomas, 2 of which became infected.
- The incidence of seroma, wound dehiscence, hematoma, and DVT was found to be lower using this technique compared to traditional abdominoplasty.
- The authors conclude lipo
Pseudomyxoma peritonei, also known as "jelly belly", is a condition characterized by mucus accumulation and disseminated tumor cells in the peritoneal cavity. It typically arises from a primary appendiceal or colon tumor that ruptures, releasing mucus and cells. Treatment involves surgical debulking to remove all visible tumor, followed by hyperthermic intraperitoneal chemotherapy to address remaining microscopic disease. Complete cytoreduction and low disease burden based on the peritoneal cancer index are associated with improved outcomes.
Esophagectomy : APPROACHES, CONTROVERSIES AND CURRENT EVIDENCEDr Amit Dangi
This document discusses esophagectomy, the surgical approaches for esophageal cancer resection. It covers the relevant anatomy, blood supply, lymph drainage, and histology of esophageal cancer. It then discusses pre-treatment evaluation including staging assessments and criteria for resection. The key surgical procedures for cervical, thoracic, and esophagogastric junction cancers are described including the transhiatal, Ivor-Lewis, and tri-incisional approaches. Post-operative outcomes from recent studies comparing these approaches are summarized.
This document discusses the history and technique of the extended abdominoperineal excision (ELAPE) surgery for rectal cancer. It begins with Miles' description of the standard abdominoperineal resection (APR) in 1908. The ELAPE technique was developed to address high circumferential resection margin positivity and local recurrence rates with APR for low rectal cancers. The ELAPE surgery extends the abdominal phase of resection using total mesorectal excision principles and removes the levator muscles en bloc during the perineal phase. Initial studies show ELAPE reduces bowel perforation and positive margin rates compared to APR, with potentially lower local recurrence. However, large randomized controlled trials are still needed to establish EL
Surgical management of Carcinoma EsophagusLoveleen Garg
A detailed dicussion on surgical procedures & steps to be followed during surgery for Carcinoma esophagus.
Source- Schwartz's Principles of Surgery, 9th Edition
1) The authors reviewed outcomes of 104 consecutive minimally invasive esophagectomies (MIEs) performed between 1998-2007.
2) Surgical approaches included thoracoscopic/laparoscopic esophagectomy with cervical anastomosis (n=47), minimally invasive Ivor Lewis esophagectomy (n=51), and others.
3) Complications included anastomotic leak in 9.6% of patients and stricture in 26%. Mortality was 1.9% at 30 days and 2.9% in-hospital. Mean lymph nodes retrieved was 13.8.
This study analyzed 101 patients who underwent esophagectomy and gastric pull-up surgery for advanced achalasia over a mean follow-up of 10.5 years. The incidence of esophagitis and Barrett's epithelium in the esophageal stump increased significantly over time, with 70% of patients exhibiting esophagitis and 57.5% exhibiting Barrett's epithelium at 10 or more years post-surgery. Five patients developed cancer in the esophageal stump, including three squamous cell carcinomas and two adenocarcinomas. The development of these mucosal alterations is likely due to exposure of the esophageal stump to duodenogastric reflux and increasing gastric acid secretion over time.
The document discusses the anatomy, histology, staging, and workup of esophageal cancer. It describes the esophagus as a hollow muscular tube connecting the pharynx to the stomach. Esophageal cancer most often presents with dysphagia and can spread through lymphatic channels or directly invade nearby structures. Staging involves endoscopy, endoscopic ultrasound, CT, and PET scans to determine the depth of invasion and presence of metastases.
Short term endpoints of conventional versus laparoscopic assisted surgerymanjil malla
This randomized controlled trial compared short-term outcomes of laparoscopic versus open surgery for colorectal cancer. It found that laparoscopic surgery was as safe as open surgery based on similar tumor and node status, short-term outcomes, and quality of life. However, laparoscopic rectal resection had higher positive margin rates and more complications, so it cannot yet be routinely recommended for rectal cancer. Overall, the laparoscopic approach provided equivalent cancer resection as open surgery for colon cancer.
Pseudomyxoma peritonei, also known as "jelly belly", is a condition characterized by mucus accumulation and disseminated tumor cells in the peritoneal cavity. It typically arises from a primary appendiceal or colon tumor that ruptures, releasing mucus and cells. Treatment involves surgical debulking to remove all visible tumor, followed by hyperthermic intraperitoneal chemotherapy to address remaining microscopic disease. Complete cytoreduction and low disease burden based on the peritoneal cancer index are associated with improved outcomes.
Esophagectomy : APPROACHES, CONTROVERSIES AND CURRENT EVIDENCEDr Amit Dangi
This document discusses esophagectomy, the surgical approaches for esophageal cancer resection. It covers the relevant anatomy, blood supply, lymph drainage, and histology of esophageal cancer. It then discusses pre-treatment evaluation including staging assessments and criteria for resection. The key surgical procedures for cervical, thoracic, and esophagogastric junction cancers are described including the transhiatal, Ivor-Lewis, and tri-incisional approaches. Post-operative outcomes from recent studies comparing these approaches are summarized.
This document discusses the history and technique of the extended abdominoperineal excision (ELAPE) surgery for rectal cancer. It begins with Miles' description of the standard abdominoperineal resection (APR) in 1908. The ELAPE technique was developed to address high circumferential resection margin positivity and local recurrence rates with APR for low rectal cancers. The ELAPE surgery extends the abdominal phase of resection using total mesorectal excision principles and removes the levator muscles en bloc during the perineal phase. Initial studies show ELAPE reduces bowel perforation and positive margin rates compared to APR, with potentially lower local recurrence. However, large randomized controlled trials are still needed to establish EL
Surgical management of Carcinoma EsophagusLoveleen Garg
A detailed dicussion on surgical procedures & steps to be followed during surgery for Carcinoma esophagus.
Source- Schwartz's Principles of Surgery, 9th Edition
1) The authors reviewed outcomes of 104 consecutive minimally invasive esophagectomies (MIEs) performed between 1998-2007.
2) Surgical approaches included thoracoscopic/laparoscopic esophagectomy with cervical anastomosis (n=47), minimally invasive Ivor Lewis esophagectomy (n=51), and others.
3) Complications included anastomotic leak in 9.6% of patients and stricture in 26%. Mortality was 1.9% at 30 days and 2.9% in-hospital. Mean lymph nodes retrieved was 13.8.
This study analyzed 101 patients who underwent esophagectomy and gastric pull-up surgery for advanced achalasia over a mean follow-up of 10.5 years. The incidence of esophagitis and Barrett's epithelium in the esophageal stump increased significantly over time, with 70% of patients exhibiting esophagitis and 57.5% exhibiting Barrett's epithelium at 10 or more years post-surgery. Five patients developed cancer in the esophageal stump, including three squamous cell carcinomas and two adenocarcinomas. The development of these mucosal alterations is likely due to exposure of the esophageal stump to duodenogastric reflux and increasing gastric acid secretion over time.
The document discusses the anatomy, histology, staging, and workup of esophageal cancer. It describes the esophagus as a hollow muscular tube connecting the pharynx to the stomach. Esophageal cancer most often presents with dysphagia and can spread through lymphatic channels or directly invade nearby structures. Staging involves endoscopy, endoscopic ultrasound, CT, and PET scans to determine the depth of invasion and presence of metastases.
Short term endpoints of conventional versus laparoscopic assisted surgerymanjil malla
This randomized controlled trial compared short-term outcomes of laparoscopic versus open surgery for colorectal cancer. It found that laparoscopic surgery was as safe as open surgery based on similar tumor and node status, short-term outcomes, and quality of life. However, laparoscopic rectal resection had higher positive margin rates and more complications, so it cannot yet be routinely recommended for rectal cancer. Overall, the laparoscopic approach provided equivalent cancer resection as open surgery for colon cancer.
