CASE REPORT

Mercedes Panniculectomy with SimultaneousComponent Separation Ventral Hernia Repair

Charles E. Butler, M.D.Scott M. Reis, B.S.

Houston, Texas

Concurrent panniculectomy and ventral her-nia repair has been shown to safely reducepannus size, wound-healing morbidity (e.g.,infection, hematoma, seroma, and dehiscence)rates, and hernia recurrence rates in obese herniapatients.15 Infraumbilical hernias can often berepaired through horizontal panniculectomy in-cisions, with no need for vertical incisions. How-ever, extensive undermining of the skin flap toaccess the upper abdomen causes additional deadspace and may increase the risk of wound-healingcomplications.2 Therefore, vertical incisions areuseful for hernias that extend to near the xiphoidand for when high laparotomy incisions areneeded for additional intraoperative procedures.

T-point necrosis and wound dehiscence arecommon wound-healing complications associatedwith concurrent horizontal and vertical incisions.69In one study, all patients who underwent supraum-bilical hernia repair with panniculectomy and in-verted-T closure developed complications, includ-ing abscesses and dehiscence.10 To reduce T-pointnecrosis, improve distal flap vascularity, and reducecomplication risks, we propose an alternative inci-sion design that allows horizontal and vertical pan-niculectomy and simultaneous ventral hernia repairwith component separation and inlay mesh.

TECHNIQUEThe Mercedes panniculectomy includes a hori-

zontal and vertical skin and fat resection in a fleur-de-lis pattern (Figs. 1 through 5). The lower borderof the horizontal component is marked with a cur-vilinear line, 2 cm cephalad and parallel to the groincrease between the anterior axillary lines. An equi-lateral triangle (each side, 15 to 20 cm) is drawnwithits base along the center of this line and tip justcaudal to the umbilicus (Figs. 1 and 2). This triangle

serves as a caudal-based flap and remains attachedduring the excision. The cephalad border of thehorizontal component is based on the amount ofskin and fat that canbe safely resected and ismarked

From the Department of Plastic Surgery, University of TexasM. D. Anderson Cancer Center.Received for publication August 25, 2009; accepted October2, 2009.Copyright 2010 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3181cb641d

Disclosure: There was no external funding supportfor this study. Dr. Butler serves on the SpeakersBureau for LifeCell Corporation. The authors haveno other financial interest to declare.

Fig. 1. A60-year-oldwomanwith ahistory of hysterectomyandbilateral salpingo-oophorectomy for endometrial cancer andtwoprevious failedmesh ventral hernia repairs presentedwith athird hernia recurrence and intermittent small bowel obstruc-tion. The Mercedes panniculectomy incision was marked withthe lower border of the resection 2 cmcranial to the groin creaseexcept the central aspect, where an equilateral triangle wasmarked with the superior tip just below the umbilicus. The esti-mated amounts of horizontal and vertical skin and fat to be re-sected were also marked. Bilateral costal margin incisions weremarkedover the semilunar lines for additional access to performcomponent separation onto the chest wall if needed.

www.PRSJournal.com94e

bymanually pinching the tissue above andbelow thepannus. The panniculectomy borders are incised tothe anterior abdominal fascia.

After the pannus has been removed, the tri-angular flap is elevated from the anterior rectusfascia, cranial to caudal, to perform the inferiorextent laparotomy. The midline laparotomy, ad-hesion lysis, and planned intraabdominal proce-dures are then performed. The fascial edges of thedefect are mobilized and the hernia is repaired(Fig. 3).Minimally invasive component separationcan be performed by creating subcutaneous tun-nels over the planned external oblique aponeu-rosis releases from the panniculectomy wound,with or without transverse incisions at the costalmargins for additional superior access to the semi-lunar line. A narrow tunnel over the semilunarline is created using a narrow lighted retractor toincise the aponeurosis and dissect between theinternal and external oblique muscles. The skinand subcutaneous tissue over the rectus com-plexes, including the perforators, are preserved toreduce dead space and improve skin edge vascu-larity. Themyofascial edges are reapproximated inthe midline, with bioprosthetic mesh inlay rein-forcement, as described previously.11

The vertical resection is marked bilaterallyand excised. The triangular flap is retracted su-periorly, and the inferomedial tips of the upperskin flaps are marked and excised to allow ten-sion-free closure, creating a Mercedes closurepattern (Fig. 4). The incisions are closed overlarge-caliber, closed-suction drainage catheters

Fig. 2. Same patient as shown in Figure 1. The failed compositepolypropylene/polytetrafluoroethylene mesh was removed,and the 20 20-cm ventral hernia and left stomal site herniaswere repaired with bilateral component separation and inlayacellular dermalmatrix. The horizontal and vertical componentsof thepanniculectomywere resected. The inferior triangular flapwas advanced superiorly, and the distalmost upper abdominalflaps were transected and inset to the triangular flap in a Mer-cedes incisionpattern.Note that this patient hada lowermidlineincisionextending to thepubis thatdidnot compromise thevas-cularity of the triangular flap.

