Clinical and perioperative outcomes of abdominal wall reconstruction and panniculectomy in a single surgical procedure: experience from a high-complexity center in bogotá, Colombia

In the United States, approximately 4 million laparotomies are performed annually [1]– [2]. Between 5% and 24% of these procedures result in incisional hernias [3]. Recurrence rates after surgical repair range from 30 to 54%, depending on factors such as hernia defect size, anatomical location, and associated patient comorbidities [4]. However, local data on the incidence of these hernias in Colombia is limited, making it difficult to accurately estimate the economic and social burden they represent in the country.

Abdominal wall hernias—particularly ventral hernias—are a common complication in patients who have undergone laparotomy. This risk is significantly increased in individuals who are overweight or obese due to sustained elevated intra-abdominal pressure and potential alterations in connective tissue integrity. Obesity, in particular, has been identified as an independent risk factor contributing to both the development and recurrence of primary hernias, with rates reported as high as 45% [5]. Excess body weight is also associated with reduced mobility, hygiene difficulties, and a higher predisposition to metabolic disorders and chronic infections, all of which negatively affect quality of life. Moreover, it correlates with increased surgical and medical complications, which tend to rise proportionally with the patient’s body fat percentage [6, 7].

There are several chronic abdominal wall conditions that present a challenge for abdominal wall reconstruction (AWR) surgery. These include lipodystrophy, sequelae of open abdomen management, loss of domain hernias, history of multiple hernia recurrences, parastomal hernias, abdominal wall tumors, and large hernia defects [8]. Such conditions require a comprehensive approach that addresses both functional and aesthetic aspects. Skin and subcutaneous tissue play a crucial role in the incidence of local surgical complications such as seroma, hematoma, surgical site infection, and mesh contamination or infection [8]. Achieving both functional and aesthetic outcomes improves treatment effectiveness and optimizes resource use [9].

Therefore, performing abdominal wall reconstruction and panniculectomy simultaneously in selected patients is becoming a viable option, as it minimizes the number of surgical interventions, provides better surgical exposure, facilitates the resection of poorly perfused tissue, reduces flap tension during repair, and improves both aesthetic outcomes and patient quality of life [8]. However, the literature has debated the role of concomitant panniculectomy during abdominal wall reconstruction due to concerns about increased operative time and surgical complications. It has been associated with a higher incidence of surgical site occurrences (SSOs), the need for reoperation, and longer hospital stays [5], raising questions about the advisability of performing both procedures at the same time. Variability in surgical teams, techniques used, and patient characteristics, among other factors, may contribute to these outcomes [10].

Managing such cases requires the involvement of multidisciplinary surgical teams, including specialists in plastic surgery, abdominal wall surgery, nutrition, physiatry, radiology, and others. It also demands additional efforts from healthcare institutions, insurers, and patients themselves to align the interests of all parties involved [8]. A comprehensive approach includes joint preoperative evaluation (medical board review, clarity of team roles), along with administrative and logistical support from institutions to implement standardized management protocols for these patients. There is evidence supporting the positive impact of these measures on surgical outcomes [11]. The purpose of this study was to describe the institutional experience of integrating abdominal wall reconstruction and panniculectomy in selected patients, in order to characterize outcomes associated with different surgical strategies and to identify key factors influencing the results.

Regarding the ASA classification, 73.9% of the patients were categorized as ASA II, and 27.7% as ASA III. Among the comorbidities, 26.3% had a history of hypertension, 15.2% had diabetes mellitus, and 3.5% had coronary artery disease. Additionally, 38% had a history of previous abdominal wall hernia repair. Indication for surgery to resect abdominal wall tumors was present in 10% (17/170) of the cases. Demographic results are included in Table. 1.

Concerning hernia characteristics, the mean defect area ranged between 10 ± 9.9 cm. Progressive preoperative pneumoperitoneum was indicated in 3.5% of the patients, and botulinum toxin use was applied in up to 29.5% of the patients.

Table 2 summarizes the technical and surgical characteristics used in the patients. In all procedures, a synthetic polypropylene mesh was employed. An underlay position was used in 59.3% of cases, followed by an onlay position in 40%, and an inlay position in 0.6%. The inlay approach was used in one patient due to a coverage defect following resection of an endometrioma.

The Rives-Stoppa technique was performed in 23.3% of cases. The posterior sheath was closed using a 2/0 absorbable monofilament suture (polydioxanone). The mesh was shaped to fit the retrorectal space.

Fixation was performed using either traumatic methods—such as sutures, staples, and anchors—in 29.2% of cases, or atraumatic methods—using fibrin sealant and N-butyl-2-cyanoacrylate (NBCA)—in 72.5% of cases. A double-mesh technique (onlay-sublay) was required in 7.6% of the patients (Fig. 2).

To estimate the size of the adipose panniculus in relation to fixed anatomical structures, the Iglesias classification was used. In patients with morbid obesity—particularly those with a redundant panniculus (types II and III according to this classification)—significant surgical morbidity was observed, associated with pannus volume [10]. In 77.7% of cases, the panniculus extended beyond the inguinal ligament, and in 14.3%, it reached the mid-thigh.

