Case 5: Giant Panniculectomy in schizophrenic patient
Authors: Sahar Vanessa Amiri, Resident, Herlev Hospital, Denmark
A 47-year-old male, with known schizophrenia, severe adiposities and hypertension and who lives in a protected home was referred to the department of plastic surgery in October 2021. The patient had lost in total 39 kgs on Saxenda and calorie reduced diet to a weight of 167 kg (BMI 54) pre-operatively, over a period of one year. He had physical difficulties mobilizing (for example turning in bed which effected his sleeping), hygiene problems, multiple skin ulcers and had previously been admitted with erysipelas. He had psycho-social disturbances affecting his daily life, he isolated himself in his home and couldn’t participate in communal activities. He had to discontinue smoking (smoked around 30 cigarettes daily) and maintain the weight loss. He was approved for surgery in November 2021, however the operation got postponed because of covid-19 and delayed proper diagnostic imaging of the patient pre-operatively. An MRI from February 2022 was inadequate, therefore a CT- abdomen was done in March 2023, that showed minimal herniation of the umbilicus but no defects on the abdominal wall or intraabdominal pathology. Planned operation in 2022 was postponed because the patient had covid-19 infection. The patient had gained weight up to 190 kilograms (BMI 62) pre-operatively. However, he was motivated to lose weight again if the giant pannus could be removed, he had still managed to maintain cessation of smoking.
Before and after
Patient examination
• Good general condition. Awake, and oriented. Normal colors. Not psychologically striking. Not psychotic. • Height: 175 cm, Weight: 167 kg, BMI is 54.5. • Skin: Abdomen is found with giant pannus, descending down to crus, with heavy lymphedema and minor superficial wounds in the skin. Penis and mons hidden under pannus but not involved. Possible to operate by simple panniculectomy. Intra-abdominal conditions and anterior abdominal wall cannot be assessed.
Pre-Operative Considerations
Blodtest and pre-operative imaging was taken and because of the psychiatric diagnosis, the surgeon kept regular contact with the patient in a period of one and a half years and had correspondence with the psychiatrist regularly in order to make sure all expectations were met.
Step 1: The patient pre-operative
Drawing on patient was done in standing position, before anesthesia.
Step 2: Sterile wash
The soft tissue hung op on hooks, in order to properly clean the skin and ease the surgeons work. Panniculectomy was performed on 3rd of March 2023
Step 3: Per-operative
Instrument on large vessels.
Step 4: Soft tissue removed
In total 34.6 skin and fatty tissue was removed. There were no ventral hernias or pathological rectus diastasis.
Post-Operative Plan
Drainage discontinued post-operative day (POD) two and the patient was discharged POD three. The prevena-VAC discontinued POD five. The patient is currently on physical rehabilitation. There haven’t been any significant complications, in four weeks follow-up period.
- The patient was treated with per-operative broad-spectrum antibiotics and there were three surgeons operating in total 4 h and10 minutes. Patient got per-operative infiltration analgesia, drainage before closure, prevena VAC on wound and stomach belt.
- Infection
- weight gain pre-opereative
- possible psychosis