Content area
Full Text
Background
Lymphoedema of the abdominal wall (panniculus morbidus) is a rare entity, with only a few retrospective reviews of panniculectomies and their complications having been described. Panniculus morbidus is associated with obesity and is likely to become more common with increasing levels of obesity. In the UK, the prevalence of obesity has increased from 15% to 26% in the last 20 years. 1 Panniculus morbidus is thought to be caused by obstruction of lymphatic channels leading to the hypertrophy of skin and subcutaneous tissues. In this case, obstruction of the superficial veins of the anterior abdominal wall also appears to have contributed to the oedema.
Case presentation
A 52-year-old British woman presented to the clinic with increasing swelling on the right side of her abdominal wall which had gradually developed over the preceding 5-6 years. The mass caused a significant reduction in her mobility and affected her day-to-day activities such that she had become housebound. She also had poor personal hygiene and an impaired quality of life. The patient had previous multiple admissions for repeated attacks of cellulitis in the skin overlying the lump, which necessitated treatment with intravenous antibiotics. Her medical history included non-insulin-dependent diabetes mellitus, hypertension and hypercholesterolaemia. There was no history of hepatic or renal failure or malignancy.
On examination, the patient weighed 177kg (body mass index (BMI): 62.7) and the swelling extended below the level of her knees ( figure 1 ). The overlying skin was erythematous, hyperpigmented and indurated, with evidence of peau d'orange inferiorly. The pannus felt tense on palpation and was irreducible.
Investigations
To determine the cause of the swelling and to exclude the possibility of an abdominal wall hernia or a liposarcoma, an abdominal-pelvis CT scan was performed. The scan revealed a large right-sided abdominal mass (30x30x50cm) consisting of markedly oedematous adipose tissue with extensive thickening of the overlying skin (up to 2.7cm in thickness). The adipose tissue was highly vascular with large veins draining into the right femoral vein and also into the subcutaneous veins of the anterior abdominal wall ( figure 2A,B ).
Treatment
At the time of presentation to the surgical clinic, the site, size and weight of the pannus precluded the possibility of treatment by manual lymphatic drainage or fitted compression/bandaging. A decision...