This document discusses the current evidence for D1 and D2 gastrectomy in treating gastric cancer. It begins by defining the lymph node stations and different levels of lymphadenectomy. It then reviews several key randomized controlled trials that compared D1 and D2 gastrectomy. While initial Western trials found higher morbidity and mortality with D2 without survival benefits, later long-term follow up and recent trials demonstrate lower recurrence rates and improved survival with D2 gastrectomy when performed safely. The consensus is that D2 gastrectomy with preservation of the spleen and pancreas can achieve radical treatment for gastric cancer with excellent outcomes when performed by experienced surgeons.
The document discusses gastric cancer surgery, including classifications of resection margins (R0, R1, R2) and lymph node dissection (D1, D2, D3, D4). It describes procedures for different tumor locations like total gastrectomy for proximal or middle tumors versus subtotal gastrectomy for distal tumors. Complications after different reconstruction methods are outlined, and the use of palliative treatments for advanced cancer is covered.
This document discusses the surgical anatomy and procedure for an Ivor Lewis esophagectomy. Key points include:
- The esophagus passes from the neck to the abdomen, with blood supply from the inferior thyroid, bronchial, and left gastric arteries. Lymph drains to cervical, paratracheal, and subcarinal nodes.
- An Ivor Lewis esophagectomy involves both a laparotomy and right thoracotomy to fully mobilize the esophagus. The stomach is used as a conduit for reconstruction.
- The procedure involves extensive mobilization of the esophagus in both the abdomen and right chest. The conduit is pulled into the chest and a stapled anastomosis is
The surgical management of gastroesophageal cancerforegutsurgeon
This document discusses surgical techniques for treating gastroesophageal cancers and early stage esophageal adenocarcinoma. It finds that laparoscopic staging is useful for gastric cancer and laparoscopic resection may provide benefits over open surgery. While D2 lymphadenectomy provides more thorough staging, it also carries higher risks than D1 with no clear survival benefit. For early esophageal cancers, esophagectomy carries a small but definite risk of recurrence compared to endoscopic mucosal resection, but laparoscopic esophagectomy outcomes are similar to open surgery.
Laparoscopic surgery for small bowel tumoursforegutsurgeon
This document discusses the role of laparoscopic surgery for small bowel tumors. It outlines that laparoscopy can be used for diagnosis, staging, and in some cases curative resection of small bowel tumors, extending techniques used for gastric and colorectal cancers. Specific tumor types that may be suitable for laparoscopic resection include gastrointestinal stromal tumors and adenocarcinomas. The document reviews techniques for laparoscopic resection and anastomosis of different small bowel segments.
1) Transanal total mesorectal excision (TME) is a novel technique for resection of rectal cancers.
2) TME involves excising the rectum and the surrounding mesorectum in one block through the anus to minimize local recurrence.
3) This "down-to-up" transanal approach aims to improve on open TME by reducing morbidity and impairment of function compared to traditional surgery.
The document describes the anatomy and pathophysiology of the esophagus. It discusses:
- The esophagus is a 25 cm muscular tube that extends from the cricopharyngeus to the gastroesophageal junction.
- There are four layers of the esophageal wall and four regions of the esophagus.
- Esophageal cancer is most commonly squamous cell carcinoma or adenocarcinoma. Risk factors include smoking, alcohol, obesity, and Barrett's esophagus.
- Staging of esophageal cancer involves evaluating the primary tumor, lymph nodes, and distant metastases. Treatment depends on the cancer stage but may include surgery, chemotherapy, or radiation therapy.
reviewed the literature ;Multidisciplinary management of gastric cancer
Yixing Jianga and Jaffer A. Ajani
; pictures taken from Sabiston textbook of surgery.
This document discusses the anatomy and patterns of lymph node metastasis in head and neck cancers. It covers the history of neck dissection techniques, anatomy of cervical lymph nodes, levels of lymph node involvement, factors affecting prognosis, and terminology such as occult metastasis and skip metastasis. Select sections discuss findings from studies on patterns of nodal spread in oral cancers and the risk of occult metastases. The conclusion is that lymph node level IV must be included in neck dissections for tongue cancers due to the risk of skip metastases bypassing upper levels.
Oesophageal cancer is a disease that affects the esophagus. The document provides details about:
1) The anatomy, histology, blood supply, lymphatic drainage and functions of the esophagus.
2) Risk factors, symptoms, epidemiology, macroscopic and microscopic appearance of oesophageal cancer.
3) Diagnostic tests and staging of oesophageal cancer including endoscopy, imaging, and biopsy.
4) Treatment options for oesophageal cancer including surgery, chemotherapy, radiation therapy and palliative care based on the cancer stage. Prognostic factors and performance status scales are also discussed.
This document discusses esophageal cancer, including:
- It remains the 6th most common malignancy and rates vary globally. Squamous cell carcinoma is most common.
- Risk factors include smoking, alcohol, hot liquids and micronutrient deficiencies. Barrett's esophagus increases adenocarcinoma risk.
- Symptoms depend on location and stage but include dysphagia, weight loss, pain and cough.
- Diagnostic tools include endoscopy, CT, PET, MRI and EUS to determine stage.
- Treatment involves chemotherapy, radiation, and surgery depending on location and stage. Surgical techniques include transhiatal, Ivor Lewis and minimally invasive approaches.
This document discusses carcinoma of the rectum. It begins by explaining the anatomy of the rectum and its blood supply, lymphatic drainage and innervation. It then discusses the epidemiology, risk factors, staging systems including Dukes and TNM classification. Signs and symptoms, diagnostic workup including endoscopic, radiological and biopsy evaluation are explained. Principles of surgical treatment including resection margins are outlined. The goal of surgery is eradication of the primary tumor along with adjacent mesorectal tissue.
This document discusses neoplasms of the esophagus, specifically carcinoma. It is most common in China, South Africa, and parts of Asia. The majority of esophageal cancers are squamous cell carcinomas located in the middle third of the esophagus. Risk factors include deficiencies in vitamins, mycotoxins, alcohol, and tobacco. Advanced stages present with dysphagia and are usually treated with palliation. Surgery is the treatment of choice for early-stage cancers. The prognosis is generally poor due to late presentation and aggressive nature of the disease.
Information about Low Anterior Resection by Dr Dhaval Mangukiya.
Details of GOAL of LAR, Margins, Reconstructions, Anal Anastomosis, End to Side Colorectal Anastomosis, Stapler Vs Hand Sewn, Intersphincteric Resection, Colonic J pouch Anastomosis etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
The document describes the anatomy and clinical aspects of the esophagus. It notes that the esophagus is a tubular structure about 25 cm long that begins at the pharynx and pierces the diaphragm to join the stomach. It discusses the relations of the esophagus in the neck, thorax, and abdomen. The document also summarizes the blood supply, lymphatic drainage, and innervation of the esophagus. Finally, it reviews esophageal cancer risk factors, staging, and treatment options including surgery, chemotherapy, and radiation therapy.
This document provides information on the investigations, management, surgery, radiotherapy, chemotherapy, and treatment algorithm for gastric cancer. It discusses the role of endoscopy, CT, EUS, PET/CT, MRI, and laparoscopic staging in evaluating gastric cancer. It describes the principles and types of surgery, including endoscopic mucosal resection, gastrectomy, and lymph node dissection. It outlines the evidence for adjuvant radiotherapy and chemoradiotherapy post-operatively. It also discusses chemotherapy regimens for locally advanced and metastatic gastric cancer.
