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CASE REPORT

Mercedes Panniculectomy with Simultaneous


Component Separation Ventral Hernia Repair
Charles E. Butler, M.D.
Scott M. Reis, B.S.
Houston, Texas

oncurrent panniculectomy and ventral hernia repair has been shown to safely reduce
pannus size, wound-healing morbidity (e.g.,
infection, hematoma, seroma, and dehiscence)
rates, and hernia recurrence rates in obese hernia
patients.15 Infraumbilical hernias can often be
repaired through horizontal panniculectomy incisions, with no need for vertical incisions. However, extensive undermining of the skin flap to
access the upper abdomen causes additional dead
space and may increase the risk of wound-healing
complications.2 Therefore, vertical incisions are
useful for hernias that extend to near the xiphoid
and for when high laparotomy incisions are
needed for additional intraoperative procedures.
T-point necrosis and wound dehiscence are
common wound-healing complications associated
with concurrent horizontal and vertical incisions.6 9
In one study, all patients who underwent supraumbilical hernia repair with panniculectomy and inverted-T closure developed complications, including abscesses and dehiscence.10 To reduce T-point
necrosis, improve distal flap vascularity, and reduce
complication risks, we propose an alternative incision design that allows horizontal and vertical panniculectomy and simultaneous ventral hernia repair
with component separation and inlay mesh.

TECHNIQUE
The Mercedes panniculectomy includes a horizontal and vertical skin and fat resection in a fleurde-lis pattern (Figs. 1 through 5). The lower border
of the horizontal component is marked with a curvilinear line, 2 cm cephalad and parallel to the groin
crease between the anterior axillary lines. An equilateral triangle (each side, 15 to 20 cm) is drawn with
its base along the center of this line and tip just
caudal to the umbilicus (Figs. 1 and 2). This triangle
From the Department of Plastic Surgery, University of Texas
M. D. Anderson Cancer Center.
Received for publication August 25, 2009; accepted October
2, 2009.
Copyright 2010 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181cb641d

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Fig. 1. A 60-year-old woman with a history of hysterectomy and


bilateral salpingo-oophorectomy for endometrial cancer and
two previous failed mesh ventral hernia repairs presented with a
third hernia recurrence and intermittent small bowel obstruction. The Mercedes panniculectomy incision was marked with
the lower border of the resection 2 cm cranial to the groin crease
except the central aspect, where an equilateral triangle was
marked with the superior tip just below the umbilicus. The estimated amounts of horizontal and vertical skin and fat to be resected were also marked. Bilateral costal margin incisions were
marked over the semilunar lines for additional access to perform
component separation onto the chest wall if needed.

serves as a caudal-based flap and remains attached


during the excision. The cephalad border of the
horizontal component is based on the amount of
skin and fat that can be safely resected and is marked

Disclosure: There was no external funding support


for this study. Dr. Butler serves on the Speakers
Bureau for LifeCell Corporation. The authors have
no other financial interest to declare.

www.PRSJournal.com

Volume 125, Number 3 Panniculectomy with Hernia Repair

Fig. 2. Same patient as shown in Figure 1. The failed composite


polypropylene/polytetrafluoroethylene mesh was removed,
and the 20 20-cm ventral hernia and left stomal site hernias
were repaired with bilateral component separation and inlay
acellular dermal matrix. The horizontal and vertical components
of the panniculectomy were resected. The inferior triangular flap
was advanced superiorly, and the distalmost upper abdominal
flaps were transected and inset to the triangular flap in a Mercedes incision pattern. Note that this patient had a lower midline
incision extending to the pubis that did not compromise the vascularity of the triangular flap.

by manually pinching the tissue above and below the


pannus. The panniculectomy borders are incised to
the anterior abdominal fascia.
After the pannus has been removed, the triangular flap is elevated from the anterior rectus
fascia, cranial to caudal, to perform the inferior
extent laparotomy. The midline laparotomy, adhesion lysis, and planned intraabdominal procedures are then performed. The fascial edges of the
defect are mobilized and the hernia is repaired
(Fig. 3). Minimally invasive component separation
can be performed by creating subcutaneous tunnels over the planned external oblique aponeurosis releases from the panniculectomy wound,
with or without transverse incisions at the costal
margins for additional superior access to the semilunar line. A narrow tunnel over the semilunar
line is created using a narrow lighted retractor to
incise the aponeurosis and dissect between the
internal and external oblique muscles. The skin
and subcutaneous tissue over the rectus complexes, including the perforators, are preserved to
reduce dead space and improve skin edge vascularity. The myofascial edges are reapproximated in
the midline, with bioprosthetic mesh inlay reinforcement, as described previously.11

Fig. 3. A 46-year-old woman presented with advanced endometrial and ovarian cancer. She had a massive ventral hernia and
left upper quadrant colostomy site hernia after sigmoid colon
resection; she had undergone a diverting colostomy for diverticular abscess and subsequent colostomy takedown, both complicated by wound infection and dehiscence that required secondary intention healing. Four previous mesh ventral hernia repairs
had failed, and she presented for tumor debulking and recurrent
ventral and stomal site hernia repair. (Above) The previous
polypropylene mesh was removed, component separation was
performed, and acellular dermal matrix was inset into the ventral
hernia defects as an inlay reinforcement. The inferior triangular
flap was elevated inferiorly to the pubis for laparotomy access.
(Below) Using minimally invasive access to the semilunar lines
through the horizontal component of the panniculectomy
wound, we performed a bilateral component separation to allow
primary fascial midline closure.

