Discussion: Concomitant Panniculectomy Affects Wound Morbidity but Not Hernia Recurrence Rates in Abdominal Wall Reconstruction

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Giordano et al. compared the effect of an added panniculectomy on wound morbidity and hernia recurrence in their prospectively maintained database of over 500 incisional hernia patients. Unfortunately, by labeling a vertical dermolipectomy by the term panniculectomy, this article has mixed otherwise distinct procedures that have been clearly separated since first described at the turn of the nineteenth century. In my opinion, this added confusion detracts from the conclusions of the article.
In English, the first report of a significant dermolipectomy weighing 7.5 kg was written by Kelly in the Johns Hopkins Medical Journal in 1899.1 This 12-line communique failed to describe details of the surgical procedure. In 1900, James Bullitt in Louisville described the removal of fat through a transverse incision in a 240-lb woman at the time of an umbilical hernia repair.2 The clinical image supplied was not impressive by modern comparisons. Peters, in 1901, described the surgery performed earlier by Kelly in great detail and provided an illustration of the panniculus adiposus that was removed.3 A transverse incision 85 cm in length was used, 15 perforators were ligated, and the surgeons kept her at bed rest for an entire month. Babcock in 1916 focused on vertical lipectomies and preferred them over transverse excisions, emphasizing the abdominal muscle suturing with silver chains to tighten the fascial envelope.4 He preferred vertical incisions because of the dog-ears that resulted at the midlateral lines after transverse skin lipectomy patterns. Schepelman in German demonstrated both transverse and vertical skin excisions, along with diagrams and excellent clinical photographs.5 Max Thorek gave credit to Schepelman regarding the two anatomical entities that require a lipectomy.6 A globular abdomen (German, Kugelbauch) (Fig. 1) would be addressed with fascial plication and a vertically oriented dermolipectomy, whereas a protuberant abdomen (German, Hängebauch) (Fig. 2) would undergo a skin incision with a transverse elliptical shape. It is interesting that neither Thorek (1940), Bankoff (1950),7 nor other writers of the first half of the twentieth century used the word “panniculectomy” to describe the removal of a lower apron of abdominal fat, strongly suggesting that this word was not in common use at that time.
Panniculectomy is the removal of the panniculus adiposus. First defined by Steven Blankaart,8 the panniculus adiposus was defined to be the same as the panniculus carnosus, which in turn was described as a “fat sort of membrane, in some parts thick and musculous, in other parts thin, with many ducts of fat in it.” The words panniculus adiposus and “apron” were both used to describe the fat that was removed in these early accounts of dermolipectomies through transverse incisions.2,3 The visual image of a suprapubic tissue apron is particularly appropriate, as panniculus is the diminutive of the word pannus, or cloth.9 The term “panniculectomy” was in the Discussion section in a 1953 publication.10 The Current Procedural Terminology code for panniculectomy, 15830, identifies the skin to be removed to be located in the infraumbilical position, but does not specify the direction of the incision.11
Herein lies the problem with the article by Giordano and colleagues. Common use of the term panniculectomy is the removal of infraumbilical fat through a transverse incision, a procedure that occurred in only 12 percent of the patients in this study. The remaining 88 percent underwent dermolipectomies that used the existing midline dissection. Primary fascial approximation brings soft tissues still attached to the abdominal wall to the midline, especially when perforator preservation techniques for large hernias requiring anterior components release are performed.
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