Fig. 3. A 46-year-old woman presented with advanced endo-metrial andovarian cancer. Shehadamassive ventral hernia andleft upper quadrant colostomy site hernia after sigmoid colonresection; she hadundergone adiverting colostomy for divertic-ular abscess and subsequent colostomy takedown, both compli-cated bywound infection and dehiscence that required second-ary intention healing. Four previous mesh ventral hernia repairshad failed, and shepresented for tumordebulking and recurrentventral and stomal site hernia repair. (Above) The previouspolypropylene mesh was removed, component separation wasperformed, andacellular dermalmatrixwas inset into theventralhernia defects as an inlay reinforcement. The inferior triangularflap was elevated inferiorly to the pubis for laparotomy access.(Below) Using minimally invasive access to the semilunar linesthrough the horizontal component of the panniculectomywound,weperformedabilateral component separation toallowprimary fascial midline closure.

Volume 125, Number 3 Panniculectomy with Hernia Repair

95e

Fig. 4. (Left) The inferior triangular flap was retracted superiorly, and the horizontal compo-nentsof thepanniculectomyspecimenswereremoved.The inferomedialaspectsof theupperskin flapswere subsequently resectedand the triangular flapwas advancedand inset into thedefectwith aMercedes closurepattern. (Right) Anterior photographobtained5monthspost-operatively. The redundant suprapubic tissue just below the triangular flap allowed for un-derminingandadvancementof the triangular flap superiorly in theeventof amidlinewound-healing complication.

Fig. 5. Preoperative (left) and 6-month postoperative (right) lateral views of the same pa-tient. Therewas a considerable reduction inpannus size andamount of protuberanceoverthe groin crease.

Plastic and Reconstructive Surgery March 2010

96e

in a layered fashion, including the Scarpa fascia,dermis, and skin. This combined vertical andhorizontal panniculectomy resulted in a notice-able reduction in pannus size and protuberanceover the groin crease (Fig. 5).

We used this technique to repair large recur-rent ventral hernias with or without concurrentstomal hernias in three patients from March 1,2007, to December 1, 2007. The mean ventralhernia musculofascial defect size was 367 cm2(range, 300 to 400 cm2) and extended cranially tothe xiphoid. The patients mean body mass indexwas 44.8, and the mean follow-up duration was41.5 months. The mean resected surface area was1057 cm2 (range, 720 to 1550 cm2). A stomal sitehernia (120 cm2) was repaired in one patient, andbilateral parastomal hernia sites (120 cm2) wererepaired after ostomy re-siting in another patient(Fig. 6). All parastomal and stomal site herniarepairs were performed with primary musculofas-cial closure in the transverse direction. Inlay acel-lular dermal matrix was used to reinforce thestomal and ventral hernias. No wound-healingcomplications occurred: in all cases, the Mer-cedes point healed without eschar or dehiscence.In one patient, bilateral stomas were excised withthe panniculectomy, the ostomies were re-sited,

and new stomas were created through the upperflaps (Fig. 6).

DISCUSSIONThis modified panniculectomy technique ap-

peared to be beneficial for vertical incisions, par-ticularly for upper abdominal hernia repairs usingminimally invasive component separation. Preser-vation of the rectus perforating vessels and resect-ing the most distal, least vascularized tips of theupper flaps improved vascularity and, in combi-nation with the triangular flap, distributed insettension more evenly at the trifurcation point.

This technique is indicated for ventral herniarepairs with panniculectomies that require verticalincisions. We prefer to remove the umbilicus, as itssubsequentpositionwouldbe locatedmorecraniallyafter the triangular flap has been elevated and ad-vanced. The triangular flap is elevated caudally as faras required to extend the vertical midline fascialincision; in some cases, it requires no elevation, par-ticularly if the fascial incision is limited to the upperabdomen. This technique is safe in patients withprevious vertical incisions extending inferiorly to thepubis because it does not interfere with the inferior-based vascularity of the triangular flap. However, wefeel that this technique is contraindicated inpatientswith long Pfannenstiel incisions that could causeischemia of the triangular flap, particularly if it iselevated far inferiorly.

The Mercedes panniculectomy technique hasother advantages. The trifurcation point is movedcranially, away from the pubis and groin crease,where it is less likely to be irritated by clothing orbe located in a skin fold, possibly resulting in skinmaceration. Resection of both vertical and hori-zontal components has been shown to result inimproved aesthetic outcomes.1214 Ostomy sitescan be resected in panniculectomy incisions andre-sited through upper flaps without vascular com-promise (Fig. 4). The triangular flap provides aneffective lifeboat for wound complications at thetrifurcation point: if debridement is needed be-cause of necrosis or dehiscence, sufficient supra-pubic tissue exists to advance the flap superiorly,as a V-Y flap, into the resulting defect.

