Abdominal integument atrophy after operative procedures.

THE AIM OF THE STUDY: was to analyze clinical material concerning postoperative atrophy of abdominal integument.
MATERIAL AND METHODS: The evaluated group consisted of 29 patients with sonographically revealed atrophy of the abdominal wall. Those changes were observed after various surgical procedures: mainly after long, anterolateral laparotomies or several classical operations. Ultrasound examinations up to the year 2000 were performed with analog apparatus, in the latter years only with digital apparatus with linear transducers (7-12 MHz) and sometimes convex type conducers (3-5 MHz). The location, size and intestine stratified wall structure were evaluated. In each case the integument thickness was measured in millimeters in the site of the greatest atrophy and it was compared with the integument thickness from the side that had not been operated which enabled the calculation of the percentage reduction of integument in the area of the scar.
RESULTS: In 3 patients who underwent several laparotomies there was a total reduction of muscular mass in the operated area. In these cases we stated only skin and slightly echogenic subcutaneous strand; probably corresponding to fibrous tissue - the thickness of integument in this area was in the range from 3 to 8 mm. In the remaining 26 patients the integument atrophy on the scar level included muscles in a greater extent and covered an extensive area after classical urological procedures on the upper urinary tract: after nephrectomy and even ureter stone evacuation or kidney cyst excision by means of classical anterolateral approach with the integument incision on the length of almost 20 cm. Reduction in the integument thickness was observed on the smaller area after classical cholecystectomies, appendectomies and other surgical procedures with the incision across the integument. The integument atrophy in the operated sites expressed in absolute numbers was in the range of 7-20 mm (average 14 mm). These values are markedly lower than the comparative integument thickness on the not operated side: 17-52 mm (average 25.4 mm). The percentage value of the integument thickness reduction oscillated in the range of 32-67% (average 44.2%). In most cases the atrophy involved all layers of the abdominal wall, what demonstrated as regional prominence of the integument, mimicking the presence of hernia.
CONCLUSIONS: Ultrasonography allows precise evaluation of the size and extent of atrophy as well as depiction of other lesions simulating that effect. Establishing the correct diagnosis should prevent the unnecessary reconstructions of the abdominal integument.

Introduction

An increase in the performance of little invasive surgical procedures has been observed for many years. An example can be a standard laparoscopic cholecystectomy. Other surgeons go even further developing transluminal endoscopic procedures through natural orifices NOTES (natural orifice transluminal endoscopic surgery), e.g. transvaginal or transgastrical cholecystectomy(.

The aim of this study is the retrospective analysis of our own ultrasound examination material (US) with regard to the influence of classical surgical procedures on the condition of abdominal integument.

Material and methods

In the years 1998–2011 clinical data regarding 29 patients were collected (12 women and 17 men) aged from 34 to 72 years old (average age 54) who reported different complaints related to the area of performed surgical procedure. In 23 of them in the scar location an integument prominence appeared. In the remaining 6 patients a slight cicatricle integument dimpling. Moreover, 21 patients felt paresthesiae in this region, some of them reported also slight pain. Twenty patients had undergone urological surgery: classical nephrectomy (n = 18), removal of a cyst from the right kidney (n = 1) and stone from right ureter (n = 1). Three patients had cholecystectomy (one of them also appendectomy) and 2 of them only appendectomy. Moreover, 2 other patients had undergone multiple surgical procedures because of iatrogenic bile duct injuries and acute pancreatitis complicated by phlegmon. One patient underwent urgent laparotomy because of the perforation of the right side of colon during colonoscopy, the other one had the abdominal cavity revision performed because of a stab wound caused by a knife.

The US examination was performed using different apparatus: up to the year 2000 analog and in the latter years only digital with the use of mainly linear transducers (7–12 MHz) and sometimes convex transducers (3–5 MHz). The assessment of the lesion consisted in the evaluation of the location, size and also the maintaining of the stratified wall structure. In each case the integument thickness was measured in millimeters in the site of the greatest atrophy and it was compared with the integument thickness from the side that had not been operated which enabled the calculation of the percentage reduction of integument in the area of the scar.

Results

In 3 patients who underwent several laparotomies there was a total reduction of muscular mass in the operated area. In these cases we stated only skin and slightly echogenic subcutaneous strand; probably corresponding to fibrous tissue – the thickness of integument in this area was in the range from 3 to 8 mm (fig. 1). In table 1 (tab. 1) the results regarding 26 patients were listed. The integument atrophy on the scar level included muscles in a greater extent and covered an extensive area after classical urological procedures on the upper urinary tract: after nephrectomy (fig. 2) and even after ureter stone evacuation or kidney cyst excision by means of classical anterolateral approach with the integument incision on the length of almost 20 cm (fig. 3). Reduction in integument thickness was observed on the smaller area after classical cholecystectomies, appendectomies and other surgical procedures with the incision across the integument (fig. 4–6). In one patient after laparotomy because of intraperitoneal bleeding after knifing the integument atrophy was stated in the site of the introduced drain where there was stuck small intestine loop (fig. 7).