Minimally invasive esophagectomy (MIE) is an evolving technique for treating esophageal cancer that offers advantages over traditional open esophagectomy. MIE uses small incisions and video-assisted thoracic surgery to mobilize the esophagus, allowing for less post-operative pain, quicker recovery times, and reduced pulmonary complications compared to open techniques. While short-term outcomes are improved with MIE, long-term oncological outcomes still need to be defined as surgery aims to completely remove the cancer while preserving quality of life. MIE represents a shift toward less invasive options for esophageal cancer treatment when surgery is required.
Acs0532 Procedures For Diverticular Disease 2004medbookonline
This document describes procedures for diverticular disease, including emergency and elective operations. The Hartmann procedure is described, which involves resection of the sigmoid colon and rectum with construction of an end colostomy. Alternatively, a primary anastomosis with diverting loop ileostomy can be performed. For emergency cases with perforation or obstruction, a temporary stoma such as a Hartmann is preferred to avoid the risk of anastomotic leakage. Elective/planned cases can undergo primary resection and anastomosis with diverting ileostomy. Laparoscopic techniques for resection are also discussed.
This document discusses the current evidence for D1 and D2 gastrectomy in treating gastric cancer. It begins by defining the lymph node stations and different levels of lymphadenectomy. It then reviews several key randomized controlled trials that compared D1 and D2 gastrectomy. While initial Western trials found higher morbidity and mortality with D2 without survival benefits, later long-term follow up and recent trials demonstrate lower recurrence rates and improved survival with D2 gastrectomy when performed safely. The consensus is that D2 gastrectomy with preservation of the spleen and pancreas can achieve radical treatment for gastric cancer with excellent outcomes when performed by experienced surgeons.
The document discusses gastric cancer surgery, including classifications of resection margins (R0, R1, R2) and lymph node dissection (D1, D2, D3, D4). It describes procedures for different tumor locations like total gastrectomy for proximal or middle tumors versus subtotal gastrectomy for distal tumors. Complications after different reconstruction methods are outlined, and the use of palliative treatments for advanced cancer is covered.
This document discusses the surgical anatomy and procedure for an Ivor Lewis esophagectomy. Key points include:
- The esophagus passes from the neck to the abdomen, with blood supply from the inferior thyroid, bronchial, and left gastric arteries. Lymph drains to cervical, paratracheal, and subcarinal nodes.
- An Ivor Lewis esophagectomy involves both a laparotomy and right thoracotomy to fully mobilize the esophagus. The stomach is used as a conduit for reconstruction.
- The procedure involves extensive mobilization of the esophagus in both the abdomen and right chest. The conduit is pulled into the chest and a stapled anastomosis is
The surgical management of gastroesophageal cancerforegutsurgeon
This document discusses surgical techniques for treating gastroesophageal cancers and early stage esophageal adenocarcinoma. It finds that laparoscopic staging is useful for gastric cancer and laparoscopic resection may provide benefits over open surgery. While D2 lymphadenectomy provides more thorough staging, it also carries higher risks than D1 with no clear survival benefit. For early esophageal cancers, esophagectomy carries a small but definite risk of recurrence compared to endoscopic mucosal resection, but laparoscopic esophagectomy outcomes are similar to open surgery.
Laparoscopic surgery for small bowel tumoursforegutsurgeon
This document discusses the role of laparoscopic surgery for small bowel tumors. It outlines that laparoscopy can be used for diagnosis, staging, and in some cases curative resection of small bowel tumors, extending techniques used for gastric and colorectal cancers. Specific tumor types that may be suitable for laparoscopic resection include gastrointestinal stromal tumors and adenocarcinomas. The document reviews techniques for laparoscopic resection and anastomosis of different small bowel segments.
1) Transanal total mesorectal excision (TME) is a novel technique for resection of rectal cancers.
2) TME involves excising the rectum and the surrounding mesorectum in one block through the anus to minimize local recurrence.
3) This "down-to-up" transanal approach aims to improve on open TME by reducing morbidity and impairment of function compared to traditional surgery.
The document describes the anatomy and pathophysiology of the esophagus. It discusses:
- The esophagus is a 25 cm muscular tube that extends from the cricopharyngeus to the gastroesophageal junction.
- There are four layers of the esophageal wall and four regions of the esophagus.
- Esophageal cancer is most commonly squamous cell carcinoma or adenocarcinoma. Risk factors include smoking, alcohol, obesity, and Barrett's esophagus.
- Staging of esophageal cancer involves evaluating the primary tumor, lymph nodes, and distant metastases. Treatment depends on the cancer stage but may include surgery, chemotherapy, or radiation therapy.
reviewed the literature ;Multidisciplinary management of gastric cancer
Yixing Jianga and Jaffer A. Ajani
; pictures taken from Sabiston textbook of surgery.
This document discusses the anatomy and patterns of lymph node metastasis in head and neck cancers. It covers the history of neck dissection techniques, anatomy of cervical lymph nodes, levels of lymph node involvement, factors affecting prognosis, and terminology such as occult metastasis and skip metastasis. Select sections discuss findings from studies on patterns of nodal spread in oral cancers and the risk of occult metastases. The conclusion is that lymph node level IV must be included in neck dissections for tongue cancers due to the risk of skip metastases bypassing upper levels.
Oesophageal cancer is a disease that affects the esophagus. The document provides details about:
1) The anatomy, histology, blood supply, lymphatic drainage and functions of the esophagus.
2) Risk factors, symptoms, epidemiology, macroscopic and microscopic appearance of oesophageal cancer.
3) Diagnostic tests and staging of oesophageal cancer including endoscopy, imaging, and biopsy.
4) Treatment options for oesophageal cancer including surgery, chemotherapy, radiation therapy and palliative care based on the cancer stage. Prognostic factors and performance status scales are also discussed.
This document discusses esophageal cancer, including:
- It remains the 6th most common malignancy and rates vary globally. Squamous cell carcinoma is most common.
- Risk factors include smoking, alcohol, hot liquids and micronutrient deficiencies. Barrett's esophagus increases adenocarcinoma risk.
- Symptoms depend on location and stage but include dysphagia, weight loss, pain and cough.
- Diagnostic tools include endoscopy, CT, PET, MRI and EUS to determine stage.
- Treatment involves chemotherapy, radiation, and surgery depending on location and stage. Surgical techniques include transhiatal, Ivor Lewis and minimally invasive approaches.
This document discusses carcinoma of the rectum. It begins by explaining the anatomy of the rectum and its blood supply, lymphatic drainage and innervation. It then discusses the epidemiology, risk factors, staging systems including Dukes and TNM classification. Signs and symptoms, diagnostic workup including endoscopic, radiological and biopsy evaluation are explained. Principles of surgical treatment including resection margins are outlined. The goal of surgery is eradication of the primary tumor along with adjacent mesorectal tissue.
This document discusses neoplasms of the esophagus, specifically carcinoma. It is most common in China, South Africa, and parts of Asia. The majority of esophageal cancers are squamous cell carcinomas located in the middle third of the esophagus. Risk factors include deficiencies in vitamins, mycotoxins, alcohol, and tobacco. Advanced stages present with dysphagia and are usually treated with palliation. Surgery is the treatment of choice for early-stage cancers. The prognosis is generally poor due to late presentation and aggressive nature of the disease.
Information about Low Anterior Resection by Dr Dhaval Mangukiya.
