Laparoscopic Abdominoplasty - Indications, Procedure, and Complications

Introduction

Abdominoplasty is a cosmetic surgical procedure to remove the excess fat and skin around the abdomen to improve its shape and appearance and strengthens the abdominal wall using laparoscopy, which has a video camera attached and specialized keyhole instruments are inserted to operate, which can reduce the size of incision and scarring. However, traditional open abdominal surgery can cause a severe complication, umbilical necrosis; therefore, abdominoplasty combined with laparoscopic umbilical hernia repair is done to avoid the devascularisation of the umbilicus.

What Are the Advantages of Laparoscopic Abdominoplasty?

The advantages of laparoscopic abdominoplasty are:

• Decreased scarring.

• Extended reach (the entire abdominal fascial surface is exposed through a single incision, and exposure is facilitated without the division of the umbilicus).

• Excellent visualization (bright illumination, magnification, clear visualizations of operative field).

• Preservation of anatomic structures because the incisions are limited.

• Vascularity of fap is maintained. Therefore, with improved blood supply, aggressive liposuction can be done.

• Decreased morbidity.

• There is no skin tension because skin resection is not done.

What Are the Indications of Laparoscopic Abdominoplasty?

The indications of laparoscopic abdominoplasty include:

• To improve the aesthetic of the abdomen.

• The selection of a patient depends on the skin, fat and musculofacial integrity of the abdomen because this technique does not incorporate extensive skin resection. Therefore, very less or no excess skin should be present, and the skin should be of good quality. Otherwise, extensive procedures should be carried out, such as open surgery.

• Minimal to moderate fat that can be adequately addressed by liposuction.

• Diffuse musculofacial weakening.

• Frank diastasis recti.

• Ventral or umbilical hernia.

What Are the Contraindications of Laparoscopic Abdominoplasty?

The contraindications of laparoscopic abdominoplasty include:

• Significant excessive skin that cannot be improved by contraction or retraction alone.

• Skin quality is poor, with severe striae or scars.

• A large amount of excess fat.

• Patients with poor health due to cardiopulmonary disease, cirrhosis, and uncontrolled diabetes.

• Patients who smoke (harm the blood supply to the abdomen).

What Are the Instruments Used in Laparoscopic Abdominoplasty?

The instruments that are used in laparoscopic abdominoplasty are:

• The laparoscopic cart contains the light source, camera, monitor, video, and image recording equipment.

• Virtually video electronic imaging system is used. The laparoscopy is correctly positioned using a retractor with a long blade.

• Laparoscopic scissors (disposable or reusable, easy to bend) and suction-cautery dissectors are used for dissection.

• Metzenbaum or hook-type blades.

• Endoscopic electrocautery instrument.

• Laparoscopic with which the fascia is marked.

• Running suture.

• Laparoscopic needle holder.

• Laparoscopic knot pusher to secure knots.

What Is the Procedure of Laparoscopic Abdominoplasty?

Before the procedure, a thorough history, plastic surgeons should obtain medical clearances, and appropriate antibiotics should be given before the procedure to reduce skin flora contamination of the wound. In addition, patients should have good nutritional status and medical health because wound healing is vital. The procedure includes the following steps:

• Preoperative markings should be done with the patient standing, location of access should be included, site for skin removal if necessary, and areas for liposuction (a suction technique to remove fat).

• Intravenous access is gained.

• Proper connection and function of endoscopic equipment are checked.

• The patient should lie on his back for this procedure, and general anesthesia is used.

• Pneumatic compression stockings are activated to avoid deep venous thrombosis (blood clot formation in deep veins, usually in the leg) and pulmonary embolism (blood clot in the lung artery).

• The tumescent fluid, which helps in liposuction, is infiltrated through the access site.

• Liposuction is done before flap removal helps lighten the flap and stabilize tissues, but the tissue may be stained, limiting visualization, and flap elevation may have honeycombing.

• Access incisions are made based on the surgeon's preference; generally, a single incision is made in the pubic region. The incision is usually 2.5 centimeters. If the incision is larger, up to 4 to 5 centimeters, insertion and suturing are more efficient.

• Umbilical incisions are useful in accessing the upper abdomen and can help in umbilicoplasty and helps preserve the umbilical stalk if secondary transposition is required.

• In case of isolated pubic incision access, an incision is directed to the anterior rectus fascia using laparoscopy scissors. Then, dissection is done around the umbilical stalk and can be divided.

• Flap elevation extends from the pubis to the xiphoid vertically and from the lateral borders of the rectus abdominis laterally.

• Facial repair is done, and the width of the plication (folding) is based on the degree of facial laxity or visible diastasis. It can be completed with fascial staples or a laparoscopic suturing device. Generally, two plication layers are placed if necessary oblique or transverse plication layers can be placed until optimal fascial tension is achieved.

• The closure is done by reimplanting the umbilicus to the midline fascial using a laparoscopic knot pusher, and the shape of the umbilicus is examined.

• Drains are placed, access incisions are closed, sterile dressings and abdominal binders are placed.

What Are the Post-operative Measures of Laparoscopic Abdominoplasty?

The postoperative measures should include the following:

• Patients are generally discharged with the suction drains in place until the output decreases below 30 milliliters daily.

• An abdominal binder is placed for two weeks.

• Patient massage of suctioned areas is generally done within the first week and is continued until the edema is resolved.

• The patient should limit activities for the first two weeks.

• Patients should avoid heavy lifting for six weeks, and abdominal exercises should be done to maintain the tone.

• Doctors should educate patients on lifestyle changes to prevent fat re-accumulation around the waist area. Therefore regular physical exercise, eating a healthy diet, discontinuing smoking, and refraining from excess alcohol should be considered.

What Are the Complications of Laparoscopic Abdominoplasty?

The complications of laparoscopic abdominoplasty are:

• If left untreated, seromas (accumulation of clear fluid around the skin) and hematomas (localized bleeding) can result in flap necrosis due to a lack of blood supply and infections.

• Vascular compromise to the umbilicus can cause Umbilical necrosis by not maintaining enough fat around the umbilicus. Added risk factors for preserving blood supply are large abdominal aprons, smoking, diabetes, steroids, postbariatric population, and patients with long umbilical stalks.

• Infection and the wound can result when the closure bears excessive tension.

• Cellulitis through the isolated umbilical incision.

Conclusion

Although abdominal recontouring procedures have been done for many years, liposuction has a significant impact. In addition, this technique is safe and efficacious in selected patients.