The vertical resection is marked bilaterally


and excised. The triangular flap is retracted superiorly, and the inferomedial tips of the upper
skin flaps are marked and excised to allow tension-free closure, creating a Mercedes closure
pattern (Fig. 4). The incisions are closed over
large-caliber, closed-suction drainage catheters

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Plastic and Reconstructive Surgery March 2010

Fig. 4. (Left) The inferior triangular flap was retracted superiorly, and the horizontal components of the panniculectomy specimens were removed. The inferomedial aspects of the upper
skin flaps were subsequently resected and the triangular flap was advanced and inset into the
defect with a Mercedes closure pattern. (Right) Anterior photograph obtained 5 months postoperatively. The redundant suprapubic tissue just below the triangular flap allowed for undermining and advancement of the triangular flap superiorly in the event of a midline woundhealing complication.

Fig. 5. Preoperative (left) and 6-month postoperative (right) lateral views of the same patient. There was a considerable reduction in pannus size and amount of protuberance over
the groin crease.

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Volume 125, Number 3 Panniculectomy with Hernia Repair


in a layered fashion, including the Scarpa fascia,
dermis, and skin. This combined vertical and
horizontal panniculectomy resulted in a noticeable reduction in pannus size and protuberance
over the groin crease (Fig. 5).
We used this technique to repair large recurrent ventral hernias with or without concurrent
stomal hernias in three patients from March 1,
2007, to December 1, 2007. The mean ventral
hernia musculofascial defect size was 367 cm2
(range, 300 to 400 cm2) and extended cranially to
the xiphoid. The patients mean body mass index
was 44.8, and the mean follow-up duration was
41.5 months. The mean resected surface area was
1057 cm2 (range, 720 to 1550 cm2). A stomal site
hernia (120 cm2) was repaired in one patient, and
bilateral parastomal hernia sites (120 cm2) were
repaired after ostomy re-siting in another patient
(Fig. 6). All parastomal and stomal site hernia
repairs were performed with primary musculofascial closure in the transverse direction. Inlay acellular dermal matrix was used to reinforce the
stomal and ventral hernias. No wound-healing
complications occurred: in all cases, the Mercedes point healed without eschar or dehiscence.
In one patient, bilateral stomas were excised with
the panniculectomy, the ostomies were re-sited,

Fig. 6. A 73-year-old woman developed bilateral parastomal


hernias and a ventral hernia after pelvic exenteration with a right
Indiana pouch and permanent left colostomy. She underwent
revision of the neobladder, open lithotomy with hernia repairs,
and a Mercedes panniculectomy. The ostomies were re-sited 6
cm cranial to the stomal site hernia repairs. The ostomy skin exit
sites were removed with the panniculectomy specimen and the
stomas replaced through the upper abdominal flaps without
compromise of vascularity to the trifurcation point.

and new stomas were created through the upper


flaps (Fig. 6).

DISCUSSION
This modified panniculectomy technique appeared to be beneficial for vertical incisions, particularly for upper abdominal hernia repairs using
minimally invasive component separation. Preservation of the rectus perforating vessels and resecting the most distal, least vascularized tips of the
upper flaps improved vascularity and, in combination with the triangular flap, distributed inset
tension more evenly at the trifurcation point.
This technique is indicated for ventral hernia
repairs with panniculectomies that require vertical
incisions. We prefer to remove the umbilicus, as its
subsequent position would be located more cranially
after the triangular flap has been elevated and advanced. The triangular flap is elevated caudally as far
as required to extend the vertical midline fascial
incision; in some cases, it requires no elevation, particularly if the fascial incision is limited to the upper
abdomen. This technique is safe in patients with
previous vertical incisions extending inferiorly to the
pubis because it does not interfere with the inferiorbased vascularity of the triangular flap. However, we
feel that this technique is contraindicated in patients
with long Pfannenstiel incisions that could cause
ischemia of the triangular flap, particularly if it is
elevated far inferiorly.
The Mercedes panniculectomy technique has
other advantages. The trifurcation point is moved
cranially, away from the pubis and groin crease,
where it is less likely to be irritated by clothing or
be located in a skin fold, possibly resulting in skin
maceration. Resection of both vertical and horizontal components has been shown to result in
improved aesthetic outcomes.1214 Ostomy sites
can be resected in panniculectomy incisions and
re-sited through upper flaps without vascular compromise (Fig. 4). The triangular flap provides an
effective lifeboat for wound complications at the
trifurcation point: if debridement is needed because of necrosis or dehiscence, sufficient suprapubic tissue exists to advance the flap superiorly,
as a V-Y flap, into the resulting defect.

SUMMARY
The Mercedes panniculectomy technique is
simple and allows simultaneous supraumbilical
hernia repair and horizontal and vertical panniculectomy, with access to the semilunar line for component separation; it may reduce wound-healing
complication rates, particularly at the trifurcation
point. Further prospective studies are needed to

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Plastic and Reconstructive Surgery March 2010


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

CODING PERSPECTIVE
This information prepared by Dr. Raymond
Janevicius is intended to provide coding
guidance.
15734
15734-51
49560-51
15830-51
49568

Component separation, right


Component separation, left
Ventral hernia repair
Panniculectomy
Mesh placement

Use the muscle flap code, 15734, for component separation. Each side is reported
separately.
Even though 15734 is performed bilaterally, the bilateral modifier, 50, is not used,
as many payers, including Medicare, do
not recognize 15734 as a bilateral procedure. Use the multiple procedure modifier, 51.
Panniculectomy is reported with code
15830. Many insurance companies will not
reimburse for this procedure, so preauthorization in writing is necessary prior
to performing the procedure.
Code 49568 is an add-on code and does
not take the multiple procedure modifier, 51.
If the hernia is recurrent, report code
49565.

Charles E. Butler, M.D.


Department of Plastic Surgery, Unit 443
University of Texas M. D. Anderson Cancer Center
1515 Holcombe Boulevard
Houston, Texas 77030
cbutler@mdanderson.org

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