Details of GOAL of LAR, Margins, Reconstructions, Anal Anastomosis, End to Side Colorectal Anastomosis, Stapler Vs Hand Sewn, Intersphincteric Resection, Colonic J pouch Anastomosis etc.
https://drdhavalmangukiya.com/
http://www.youtube.com/c/DrDhavalMangukiyaGastrosurgeonSurat
https://gastrosurgerysurat.blogspot.com/
The document describes the anatomy and clinical aspects of the esophagus. It notes that the esophagus is a tubular structure about 25 cm long that begins at the pharynx and pierces the diaphragm to join the stomach. It discusses the relations of the esophagus in the neck, thorax, and abdomen. The document also summarizes the blood supply, lymphatic drainage, and innervation of the esophagus. Finally, it reviews esophageal cancer risk factors, staging, and treatment options including surgery, chemotherapy, and radiation therapy.
This document provides information on the investigations, management, surgery, radiotherapy, chemotherapy, and treatment algorithm for gastric cancer. It discusses the role of endoscopy, CT, EUS, PET/CT, MRI, and laparoscopic staging in evaluating gastric cancer. It describes the principles and types of surgery, including endoscopic mucosal resection, gastrectomy, and lymph node dissection. It outlines the evidence for adjuvant radiotherapy and chemoradiotherapy post-operatively. It also discusses chemotherapy regimens for locally advanced and metastatic gastric cancer.
Minimally invasive esophagectomy (MIE) is an evolving technique for treating esophageal cancer that offers advantages over traditional open esophagectomy. MIE uses small incisions and video-assisted thoracic surgery to mobilize the esophagus, allowing for less post-operative pain, quicker recovery times, and reduced pulmonary complications compared to open techniques. While short-term outcomes are improved with MIE, long-term oncological outcomes still need to be defined as surgery aims to completely remove the cancer while preserving quality of life. MIE represents a shift toward less invasive options for esophageal cancer treatment when surgery is required.
Acs0532 Procedures For Diverticular Disease 2004medbookonline
This document describes procedures for diverticular disease, including emergency and elective operations. The Hartmann procedure is described, which involves resection of the sigmoid colon and rectum with construction of an end colostomy. Alternatively, a primary anastomosis with diverting loop ileostomy can be performed. For emergency cases with perforation or obstruction, a temporary stoma such as a Hartmann is preferred to avoid the risk of anastomotic leakage. Elective/planned cases can undergo primary resection and anastomosis with diverting ileostomy. Laparoscopic techniques for resection are also discussed.
Laparoscopy in obesity Dr.Nutan Jain Indiajainnutan
This document discusses obesity and minimally invasive surgery in gynecological procedures. It provides definitions of obesity, assessments for obese patients undergoing surgery, and techniques for laparoscopic surgery in obese patients. Key points include the use of longer instruments, perpendicular trocar insertion, and positioning to accommodate excess tissue. Minimally invasive surgery is shown to be as safe for obese patients as non-obese with proper precautions. It can significantly reduce morbidity compared to open surgery for procedures like hysterectomy and lymph node dissection in endometrial cancer.
1) The document reviews various incision and closure techniques used in obstetrics and gynecology, including transverse (e.g. Pfannenstiel), vertical (e.g. midline), and laparoscopic incisions.
2) It discusses factors to consider when selecting an incision such as patient characteristics, pathology, and risk of adhesions or malignancy. It also reviews various suturing and closure methods like continuous versus interrupted sutures.
3) The ideal closure method provides good approximation with minimal risk of complications like infection, hemorrhage or wound dehiscence while allowing for the best cosmetic outcome. Layered versus mass closure techniques are evaluated.
VARIOUS Temporary CLOSURE TECHNIQUES IN OPEN ABDOMEN.pptxSyedSherazAli10
The document discusses the use of the Bogota bag technique for temporary abdominal closure in patients requiring an open abdomen procedure. Several studies are summarized that examine outcomes in patients managed with the Bogota bag versus other temporary closure methods. The studies found rates of complications like wound infection, intestinal fistula and hernia formation ranging from 5-35% of patients. Mortality rates associated with the underlying conditions rather than the Bogota bag technique ranged from 9-41%. Most studies reported that the Bogota bag achieved the goal of temporary abdominal closure until definitive closure could be performed.
The document discusses open abdomen techniques and management. It defines open abdomen as requiring temporary abdominal closure after laparotomy when the skin and fascia cannot be primarily closed. Common causes for open abdomen include necrotizing fasciitis, severe bowel edema, peritonitis, and gross abdominal contamination. Temporary abdominal closure techniques discussed include simple packing, skin closure, Bogota bag, mesh, and Wittmann patch. More recently, negative pressure wound therapy including vacuum-assisted closure and variants like AB Thera have gained popularity due to advantages like improved drainage and wound contraction allowing higher rates of fascial reapproximation. The main goal of open abdomen treatment remains achieving definitive abdominal wall closure, preferably within 8 days to reduce complications.
Liposuction used to treat deep vascular accesses for hemodialysis.pptxGierelma J.T.
This study evaluated the use of liposuction to superficialize deep arteriovenous fistulas (AVFs) and arteriovenous grafts (AVGs) in 14 hemodialysis patients. Liposuction was performed to remove excess fat overlying the access to allow for cannulation. Following liposuction, the mean access depth decreased from 7mm to 5.3mm after 4 weeks of healing. For patients who previously could not use their deep access, 2 out of 3 were able to remove their tunneled catheters. For other patients, the length of accessible access increased on average from 5cm to 12.7cm. The procedure was well-tolerated with only minor bleeding in one case.
This document discusses hysterectomy procedures for benign gynecologic conditions. It notes that approximately 525,000 hysterectomies are performed annually in the US, often for conditions like fibroids, abnormal bleeding, and endometriosis. A significant portion of these procedures are complex due to factors like prior surgery, obesity, or presence of masses. The da Vinci robotic surgical system allows gynecologists to perform complex hysterectomies minimally invasively. Compared to open surgery, da Vinci hysterectomy provides benefits to both patients and surgeons such as less pain, blood loss, and recovery time as well as improved surgical capabilities. Robotic surgery allows more patients, especially those with higher BMI, to benefit
ABDOMINAL INCISIONS AND LAPAROTOMY-1.pptxAbhijitAzeez
The theoretical advantage of a paramedian over a midline incision is
a diminished risk of wound dehiscence and incisional hernia
In practice, when these incisions are reopened, the medial edge of the rectus muscle is frequently adherent to the anterior or posterior sheath incision and does not effectively buttress the wound.
A “lateral paramedian incision” refers to a vertical incision created several centimeters lateral to the location of the traditional paramedian incision.
In the patient who has had prior abdominal surgery, the cosmetic advantages of reentering the abdomen through a preexisting scar must be balanced against the challenges associated with dissection in a reoperative field. Close proximity of a new incision to an old one should be avoided in order to minimize the risk of ischemic necrosis of intervening skin and fascial bridges.
Mass closure of the abdominal wall is usually advocated, using large bites and short steps in the closure technique and either non-absorbable (e.g. nylon or polypropylene) or very slowly absorbable suture material (e.g. polydioxanone suture (PDS)). It has been estimated that, for abdominal wall closure, the length of the suture material should be at least four times the length of the wound to be closed to minimise the risk of abdominal dehiscence or later incisional hernia.
This document discusses laparoscopic colonic surgery. It provides an overview of different types of laparoscopic colon surgery techniques including standard laparoscopic surgery, laparoscopic-assisted surgery, and hand-assisted laparoscopic surgery. It also discusses indications for laparoscopic colonic resection including colon cancer. Guidelines are provided for performing laparoscopic colonic resection while maintaining oncologic principles.
