Combined Incisional Hernia Repair and Abdominoplasty Tummy Tuck

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Introduction

An incisional hernia is a weakness which has developed in part of the muscle layer of the abdominal wall at the site of a previous abdominal operation. It produces the bulging out of loops of bowel contained within a sac which is covered only by the skin and the underlying layer of subcutaneous fat. An incisional hernia often causes the patient varying intensity of pain, can appear unsightly and has the potential of producing obstruction or strangulation of its contents.

Causes of an incisional hernia are usually multifactorial but very often it is associated with some degree of obesity. Thus, in addition to the bulging hernia, the patient may also have an associated unsightly overhang of redundant abdominal skin and subcutaneous fat.

Rationale for the combined operation

Repair of the incisional hernia may be indicated on clinical grounds. If it is, and if there is also a significant associated overhang, it may be prudent to incorporate an abdominoplasty with the hernia repair. The advantages of the combined operation are:-

  • By lifting up the entire abdominal skin and subcutaneous fat, the margins of the incisional hernia can be very clearly defined and the repair can be carried out with precision.
  • There is a marked improvement in the patient’s cosmetic appearance. The combined operation removes a large amount of redundant skin and underlying fat, usually also incorporating the previous scar, thus producing a very significant cosmetic improvement.

Key points of the operation

  1. The incision is transverse across the lower abdomen, below the bikini line.
  2. The entire skin and subcutaneous fat layer of the abdominal wall is raised, up to the level of the rib cage, except for the umbilicus itself, which is left in situ as a small island, in its normal position.
  3. If an incisional hernia is present, it is now repaired using a large sheet of prolene mesh. The rest of the abdominal wall is also tightened using non-absorbable nylon sutures.
  4. The redundant overhang of skin and subcutaneous fat is trimmed off and the residual flap is pulled down to the transverse incision line. Before closing the transverse incision, a small opening is made in the flap to allow the undisturbed umbilicus to emerge in its normal position. This is sutured into place.
  5. The wound is closed under some tension, giving the tummy a taut appearance. The lines of tension are designed so that they are directed inwards, thus creating a new and more attractive waistline.

Post-operative considerations

  1. In the immediate post-operative period a special corset is worn by the patient in order to apply firm and constant pressure on the abdomen. Pillows are placed under the thighs so as to minimise the tension on the wound.
  2. Physiotherapy is an important element in the post-operative management. Thus respiratory problems are minimized, as is the risk of calf thrombosis (DVT).
  3. There is a small risk of a wound infection, or of fluid accumulation under the abdominal skin flap. There is also a very low risk of loss of viability of the umbilicus.

It should be noted than an abdominoplasty is not recommended in a patient who is grossly obese. It is largely ineffective in improving the cosmetic appearance in such a patient and would also be associated with a much higher risk of post-operative complications.

Cost of Surgery

Because both an abdominoplasty and incisional hernia repair have MBS item numbers ascribed to them, they are claimable from both Medicare and the patient’s own private health insurance. These would cover a significant portion of the cost of the surgery, although there will still be a residual out-of-pocket sum left to pay. This would be discussed at the time of the initial consultation.

Summary

Mr. Leinkram has much experience in performing abdominoplasties both with and without an associated incisional hernia. Being a General Surgeon with a special interest in hernias, he would be able to deal with all kinds of incisional hernias, irrespective of their complexity. Patients who request the operation would first need to see Mr. Leinkram and undergo a full clinical assessment. Any associated medical conditions and any medications being taken by the patients would be noted. The operation and any potential complications of surgery would be full discussed, as would the cost of the surgery.

Case 1

Preoperative front view

4 weeks postoperative front view

Preoperative side view

4 weeks postoperative side view