Vertical incision panniculectomy was performed in 42.1% of patients, while 18.1% underwent fleur-de-lis panniculectomy. Surgical drains were used in all cases, placed in the subcutaneous tissue (Fig. 3). In 2.2% of patients, management of the superficial layers of the abdominal wall required panniculectomy and reconstruction with Keystone flaps, as illustrated in the case shown in Fig. 4.

The average operative time was 155 min, with an average intraoperative blood loss of 100 ml. Following the procedure, 2.35% of patients required admission to the intensive care unit (ICU), and 5.26% underwent surgical reintervention. The median hospital stay was 2 days (RIC: 2.0–3.0), while 11.1% of patients were enrolled in an early discharge program, with follow-up through a home hospitalization program.

Regarding wound-related complications, seroma was observed in 4.68% of cases, hematoma in 2.9%, wound dehiscence in 12.87%, and enterocutaneous fistula in 1.75%. A total of 5.26% of patients required reintervention, and of these, 4% needed placement of a negative pressure wound therapy system for staged closure. No mortalities were reported Table 3.

The need for reintervention was statistically significantly associated with intraoperative bleeding (p = 0.014), skin dehiscence (p = 0.001), and a transverse defect diameter greater than 10 cm (p = 0.012).

In the analysis of factors associated with complications, no statistically significant differences were found regarding smoking, obesity, diabetes mellitus, body mass index, or defect size. The only variable significantly associated with the occurrence of complications was a longer hospital stay (p < 0.001). Furthermore, the analysis of mesh placement location (Onlay, Inlay, Underlay) showed no statistically significant association with the presence of surgical site infection (p > 0.05 for all comparisons).Table 4and Table 5.

Our study evaluated the outcomes of performing abdominal wall reconstruction and panniculectomy in a single surgical session, demonstrating that this strategy may be associated with limited morbidity. These findings support the safety and feasibility of a comprehensive approach in this complex patient population [13‐16].

As the prevalence of obesity continues to rise, so too will the number of patients requiring abdominal wall reconstruction and panniculectomy. Performing panniculectomy during the same procedure aims to remove poorly vascularized tissue and resect previous scars, thereby reducing tension on the abdominal wall during hernia repair and minimizing the anesthetic risks associated with performing these procedures separately [14‐18].

The findings of this study suggest that the concomitant performance of panniculectomy in patients undergoing abdominal wall reconstruction represents a valid therapeutic option. A significant association was found between defects larger than 10 cm, skin dehiscence, and intraoperative bleeding greater than 100 ml, and an increased risk of surgical reintervention. No statistically significant associations were found between mesh location, patient comorbidities, length of hospital stay, or the type of panniculectomy performed.

In our study, 96.5% of repairs involved the use of a medium-weight, large-pore synthetic polypropylene mesh. Regarding the techniques for midline restoration, 59.3% of cases used an underlay mesh position, followed by onlay in 40%, and inlay in 0.6%. A double-mesh technique was used in 7.6%, and no intraperitoneal meshes were implanted. Despite the inherent risks and potential complications associated with the surgical repair of complex ventral hernias, selecting the most effective approach to achieve complete closure of the anterior fascia is essential. To this end, we propose an algorithm that may facilitate the surgical strategy in such complex cases (Fig. 5). This classification is based on criteria adopted by international surgical societies such as the European Hernia Society (EHS) [19] and the Ventral Hernia Working Group (VHWG) [20], adapted to our institutional experience. Therefore, the term “complex ventral hernia” refers to those hernias that, due to their anatomical or clinical characteristics, involve greater technical difficulty for repair and require advanced reconstructive techniques, such as component separation, Transversus Abdominis Release (TAR), or the placement of double mesh.

In our group, most patients undergo prosthetic repair in the retromuscular (sublay) position, with a preference for posterior component separation techniques due to their demonstrated benefits: lower wound complication rates, reduced prosthetic exposure, and improved long- term functional integration. However, the magnitude and complexity of some hernia defects require an adapted approach. In cases where anatomical and functional restoration of the abdominal wall is not possible despite optimal preoperative optimization and posterior component separation, anterior component separation is employed. This allows repair of larger defects but is associated with a higher risk of surgical site complications (SSO). Moreover, in oncologic scenarios involving extensive abdominal wall resection and muscle loss, it may be unfeasible to conceal the prosthesis in the retromuscular space. In these contexts, advanced techniques such as dual mesh repair may be required, which sometimes necessitate placement of prosthetic material in the supra-aponeurotic (onlay) space, accepting a higher risk of wound complications.

Anterior component separation was performed in 31.5% of patients, while posterior component separation techniques were used in the remaining 68.4%. Retromuscular repair techniques were applied in 42.1% of cases; the most commonly used were the Rives technique (31.5%) and the Rives–Stoppa technique (23.3%). A delayed staged closure was required in 2.34% of cases. Follow-up was conducted at 60 days.