This document discusses surgical and interventional approaches for gallbladder disease. It describes laparoscopic cholecystectomy as the standard treatment for cholelithiasis and mild-to-moderate acute cholecystitis. Variations like single-incision laparoscopic cholecystectomy aim to reduce scarring but have technical challenges. Natural orifice transluminal endoscopic surgery (NOTES) offers improved cosmesis through transgastric or transvaginal access but requires special equipment. Percutaneous cholecystostomy effectively treats acute cholecystitis in patients who cannot undergo surgery but has frequent complications and diminishes quality of life. The optimal approach considers the patient's condition and disease consequences.
Plastic Surgery for obese, lower body lifts
Cosmetic and body reshape surgery liposuction...Dr Junaid Ahmad (MBBS FCPS) is the best plastic surgeon in Lahore. He is a well known, trained and expert in his field. He is MBBS and FCPS in Plastic and Recosntructive Surgery. He is a post graduate of the College of Physicians and Surgeons Pakistan which is oldest and best institute for post graduation in this area of the world. He is doing his practice in Lahore, Pakistan. He is always kind to the patients and listens them carefully as it is part of modern clinical skill and training. He is expert in both cosmetic as well as reconstructive surgery. He is also skin cancer and burn expert. A few of Dr Junaid Ahmad expertise are listed here..... call 03104037071
NOTES (Natural Orifice Transluminal Endoscopic Surgery) is an experimental surgical technique that performs operations through natural openings in the body without external incisions. This avoids scarring and reduces recovery time. NOTES procedures first began in the 1980s and have included cholecystectomies, appendectomies, and other abdominal surgeries. While still being developed, NOTES may eventually allow many operations to be done as outpatient procedures with even faster recovery times compared to laparoscopic surgery.
Laparoscopic colon resections are being performed with increasing frequency all over the world. However, the use of minimal access surgery in colorectal surgery has lagged behind its application in other surgical fields.
This document outlines a study protocol to evaluate a novel transvaginal surgical approach for repairing caesarean section scar defects. The study will recruit 60 symptomatic women to undergo transvaginal repair involving endometrial curettage of the scar defect cavity and suturing of the defect. Patients will be followed for 6 months with clinical and ultrasound evaluations at regular intervals to assess outcomes. The goal is to evaluate if this approach can effectively repair scar defects while avoiding complete excision of healthy myometrium.
Sugery for chronic pancreatitis.dr quiyumMD Quiyumm
Surgery can provide effective pain relief and improve quality of life for patients with chronic pancreatitis (CP). Common indications for surgery include intractable pain, complications like biliary or duodenal obstruction, and pancreatic head masses that are difficult to differentiate from cancer. Surgical options range from drainage procedures that preserve pancreatic tissue to resection procedures like pancreaticoduodenectomy. While resection can address pain and complications, drainage procedures better preserve endocrine and exocrine function but often lead to recurrent pain. Overall, surgery improves pain control and quality of life for appropriately selected CP patients.
This study evaluated the experiences and outcomes of 150 patients who underwent single incision laparoscopic cholecystectomy (SILC) between 2009-2011. Two different techniques were used for the single incision procedure. The median operative time was 29 minutes. Patients were discharged after a median hospital stay of 1.33 days. Five patients developed superficial wound infections. Port site hernias developed in 5 patients within 6 months of surgery. No other major complications occurred. The study concluded that SILC is a safe procedure that can be performed successfully with conventional laparoscopic instruments and may provide advantages of reduced postoperative pain and improved cosmetic outcomes compared to traditional laparoscopic cholecystectomy.
Today, Laparoscopy is an alternative technique for carrying out many operations that have traditionally required an open approach. The benefits of minimal access surgery have been well recorded, including lower post-operative morbidity, shorter duration of hospital stay and a shorter return to work.
This document discusses the management of burst abdomens, also known as abdominal wound dehiscence. It defines abdominal wound dehiscence and provides information on incidence, risk factors, clinical manifestations, and treatment options. Dehiscence occurs when an abdominal wound separates after surgery, with a reported incidence between 0.2-6% and mortality rates of 10-40%. Risk factors include male sex, age under 45, emergency surgery, obesity, and medical conditions like diabetes or renal failure. Treatment depends on the severity but may involve re-suturing the wound with retention sutures or using a prosthetic mesh if the wound cannot be primarily closed.
This document discusses ventral incisional hernia repair and compares the sublay retromuscular technique using lightweight Vypro mesh versus heavier Prolene mesh. It provides background on incisional hernias, risk factors, techniques for open repair including suture repair, inlay, onlay, and sublay/retromuscular approaches. The study aims to evaluate the challenge of the sublay technique with new technical points to reduce recurrence and compare results of Vypro versus Prolene mesh in postoperative complications, chronic pain, and recurrence rates.
1. The American Journal of Cosmetic Surgery Vol. 28, No. 4, 2011 241
ORIGINAL ARTICLE
One Hundred Consecutive Lipoabdominoplasty
Procedures: ModiÞed Avelar Technique for Full
Abdominoplasty Without Panniculus Undermining—
Advances, Morbidity, and Complications
Filiberto Rodriguez, MD; Marvin A. Borsand, DO, FACOS, FAACS
Introduction: Abdominoplasty can be limited by preexist-
ing scars and is associated with postoperative drains, seromas,
and deep vein thrombosis (DVT). The Avelar technique has
been described as an alternative to extensive ßap dissection.
We adopted this technique in 2007.
Materials and Methods: The lower abdomen is marked
for planned resection. Liposuction is performed throughout
the entire abdomen below Scarpa’s fascia and superÞcially
in the lower abdomen to thin the redundant pannus. The skin
is sharply incised, and the thinned pannus is bluntly avulsed,
leaving the subcutaneous fat and vessels intact. The upper
abdominal skin can be slid over the deep fascia, preserving
the perforating vessels. A narrow tunnel is dissected from
the umbilicus to the xiphoid for rectus plication. The umbili-
cus is transposed in the usual manner. All patients receive
DVT prophylaxis with perioperative heparin, sequential
compression devices, and Lovenox. Surgery is ambulatory,
and drains are not routinely used.
Results: Between April 2007 and December 2010, 100
consecutive lipoabdominoplasty procedures were performed.
There were no DVTs and no deaths. One patient sustained
small-bowel injury during liposuction, which was immedi-
ately recognized and successfully repaired. Five hematomas
(28 ± 28 mL) occurred within the early postoperative period,
2 of which became infected. Four hematomas responded to
local drainage, but 1 required surgical evacuation 3 months
later. The incidence of late seroma was 0%. Two marginal
skin necroses occurred in patients with preexisting Kocher
and laparotomy scars, which healed without ill effect.
Conclusions:Theincidenceofwounddehiscence,seroma,
hematoma, and DVT after lipoabdominoplasty is less than
that reported for traditional abdominoplasty.
Abdominoplasty is the fourth most frequently
performed cosmetic surgical operation in the
United States.1
Over the years, several technical reÞne-
ments have signiÞcantly improved the results of
abdominoplasty, yet the most common approach for
abdominal contouring remains traditional abdomino-
plasty with extensive undermining of the abdominal
ßap at the deep fascia up to the costal margin for
advancement. This approach, however, signiÞcantly
compromises the blood supply to the abdominal ßap
as the large central perforators are sacriÞced during
the ßap elevation, leaving the ßap dependent on its
lateral blood supply. Despite increased awareness and
efforts to decrease the morbidity associated with
traditional abdominoplasty, the procedure continues to
be plagued with several complications, which include
seroma formation (the most common, 5–22%), hema-
toma (6.9%), infection (12.1%), wound ischemia, skin
necrosis of the infraumbilical area, and deep vein
thrombosis (DVT) with venothromboembolism (VTE)
(0.34–3.4%).2–6
The decreased blood supply to the abdominal ßap
has led to advocacy against any liposuction of the
central abdomen (zones 2 and 3) at the time of
abdominoplasty in order to minimize the risk of ßap
necrosis.7
The extensive dissection also disrupts the
lymphatic drainage, which predisposes abdominoplasty
to seroma formation, causing most surgeons to routinely
use drains in an attempt to avoid this complication.