Fig. 1

On the transversal scan of the right epigastrium the arrows indicate a pronounced reduction of the integument mass with a total atrophy of stratification. L – liver. The patient after several laparotomies because of phlegmon in the course of acute pancreatitis

Tab. 1

Comparative listing of thickness values and the percentage reduction of integument at the level of postoperative scar and on the not operated side in 26 patients

Analyzed feature	On the level of laparotomy scar	On the not operated side
The range of abdominal integument thickness	7–20 mm	17–52 mm
Average integument thickness	14,4 mm	25,4 mm
The range of the integument thickness reduction	32–67%
Average integument thickness reduction	44,2%

Fig. 2

Abdominal integument atrophy on the right side (P) as a result of right nephrectomy. Arrows indicate the outline of the anterior abdominal wall on the right and left side

Fig. 3

On the comparative sonogram a pronounced reduction of abdominal integument (P) as a result of the removal of right kidney cyst

Fig. 4

Pronounced atrophy of the right rectus abdominis muscle (P) after laparotomy performed in order to remove a necrotic fragment of the small intestine

Fig. 6

Atrophy of the right part of abdominal integument (P) as a result of laparotomy performed because of the perforation of the right side of colon during colonoscopy

Fig. 7

Focal atrophy of the abdominal integument (small arrow) in the site after drain. In this localization stuck to the integument small intestine loop is visible (B). Large arrow indicates normal integument thickness beyond the operation site

Pronounced abdominal integument mass reduction on the right side (P) after appendectomy

The integument atrophy in the operated sites expressed in absolute numbers was in the range of 7–20 mm (average 14 mm). These values are markedly lower than the comparative integument thickness on the not operated side: 17–52 mm (average 25.4 mm). The percentage value of the integument thickness reduction oscillated in the range of 32–67% (average 44.2%) (tab. 1).

Discussion

In the latter years the development of endoscopic procedures in surgery of the abdominal cavity with the omission of classical laparotomy can be ascribed to the significant technological progress in the construction and minimization of specula introduced to different body cavities and the need to avoid sometimes serious complications after extensive incisions of abdominal integument (blemishing scars, wound infections, hematomas, hernias, pain and so on). One of the side effects can also be a local atrophy in the surrounding of the healed operation wound which usually occurs after several months or years after the surgery. It seems that there are two main factors responsible for this complications, namely blood vessels and nerve damage, the maintaining of which is sometimes difficult during integument incision. Kogut and Sanigurskij( stated the atrophy of rectus abdominis muscle of different degrees (in the range of 22–62%) in all 40 patients operated because of gall bladder and external bile ducts lesions. In advanced atrophy the authors observed also clearly impaired contraction of this muscle while launching abdominal press. Müller et al.( concentrated on a similar morphological effect of the integument after surgical procedures of the retroperitoneal space from a typical anterolateral approach. In 5 patients they stated the atrophy of the lateral group of abdominal wall muscles, which manifested itself by an extensive prominence clinically diagnosed as hernia. On the operated side the main atrophy of the thickness of the three muscles (external oblique, internal oblique and transverse) equaled 38±13%. The sonographic image was confirmed by means of magnetic resonance in all 5 patients, and in 2 assessed in terms of the innervation of the area a reduced innervation was stated. It results from the findings of experimental and anatomical studies conducted by Gardner et al.( that the disturbance in innervation may appear in the damage of the intercostal nerve stem before its division, that is in intercostal space or by the end of XI rib.

The presented material confirms these observations because a pronounced integument prominence was stated after classical urological incisions in order to get to the kidney or ureter. However, the atrophy after laparotomy has been observed also elsewhere, which in the majority of patients manifested itself by a shallow dimpling, so the influence on the integument shape was opposite. Such effect can be expected after the incision of rectus abdominis muscles. The authors mentioned before also observed the influence of the muscle atrophy on the functioning of abdominal press(, which in turn can have an influence on the decrease in stability of the lumbar vertebral column. It is worth to notice that the integument atrophy in some cases involves also other layers of integument, not only muscles. In our 3 patients after several laparotomies there was a maximum reduction in the integument mass of the operated area. The thickness of the anterior wall decreased to 3–8 mm which was accompanied by blurring of its stratified structure (fig. 1).

The study presented for the first time touches the problem of the crippling influence of classical surgical procedures on the integument condition. Similarly to magnetic resonance, the US examination enables the presentation of the abdominal integument structure with huge precision and visualization of all the abnormalities in integument skin(. This enables the differentiation of the abdominal integument atrophy with a successive prominence with postoperative hernia which has a significant clinical meaning. In contrast to hernia the atrophy with integument prominence does not qualify for a reconstructive surgery(. Moreover, in the differentiation also other pathological lesion in the integument should be taken into account, such as hematomas, abscesses, suture granulomas, implanted foreign bodies, neuromas, desmoid tumors and so on.

At the end it should be stressed that the precise presentation of abdominal integument atrophy is possible by means of panoramic imaging – a US visualization option which we did not possess.

Conclusion

Classical abdominal surgeries through the integument incision are burdened with the risk of atrophy in the range of 32–67% in relation to the opposite/healthy side. The greatest negative effects are caused by anterolateral integument incision, used in order to get to the retroperitoneal space. After several laparotomies in the same area a total reduction of integument mass may appear. Ultrasound constitutes the primary diagnostic method in the diagnosis of this type of pathology and enables relevant differentiation which decides about appropriate medical intervention.