The majority of complications were mild (Grade I–II), not requiring invasive interventions. However, 15.8% of patients (Grades IIIA and IIIB) required additional procedures— a rate consistent with that reported in the literature for abdominal wall reconstruction procedures performed concomitantly with panniculectomy.The inherent complexity of these procedures, the use of prosthetic materials, and prolonged surgical times are all contributing factors, and globally they generate concern due to the associated high morbidity, increasing the difficulty of these surgeries. According to our findings, the inclusion of a concomitant panniculectomy did not represent an additional factor increasing the complication rate. It is worth noting that most of the recorded complications were of low severity (Clavien-Dindo < II), which supports this assertion. The documented outcomes may be attributed to the surgical team’s experience, collaborative work among involved professionals, appropriate case selection, and an institutional culture focused on patient safety.

These findings are consistent with reports in the literature. For example, Diaconu et al. [14] found a significantly higher prevalence of surgical site infection (SSI) when comparing simultaneous panniculectomy and abdominal wall reconstruction (35% vs. 21%; p = 0.018). Similarly, Fischer et al. [7], In the analysis of 55,537 patients from the ACS-NSQIP database, it was demonstrated that combining panniculectomy with open ventral hernia repair (VHR-PAN) is associated with a significantly increased risk of postoperative complications compared to hernia repair alone. Specifically, the combined procedure was linked to a 69% higher likelihood of wound complications, a 2.1-fold increased risk of surgical reintervention, a 2.5-fold increase in venous thromboembolism, and a twofold increase in overall medical morbidity (p < 0.001 in all cases, except VTE p = 0.044). These findings underscore the importance of careful patient selection and individualized risk-benefit assessment when considering combined surgical approaches. These findings are to be expected, considering that panniculectomy involves the creation of large flaps and extensive dissections, generating more dead space, which is associated with a high risk of SSI. However, these complications can often be resolved conservatively without increasing the reoperation rate.

Complex ventral hernias typically require an average hospital stay of 5.33 days [18]. In our study, the average hospital stay was 2.3 days. The implementation of a strict prehabilitation protocol, standardized surgical techniques, and intra- and post-operative multidisciplinary support (HPC) proved to be a key element in patient management, optimizing the use of resources. In this cohort, 11.1% of patients were eligible for outpatient follow-up, with no readmissions recorded within 30 days. No mortality was reported during the follow-up period. Preoperative optimization has emerged as a strategy to address modifiable patient risk factors in order to improve outcomes [19]. For this reason, all our patients undergo a multidisciplinary evaluation prior to surgery to enhance postoperative results.

These findings align with the literature on standardized care, the establishment of centers of excellence, and the centralization of complex surgeries — strategies that, in the field of abdominal wall surgery, are associated with better clinical outcomes, professional development of surgeons, and economic benefits for healthcare institutions.

The results demonstrate that the methodical and systematic implementation of a multidisciplinary collaborative work model — exemplified by the simultaneous performance of panniculectomy and abdominal wall reconstruction — is feasible in a specific healthcare setting, particularly when strategies inspired by Enhanced Recovery After Surgery (ERAS) protocols, already successfully applied in other surgical specialties, are adopted. To our knowledge, this study represents a pioneering contribution in the Latin American context, as no prior research on this combined approach has been published in the region.

The limitations of this study include its retrospective and observational nature, the absence of a control group, and the sample size. Regarding the 60-day follow-up period, it focused exclusively on the detection of early complications, such as surgical site occurrence (SSO), without including the assessment of long-term hernia recurrence. We acknowledge this limitation and emphasize that a comprehensive analysis of recurrences would require a study with extended clinical follow-up. Although the descriptive nature of the study implies limited generalizability, its strengths lie in the sample size, its innovative character within the Latin American context (with few existing studies on the subject), its reporting of complication rates similar to those previously described, and the implementation of a specialized and collaborative surgical team.

One of the main limitations of this study is the lack of validated tools to objectively assess quality of life, postoperative comfort, and patient satisfaction. Although relevant clinical benefits were identified, these patient-centered outcomes were not quantified using standardized instruments. Therefore, we recommend that future research, preferably with a prospective design, incorporate validated scales that allow for a more accurate measurement of these fundamental aspects, ensuring a comprehensive evaluation of surgical outcomes.

The clinical implications of this study suggest that a multidisciplinary management approach with favorable surgical outcomes for both patients and institutions is feasible within a specific context. Furthermore, the findings open the door for future research in an area of growing clinical interest. The simultaneous achievement of functional and aesthetic goals is attainable, but it must be part of a well-structured institutional strategy that considers the potential risk of higher-than-expected adverse outcomes.

Our study suggests that combining abdominal wall reconstruction with panniculectomy is a feasible surgical strategy in selected patients, within the framework of a collaborative approach that systematically integrates preoperative, intraoperative, and postoperative interventions.

Factors such as a hernia defect with a transverse diameter greater than 10 cm, intraoperative bleeding exceeding 100 ml, and the occurrence of skin dehiscence were identified as variables associated with an increased risk of surgical reintervention.