Although progressive tension sutures without the use
of drains, as described by Pollock and Pollack8
has
Received for publication June 21, 2011.
From the Body Sculpting Center, Scottsdale, Ariz.
Presented in part at the International Symposium of Minimal Invasive
Plastic Surgery and Dermatology, Bangkok, Thailand, April 2011, and the
World Academy of Cosmetic Surgery 2nd Annual Meeting, Vienna, Austria,
September 2011.
Corresponding author: Filiberto Rodriguez, MD, The Body Sculpting
Center, 2255 N Scottsdale Rd, Scottsdale, AZ 85257 (e-mail: Filiberto
RodriguezMD@gmail.com).
2. 242 The American Journal of Cosmetic Surgery Vol. 28, No. 4, 2011
recently been shown to decrease the incidence of
seroma after abdominoplasty from 24% to 1.7%,9
this
technique has not been universally adopted. Moreover,
the fear of hematoma after the extensive dissection for
abdominoplasty may prevent surgeons from instituting
anticoagulation for DVT prophylaxis, even though
excisional contouring surgery of the abdomen remains
associated with the highest rate of thromboembolic
disease for cosmetic surgery,6
and despite published
recommendations from the American Society of Plastic
Surgeons based on the guidelines devised by the
American College of Surgeons.10,11
Alternative techniques have been described for
abdominoplasty that do not entail extensive ßap eleva-
tion and dissection.3,12,13
These techniques involve
various adaptations of aggressive liposuction in the
deep abdominal subcutaneous tissue to enable forward
advancement of the abdominal ßap after excision of
the redundant pannus. Although these techniques have
been shown to decrease the incidence of postopertive
complications,3,13,14
these methods have idiosyncrasies,
such as en bloc excision of the redundant pannus with
the umbilicus and the creation of a neoumbilicus,12
excision of small areas of skin the suprapubic region
and the upper abdomen along the inframammary
folds,3
and disruption of “skin-retaining ligaments,”13
which may preclude wide acceptance.
In 2007, the senior author (M.A.B.) began adapting
the principles of the Avelar technique to his mini-
abdominoplasty procedures (lower abdominoplasty
without translocation of the umbilicus) and has since
expanded the technique to all conventional and ßeur-de-
lis abdominoplasty procedures. The resulting modiÞ-
cations have emerged as a hybrid procedure combining
the principles of the Illouz suction abdominoplasty,12
conventional abdominoplasty with diastasis repair and
transposition of the umbilicus, and the Avelar tech-
nique for aggressive liposuction and blunt avulsion of
redundant tissue without undermining of the upper
abdominal ßap.3
The procedure has been simpliÞed to
eliminate the idiosyncratic aspects of these alternative
approaches, and a streamlined, simpliÞed technique
has emerged. This lipoabdominoplasty procedure has
proven safe and convenient when combined with
concomitant additional cosmetic procedures, with cir-
cumferential liposuction of the ßanks and back in par-
ticular. We have also been able to abandon the routine
use of postopertive drains and implement an aggressive
anticoagulation protocol for DVT prophylaxis with
minimal hematoma and seroma complications.
Patients and Methods
One hundred consecutive patients underwent
lipoabdominoplasty from April 2007, when we Þrst
adopted the procedure into our practice, through
December 2010. Of the patients, 99% were women.
The average age was 39 years (range, 18 to 62), and
the average body mass index (BMI) was 27.3 ± 4.0
(range, 20.7 to 38.9). Of the patients, 87 underwent
full abdominoplasty (Figures 1 through 3), 9 underwent
a lower abdominoplasty without translocation of
the umbilicus (ie, mini tummy tuck), and 4 patients
underwent a ßeur-de-lis abdominoplasty (Figure 4). In
addition, 65 patients underwent concomitant circum-
ferential torso liposuction of the ßanks and back, and
32 patients underwent liposuction of additional areas
(eg, thighs, chin, arms). Further, 6 patients had fat
transfer for gluteal augmentation, 1 patient underwent
fat grafting to the face, and 3 patients had additional
body contouring surgery (eg, thigh lift or mid-body
lift). Concomitant breast surgery, either implant
augmentation alone or with mastopexy, was done in
37 patients; 3 patients underwent intra-abdominal tubal
ligation, and 1 patient underwent vaginoplasty. The
overall incidence of concomitant additional procedures
was 95%, with an average of 1.8 ± 1.0 (mean ± SD)
procedures performed per patient.
Surgery was performed in a licensed outpatient
surgery center under local anesthesia with intravenous
sedation and monitored anesthesia care. The usual
length of surgery was 4 hours, and patients were
discharged within 2 hours after surgery. All patients
received aggressive DVT prophylaxis consisting of
5000 units of heparin subcutaneously at the time of
surgery, use of sequential compression devices during
surgery, and 10 days of Lovenox (SanoÞ-Aventis,
Bridgewater, NJ) 40 mg subcutaneously after surgery.
Operative Technique
Preoperatively, the redundant pannus is marked on
the patient. Circumferential liposuction of the back
and ßanks is performed while the patient is in the
prone position when indicated using a super-wet tu-
mescent technique. The patient is then rotated to the
supine position, and liposuction of the entire abdomen
is performed in the deep plane below Scarpa’s fascia.
This deep liposuction allows the upper abdominal skin
and subcutaneous tissue to be slid over the deep fascia
while preserving the perforating vessels as multiple
pedicles. Additional liposuction is performed in the
upper abdomen as needed to optimize its thickness
and enhance the Þnal contour. Liposuction is then
3. The American Journal of Cosmetic Surgery Vol. 28, No. 4, 2011 243
performed aggressively in the superÞcial plane in the
previously marked lower abdominal redundant pannus
to thin this tissue to facilitate excision.
After liposuction and before the skin is incised, the
patient is ßexed and the skin is tailor-tacked with towel
clamps to ensure that successful closure will be
possible once the pannus is excised. This is a critical
distinction from traditional abdominoplasty as the skin
excision is predetermined as opposed to being deter-
mined after the ßap has been elevated and the patient is
ßexed. The skin is sharply incised along the preopera-
tive markings, the umbilicus is freed circumferentially,
and the thinned pannus is bluntly avulsed via the Avelar
technique, leaving the underlying subcutaneous fat,
connective tissue, and vessels intact. A narrow tunnel
is dissected, when indicated, from the umbilicus to the
xiphoid, allowing complete diastasis plication from
the xiphoid to pubis. The patient is then ßexed, and
the abdominal incision is closed under minimal tension,
with interrupted deep dermal staples (INSORB, Incisive
Surgical, Plymouth, Minn) and a running subcuticular
3-0 polydioxanone Quill suture (Angiotech Pharma-
ceuticals, Vancouver, British Columbia). The patient
is then ßattened, and the umbilicus is transposed in
the usual manner. Drains were placed in 11 patients
(11%) depending on the degree of exposed fascia after
avulsion of the pannus.
