After massive weight loss, a patient may be left with a potentially serious new problem: excess abdominal pannus. Here's the latest on corrective surgery and what to teach him about it.
WHETHER YOUR MORBIDLY obese patient loses a very large amount of excess weight with bariatric surgery or by diet and exercise, he may have a new problem-a large, troublesome abdominal pannus. Sometimes called an abdominal apron, the pannus is a layer of subcutaneous fat that can weigh up to 100 pounds (45.5 kg), depending on how much weight he's lost. (See Grading the Curve: How Large Is the Pannus?) The extra skin and fat that remain after major weight loss can cause medical and psychosocial problems that impair function and quality of life.
To fully benefit from successful weight loss, the patient may need a reconstructive surgical procedure called panniculectomy. The patient must be nutritionally stable before surgery. Sometimes a patient has a large troublesome pannus removed even if he hasn't lost weight first. Here, I'll review the pros and cons of this increasingly common procedure and discuss how to teach and care for your patient.
More than a tummy tuck
Although sometimes thought to be merely cosmetic surgery because of its nickname-the "tummy tuck"-panniculectomy addresses a host of serious problems. (See Problems That Can Be Nipped by Panniculectomy.) But because many third-party payers classify it as an elective cosmetic procedure, your patient may have trouble getting his carrier to pay for it. Thoroughly document his condition to help him establish medical necessity. He'll need dated photos of the pannus, including front, side, and undersurface views. Some insurance carriers may refuse to pay for the surgery unless the pannus obscures the pubic area or causes intertrigo or other inflammation under the pannus. If all else fails, the patient may need to hire an attorney who specializes in these issues.
Once you've helped your patient secure payment for the procedure, prepare him for surgery. If he smokes, encourage him to quit before surgery. Tell him that good nutrition and exercise will help him recover faster. Advise him to ask his surgeon to estimate how long he'll be hospitalized.
If he weighs more than 300 pounds (136 kg), he'll require some special accommodation, such as a bed that's wide enough so he can turn independently, an extra-large walker to help him walk for the first few days, and an overhead trapeze to help him reposition himself. These items may help him maintain his strength and independence and make him less likely to injure himself or his caregivers. Teach him how to use this equipment before he has his surgery.
Nursing care, before and after
As with all patients, provide emotional support throughout your patient's hospital stay. Remember that he may be embarrassed by his condition, so respect his privacy and help him maintain his dignity.
As you take his history, assess him for risk factors and contraindications. Besides the usual preoperative workup, the patient will need to have endoscopic or radiographic studies to evaluate the primary weight-loss surgery. If he needs revision of the initial surgery, this is probably the time to do it.
Teach him what he needs to know about the surgery and what will be expected of him. Advise him that he may have considerable postoperative pain that requires a patient-controlled analgesia pump, then teach him how to use it. Reinforce what his surgeon has told him about the surgery and what will be expected of him.
Providing postoperative care
After the procedure, monitor the patient for signs and symptoms of complications, such as respiratory compromise, deep vein thrombosis (DVT), skin injury, infection, atelectasis, and bleeding. Prolonged surgery and hypothermia during the procedure increase the risk of complications. Elderly patients, smokers, and hypertensive patients are especially vulnerable, as are patients with chronic illnesses, such as diabetes.
Many patients can turn, walk, and transfer within 8 hours after surgery; others may take longer because of pain or sedation. As ordered, encourage your patient to ambulate as soon as he can after surgery. Maintain adequate pain control so he can move about; complications of immobility, such as atelectasis, DVT, skin breakdown, and pulmonary emboli, are the greatest threats to an uneventful recovery. Assess and document his pain level regularly using a standard numeric pain scale and make sure nurses on each shift use the same scale to document his pain rating.
If his mobility is limited, he may need treatment with a sequential compression device to prevent DVT or full-body rotation therapy to prevent postoperative atelectasis. Teach your patient to splint his incision to cough and deep-breathe and to use incentive spirometry.
Ensure adequate nutrition and hydration and assess his vital signs frequently, watching for fever and other signs of infection.
Providing wound care
After panniculectomy, your patient will have a T-shaped surgical wound. (See Technique Ends with a T.) Potential problems include wound dehiscence, seroma formation, and infection. Monitor wound drains for clotting and make sure they're in place and patent. Expect to see a small to moderate amount of serosanguineous or serous fluid. If your patient goes home with drains connected to a drainable collection bag, teach him or his caregiver how to empty the bag and care for the drains. Make sure they know what to do if the tube clots or falls out.
If your patient is still morbidly obese, he may have problems that delay wound healing, such as diabetes mellitus. Also, fatty tissue that wasn't excised can become devitalized, causing necrosis and infection.
Keep all wounds clean, especially those in skin folds. Well-approximated wounds healing by primary intention should be dry to promote healing. Follow your hospital's protocol to provide routine local cleaning. If the wound separates, contain excessive drainage and keep the skin surrounding wounds dry. Clean surrounding skin frequently with a nontoxic cleanser and secure appropriate dressings to absorb excess moisture. Consider consulting a wound care clinician as part of the interdisciplinary team. Avoid cytotoxic cleansers, such as povidone-iodine (Betadine) and Dakin's solution, because they can damage healing tissue.
Assess for wound separation, especially the low midpoint of the T in the abdominal incision. If the wound separates, notify the surgeon. Tell the patient to call his health care provider immediately if separation occurs after discharge.
Irregular body contours can make securing the dressing a challenge. Because they mold to contours, flexible cloth tapes may be a good choice for holding dressings in place.
Tell the patient he can minimize the risk of wound complications by using an abdominal binder for the first 4 weeks after surgery. Binders provide some comfort, and they minimize the shearing forces between the abdominal wall and abdominal skin, controlling edema and reducing ecchymosis. But a binder that doesn't fit properly can do more harm than good, possibly causing skin breakdown, respiratory compromise, or discomfort that discourages the patient from using it. Make sure that the xiphoid process is at least 1 inch (3 cm) above the upper edge of the binder and that two fingers fit comfortably under the binder. Remove the binder regularly and assess the underlying skin for problems.
Your patient may need nursing care at home if he has limited mobility because of pain or if coming into the office for follow-up care is difficult for him. This is a good time to ask the patient how things are going and what you as a nurse can do to help him achieve his goals. Help him find a local support group or bariatric surgery coordinator or steer him toward the Web site http://www.obesityhelp.com.
Finally, remind your patient that weight-loss surgery is just one tool in the battle against excess body weight. Encourage him to ask questions about dietary and lifestyle changes that will help him keep the weight off permanently.
Dietal, M., and Cowan, G.: Update: Surgery for the Morbidly Obese Patient. Toronto, Canada, FD-Communications, Inc., 2000.
Gallagher, S.: "Panniculectomy, Documentation, Reimbursement and the WOC Nurse," Journal of WOCN. 30(2):72-77, March 2003.
Gallagher, S., and Gates, J.: "Obesity, Panniculitis, Panniculectomy, and Wound Care: Understanding the Challenges," Journal of WOCN. 30(6):334-341, November 2003.
BY SUSAN GALLACHER, RN, CWOCN, PHD
Susan Gallagher is clinical affairs coordinator for SIZEWise Rentals of Ellis, Kan., which makes beds and other equipment for obese patients.
Copyright Springhouse Corporation Dec 2004
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