SUMMARYThe Mercedes panniculectomy technique is

simple and allows simultaneous supraumbilicalhernia repair and horizontal and vertical pannicu-lectomy, with access to the semilunar line for com-ponent separation; it may reduce wound-healingcomplication rates, particularly at the trifurcationpoint. Further prospective studies are needed to

Fig. 6. A 73-year-old woman developed bilateral parastomalhernias andaventral hernia after pelvic exenterationwith a rightIndiana pouch and permanent left colostomy. She underwentrevision of the neobladder, open lithotomy with hernia repairs,and a Mercedes panniculectomy. The ostomies were re-sited 6cm cranial to the stomal site hernia repairs. The ostomy skin exitsites were removedwith the panniculectomy specimen and thestomas replaced through the upper abdominal flaps withoutcompromise of vascularity to the trifurcation point.

Volume 125, Number 3 Panniculectomy with Hernia Repair

97e

evaluate and compare the indications for andlong-term outcomes of this approach.

CODING PERSPECTIVEThis information prepared by Dr. RaymondJanevicius is intended to provide codingguidance.

15734 Component separation, right15734-51 Component separation, left49560-51 Ventral hernia repair15830-51 Panniculectomy

49568 Mesh placement

Use the muscle flap code, 15734, for com-ponent separation. Each side is reportedseparately.

Even though 15734 is performed bilater-ally, the bilateral modifier, 50, is not used,as many payers, including Medicare, donot recognize 15734 as a bilateral proce-dure. Use the multiple procedure modi-fier, 51.

Panniculectomy is reported with code15830. Many insurance companies will notreimburse for this procedure, so pre-authorization in writing is necessary priorto performing the procedure.

Code 49568 is an add-on code and doesnot take the multiple procedure modi-fier, 51.

If the hernia is recurrent, report code49565.

Charles E. Butler, M.D.Department of Plastic Surgery, Unit 443

University of Texas M. D. Anderson Cancer Center1515 Holcombe Boulevard

Houston, Texas 77030cbutler@mdanderson.org

REFERENCES1. Hardy JE, Salgado CJ, Matthews MS, Chamoun G, Fahey AL.

The safety of pelvic surgery in the morbidly obese with andwithout combined panniculectomy: A comparison of results.Ann Plast Surg. 2008;60:1013.

2. Berry MF, Paisley S, Low DW, Rosato EF. Repair of largecomplex recurrent incisional hernias with retromus-cular mesh and panniculectomy. Am J Surg. 2007;194:199204.

3. Saxe A, Schwartz S, Gallardo L, Yassa E, Alghanem A. Simul-taneous panniculectomy and ventral hernia repair followingweight reduction after gastric bypass surgery: Is it safe? ObesSurg. 2008;18:192195; discussion 196.

4. Shermak MA. Hernia repair and abdominoplasty in gastricbypass patients. Plast Reconstr Surg. 2006;117:11451150; dis-cussion 11511152.

5. Hopkins MP, Shriner AM, Parker MG, Scott L. Panniculec-tomy at the time of gynecologic surgery in morbidly obesepatients. Am J Obstet Gynecol. 2000;182:15021505.

6. Leahy PJ, Shorten SM, Lawrence WT. Maximizing the aes-thetic result in panniculectomy after massive weight loss.Plast Reconstr Surg. 2008;122:12141224.

7. Chaouat M, Levan P, Lalanne B, Buisson T, Nicolau P, Mi-moun M. Abdominal dermolipectomies: Early postoperativecomplications and long-term unfavorable results. Plast Re-constr Surg. 2000;106:16141618.

8. Borud LJ, Warren AG. Modified vertical abdominoplasty inthe massive weight loss patient. Plast Reconstr Surg. 2007;119:19111921.

9. Dillerud E. Abdominoplasty combined with suction lipo-plasty: A study of complications, revisions, and risk factors in487 cases. Ann Plast Surg. 1990;25:333338.

10. Reid RR,DumanianGA. Panniculectomy and the separation-of-parts hernia repair: A solution for the large infraumbilicalhernia in the obese patient. Plast Reconstr Surg. 2005;116:10061012.

11. Butler CE, Langstein HN, Kronowitz SJ. Pelvic, abdominal,and chest wall reconstruction with AlloDerm in patients atincreased risk for mesh-related complications. Plast ReconstrSurg. 2005;116:12631275; discussion 12761277.

12. Leahy PJ, Shorten SM, Lawrence WT. Maximizing the aes-thetic result in panniculectomy after massive weight loss.Plast Reconstr Surg. 2008;122:12141224.

13. Cooper JM, Paige KT, Beshlian KM, Downey DL, Thirlby RC.Abdominal panniculectomies: High patient satisfaction de-spite significant complication rates. Ann Plast Surg. 2008;61:188196.

14. Blomfield PI, Le T, Allen DG, Planner RS. Panniculectomy:A useful technique for the obese patient undergoing gyne-cological surgery. Gynecol Oncol. 1998;70:8086.

Plastic and Reconstructive Surgery March 2010

98e