Results
There were no deaths or incidents of DVTs. One
patient with a preexisting laparotomy scar required
small-bowel repair at the time of abdominoplasty as a
result of small-bowel injury from the liposuction
cannula. She was admitted to the hospital overnight
and recovered without incident. Five hematomas
(28 ± 28 mL) occurred within the early postoperative
period, 2 of which became infected. Four hematomas
responded to local drainage, and 1 required surgical
evacuation 3 months later. No seromas occurred
beyond the 6-week postoperative period. Fluid collec-
tions within the initial 6-week postoperative period
Figure 1. Before-and-after photographs of a 43-year-old woman (weight, 185 lb; body mass index, 34.5; full abdominoplasty
with abdominal liposuction, 750 mL; total lipoaspirate, 2100 mL). The postoperative photograph was taken 2 months after
surgery.
4. 244 The American Journal of Cosmetic Surgery Vol. 28, No. 4, 2011
were managed with periodic tapping in 9 patients (26
± 25 mL). Four superÞcial stitch abscesses occurred,
which were successfully treated with oral antibiotics.
Marginal skin necrosis occurred in 2 patients with
preexisting Kocher and full midline laparotomy scars,
respectively, which healed without ill effect (Figure 5).
Good abdominal contour was achieved with lipoab-
dominoplasty (see Figures 1 through 4), and patient
satisfaction was high, as evidenced by our patient
referral rate of 68%.
Discussion
Over the past 30 years, increased attention has been
placed on the incidence and avoidance of the compli-
cations associated with abdominoplasty, which include
seroma formation (the most common, 5–22%), hema-
toma (6.9%), infection (12.1%), wound ischemia, skin
necrosis of the infraumbilical area, and DVT with
VTE (0.34–3.4%).2–6
Various methods for reducing complications are
described in the literature. For seroma, recommenda-
tions include quilting sutures,2,15
Þbrin glue,16
and
progressive tension sutures without the use of drains,8
which has recently been shown to decrease the
incidence of seroma after abdominoplasty from 24%
to 1.7%.9
To avoid ßap necrosis, Matarasso empha-
sized that liposuction of the central abdomen (zones 2
and 3) should not be performed at the same time as
abdominoplasty because of concerns of jeopardizing
the tenuous blood supply of the abdominal ßap
following ßap elevation and dissection.7
For DVT prophylaxis, the American Society of
Plastic Surgeons formed a task force on DVT in 1999
that published recommendations based on the guide-
lines devised by the American College of Surgeons.10,11
The focus on DVT after abdominoplasty stems from
the fact that excisional contouring surgery of the
abdomen is associated with the highest rate of throm-
boembolic disease in cosmetic surgery.6
Although the
Figure 2. Before-and-after photographs of a 47-year-old woman (weight, 214 lb; body mass index, 40.4; full abdominoplasty
with abdominal, ßank, and back liposuction, 6750 mL; total lipoaspirate, 8700 mL). The postoperative photograph was taken
3 months after surgery.
5. The American Journal of Cosmetic Surgery Vol. 28, No. 4, 2011 245
etiology of DVT after abdominoplasty is beyond the
scope of this article, an increase in intra-abdominal
pressure after diastasis repair, which may retard
venous return, combined with decreased ambulation
after the procedure, may contribute. Historically, the
incidence of DVT after isolated abdominoplasty was
reported at 1.1% in a 1977 review of 10490 cases,
with pulmonary embolus (PE) in 0.8% and death from
PE in 0.1% of patients.17
A more recent report from
2010 found the incidence of VTE to be 0.34% after
abdminoplasty alone, 0.67% after abdminoplasty with
concomitant additional cosmetic procedures, 2.17%
Figure 3. Before-and-after photographs of a 41-year-old woman (weight, 182 lb; body mass index, 34.3; full abdominoplasty
with abdominal, ßank, and back liposuction, 2050 mL; total lipoaspirate, 2500 mL). The postoperative photograph was taken
4 months after surgery.
6. 246 The American Journal of Cosmetic Surgery Vol. 28, No. 4, 2011
after abdominoplasty with intra-abdominal procedures,
and 3.4% after cirumferential abdominoplasty.6
Despite
these staggering statistics, perioperative anticoagulation
is not routinely instituted by plastic surgeons (oral
communication, University of California, Los Angeles
Department of Plastic and Reconstructive Surgery,
2008–2009), perhaps because plastic surgeons remain
more concerned about hematoma after the extensive
ßap dissection and choose to not apply the American
College of Surgeons DVT prophylaxis guidelines, which
did not speciÞcally include plastic surgery patients.6,11
A recent report discussing preventive measures to
reduce thromboembolism after cosmetic surgery, how-
ever, reveals that abdominoplasty patients fall into
moderate to high risk for DVT and warrant periopera-
tive chemoprophylaxis against DVT with Lovenox, in
addition to early ambulation and use of sequential
compression devices during surgery.18
Hence, sur-
geons performing abdominoplasty should aggressively
seek to minimize the risk of DVT for their patients.
Figure 4. Before-and-after photographs of a 46-year-old woman (weight, 116 lb; body mass index, 22.3; ßeur-de-lis abdomi-
noplasty with abdominal liposuction, 400 mL; total lipoaspirate, 1100 mL). The postoperative photograph was taken 3 months
after surgery.
An alternative approach for abdominoplasty may
help address and minimize these complications. In
1992, Illouz12
introduced the concept of the suction
abdominoplasty. Instead of extensive undermining of
the abdominal ßap at the deep fascia up to the costal
margin, Illouz described liposuction of the upper
abdomen to loosen the supraumbilical subcutaneous
tissue sufÞciently to allow downward advancement.
The redundant lower abdominal tissue was then
excised en bloc with the umbilicus. Undermining of
the midline enabled diastasis repair from the xiphoid
to the pubis. A neoumbilicus was created after
advancement of the upper abdomen and closure. The
purported advantages of this method are that it simpli-
Þes the procedure and avoids inherent complications
because undermining and subsequent devascularization
are avoided.12
Although some surgeons have reported
success with this technique19
and variations,13
it has
failed to gain wide acceptance.
7. The American Journal of Cosmetic Surgery Vol. 28, No. 4, 2011 247
In 2002, Avelar introduced a fundamentally different
approach for abdominoplasty that completely avoids
undermining and resection of the panniculus.3
Because
of the high incidence of complication rates after
conventional abdominoplasy in the 1980s, Avelar
abandoned conventional abdominoplasty and abdomi-
noplasty combined with liposuction from 1988 to
1998. During that time, Avelar carefully studied the
vascularization of the subcutaneous tissue after
liposuction.20
From these studies, a method for
abdominoplasty was described wherein small areas of
skin were excised from the suprapubic region and the
upper abdomen along the inframammary folds.3,14
Liposuction was performed throughout the abdomen
in the deep layer below Scarpa’s fascia, which allowed
the panniculus to be slid easily over the muscular
aponeurotic wall while preserving all the perforating
vessels. A fundamental element of the skin resection
technique was to perform aggressive liposuction of the
full thickness of the skin to be resected and then blunt
avulsion of this skin, rather than sharp dissection off
the fascia, thereby leaving the connective tissue and
the arterial, venous, and lymphatic vessels between
the muscles below and the thin layer of subdermal
structures above.3,14
Umbilical transposition was not
necessary, and drains were not used. Only 2 cases of
seroma treated with syringe aspiration occurred in
Avelar’s series of 97 patients, and there were no cases
of hematoma, skin ischemia, or necrosis, although
the use of perioperative anticoagulation was not
discussed.3
Our modiÞcations of the Avelar technique for
abdominoplasty have resulted in a hybrid procedure
combining the principles of the Illouz suction abdom-
inoplasty, conventional abdominoplasty with diastasis
repair and transposition of the umbilicus, and the
Avelar technique for aggressive liposuction and blunt
avulsion of redundant tissue without undermining the
panniculus. The procedure has been simpliÞed to
eliminate the idiosyncratic aspects of these alternative
approaches,3,12
and a streamlined, simpliÞed technique
has emerged. This lipoabdominoplasty procedure has
proven safe and convenient when combined with
concomitant additional cosmetic procedures.
The application of liposuction as a dissection tool
throughout the upper abdomen (without ultrasound or
laser) causes less vascular trauma to the ßap and less
bleeding than undermining with cautery or scalpel.13
Liposuction selectively disrupts the deep dermal
attachments while preserving the ßexible perforators,
thereby enhancing ßap circulation by creating a vascular
Figure 5. Before-and-after photographs of a 44-year-
old woman (weight, 213 lb; body mass index, 41.3; full
abdominoplasty with abdominal and ßank liposuction,
2600 mL; total lipoaspirate, 4200 mL). The postoperative
photographs were taken 2 weeks and 3 months after
surgery, respectively, showing successful wound healing
in this patient with large preexisting full midline
laparotomy scar.
8. 248 The American Journal of Cosmetic Surgery Vol. 28, No. 4, 2011
supporting tissue layer composed of a rich network of
blood vessels, lymphatics, connective tissue, and
nerves. This supporting tissue layer also provides a
deep layer devoid of devascularized fat and ensures
even ßap thickness and deep defatting without surface
irregularities.13
Moreover, circumferential liposuction
of the ßank and back not only optimizes the contour
correction (see Figure 3) but also facilitates abdominal
advancement anteriorly for a tension-free closure.
Our experience shows that circumferential liposuction
of the abdomen, ßanks, and back can be safely
performed in conjunction with the Avelar abdomino-
plasty technique without ßap necrosis. Even in the
presence of extensive preexisting surgical scars, such
as a right upper quadrant Kocher scar or a full midline
laparotomy, which are known risk factors for lower
skin necrosis after abdominoplasty because of the loss
of perforating vessels, the Avelar technique allows for
full abdominoplasty with minimal wound morbidity.
Although a lower midline laparotomy scar from the
umbilicus to the pubis does not normally contribute to
wound complications, because it is typically excised
as part of the abdominoplasty procedure, there is a
signiÞcant difference with a full midline laparotomy
(from xiphoid to pubis), as in our patient shown in
Figure 5. The upper abdominal skin remains compro-
mised by the surrounding scar tissue, and indeed in
this patient (Figure 5), the contracted upper component
of the midline scar limited the downward traction we
were able to place on the abdominal skin, resulting in
excess tension, which also contributed to the wound
necrosis in this area. Perhaps by performing a ßeur-
de-lis abdominoplasty (as shown in Figure 4) rather
than a standard tummy tuck, excision and revision of
the midline scar could have prevented possible skin
necrosis.
The reported incidence of seroma after abdomino-
plasty varies widely (5–22%).5
This variation may be
attributable to differences in deÞnition, because seromas
are deÞned as ßuid collections occurring after drain
removal, and the time of drain removal varies widely
from patient to patient and author to author.13
Hence,
in this report, seromas were deÞned as ßuid collection
persisting beyond the typical 6-week postopertive
interval as deÞned by Brauman and Capocci.13
Our
incidence of late seroma after lipoabdominoplasty was
0%. Consequently, drains are not routinely used, and
periodic tapping is performed for ßuid collections
during the early postoperative period as indicated
(9%). We note that most ßuid collections tend to occur
either in the most dependent aspect along the incision
or superiorly in the area of central dissection for
diastasis repair—perhaps of the thermal injury induced
by cautery in this area. The decision to place drains
(11%) is determined intraoperatively based on the de-
gree of fully exposed abdominal fascia after the blunt
avulsion of the lower abdominal pannus.
In addition to the decreased incidence of seroma,
lipoabdominoplasty has permitted us to implement an
aggressive anticoagulation protocol for DVT prophy-
laxis with minimal hematoma complications. This
aggressive protocol for DVT prophylaxis resulted in a
0% incidence of DVT in this series, despite the high
rate of concomitant additional procedures (95%) with
4% of patients undergoing additional intra-abdominal
procedures, which would typically be associated with
an incidence of 2.17% for DVT in the literature.6
With
this aggressive anticoagulation protocol for DVT
prophylaxis, our incidence of hematoma remained low
(5%) and was less than the recently reported incidence
of 6.9% after abdominoplasty by Araco and colleagues
in 2009.5
We suspect that our low hematoma rate
results from a combination of the tumescent technique
for the liposuction, which is fundamental for the Avelar
technique; minimal dissection; and the application of
pinpoint cautery for hemostasis after blunt avulsion of
the lower abdominal pannus.
The Avelar technique for lipoabdominoplasty rep-
resents a signiÞcant technical advance and departure
from traditional abdominoplasty, which results in
decreased seroma, bleeding, and wound complications.
It also allows for safe, aggressive DVT prophylaxis. In
particular, the Avelar technique enhances the safety of
abdominoplasty even in patients with BMI greater
than 30 (Figures 1 through 3). Average BMI in our
series was 27.3 ± 4, and it ranged from 20.7 to 38.9.
Only 50% of the patients had a BMI less than 30. As
is well known, abdominoplasty is not a weight-loss
procedure. Hence, once a patient is determined to be
a satisfactory candidate for abdominoplasty, BMI is
not a factor in the decision whether to use the Avelar
technique. Since adopting the Avelar technique for
abdominoplasty in April 2007, this has been our
exclusive approach for abdominoplasty, and this
report reßects the outcomes of 100 consecutive cases.
However, the Avelar technique does expose patients
to the risk of intestinal or organ perforation from the
liposuction or tumescent cannula, especially those
with preexisting surgical scars as in one of our patients.
The risk of intra-abdominal injury during liposuction,
although rare, is well known. As discussed in a recent
plastic surgery Maintenance of CertiÞcation article,
“Intestinal or organ perforation from the liposuction
9. The American Journal of Cosmetic Surgery Vol. 28, No. 4, 2011 249
cannula, though rare, usually occurs with a preexisting
abdominal scar. The abdomen, thorax, retroperitoneum,
and major vessels in the subcutaneous space are all
potential areas into which a cannula can be misdirected
and potentially result in major injury.”21
Because
liposuction throughout the abdomen and, especially,
aggressive liposuction in the lower abdomen are
fundamental components of the Avelar technique,
surgeons adopting this technique for abdominoplasty
must exercise caution and maintain a high index of
suspicion for possible penetration of the fascia during
abdominal liposuction, especially in patients with
preexisting scars. A high index of suspicion and
awareness should prompt a thorough examination of
the exposed fascia after avulsion of the lower abdminal
pannus. If identiÞed, a fascial defect warrants an
exploratory laparotomy through the already exposed
fascia so that any injuries can be immediately repaired.
In our patient, an immediate bowel repair was associ-
ated with an excellent cosmetic result and minimal
morbidity.
Conclusion
We conclude that lipoabdominoplasty, performed
as a hybrid procedure combining the principles of the
Illouz suction abdominoplasty, conventional abdomi-
noplasty with diastasis repair and transposition of the
umbilicus, and the Avelar technique for aggressive
liposuction and blunt avulsion of redundant tissue
without undermining of the panniculus, allows for
effective treatment of localized adiposity, excess
abdominal skin, and diastasis recti. The Avelar tech-
nique results in decreased seroma, bleeding, and
wound complications compared with published results
after standard abdominoplasty. In particular, the Avelar
technique enhances the safety of abdominoplasty even
in patients with BMI greater than 30. It also allows for
aggressive DVT prophylaxis with minimal risk of
hematoma. Meticulous technique and a high index of
suspicion for possible intra-abdominal injury are critical
during the abdominal liposuction, especially in
patients with preexisting scars.
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