By Casi White, RDMS, and

James E. White, MD, FACS, PVRI

We have all been there, attempting to get a good ultrasound window with transverse and longitudinal views of the saphenous femoral junction and proximal great saphenous vein while fighting the downward drift of a huge abdominal pannus or FUPA.

Now that two-thirds of American residents are overweight or obese, a whole new language has sprung up to describe various fatty body parts. Panniculus is a medical term fairly well known. FUPA is less well known. FUPA stands for fat upper pubic area or fat upper pelvic area.

The medical term panniculus is derived from the word “pannus,” which refers to a flap, or apron, of hanging tissue. Unwanted tissue can grow over corneas, joints (in rheumatoid arthritis) and artificial heart valves. When a pannus is present on the lower abdomen, it’s called a panniculus.

People afflicted with a panniculus are either currently obese, or the abdomen has shrunk several sizes post-pregnancy or after weight loss with residual excess skin. The tissue itself is made up of skin and fat and is graded by degree of severity:

• Grade 1: the panniculus reaches the pubic hair but not the genitals
• Grade 2: the panniculus lies over the genitals down to the thigh crease
• Grade 3: the panniculus reaches down to the upper thigh
• Grade 4: the panniculus hangs down to mid-thigh level
• Grade 5: the panniculus reaches the knees

Yes, in severe cases this apron of skin and fat can reach the knees and beyond. Search Google on the terms “pannus” and “panniculus” and one will find examples.

In the past during ultrasound review, our office requested that the patient hold the abdominal pannus and FUPA upward to allow exposure of the inguinal region. This positioning sometimes proved difficult with the patient in a reverse Trendelenburg position to allow for maximum venous distension for best venous ultrasound review of the lower extremities.

Requesting the patient complete manual retraction of their pannus is often awkward and not very dignified. During surgical procedures the patient is not able to manually retract the pannus; thus awkward taping techniques were used to retract and hold the excess tissues cephalad.

We have all used multiple rolls of two-inch Silk tape extending from the patient’s abdominal skin hoisting the pannus with tape extending up and over to finally attach to the bottom of the operative table under tremendous tension forces. Only to hear a loud “pop” sound in the middle of the surgical procedure followed by an avalanche of excess tissue falling down over the surgical field.  Talk about undignified!

In search for predictable, reliable retraction of the panniculus during procedures; our office has found that a three-panel abdominal binder is perfect to retract the excess tissue exposing the inguinal regions for ultrasound review. The abdominal binder retracts and holds the panniculus for the duration of the operation, freeing the surgeon’s hands and those of the staff to better care for the patient.

Most women are familiar with a griddle and most men are familiar with a lumbar support. The abdominal binder is accepted by high BMI patients who will think this is a normal part of any procedure. Application and removal are both quick and easy and will not damage the patient’s skin.

TECHNIQUE

The abdominal binder is placed with the patient in a supine, Trendelenburg position (Photo 2).   The binder is placed on the table and the patient then placed on the table in a supine position.  Trendelenburg table position is used to assist retraction of the abdominal pannus by the patient and staff.

The binder is positioned opened to the front. The binder is placed high over the thoracolumbar region, extending over the iliac crest with the opening to the front. Velcro closure is completed with manual retraction of the pannus by the patient in a safe, dignified environment with staff assistance.  (Illustration 3). Appropriate outer cover can then be utilized. Final adjustments can be completed when the patient is placed in a supine reverse Trendelenburg position on the operative table. (Photo 3).

The three panel abdominal binder is provided as a single patient use. Our office uses a system where the binder is used during initial ultrasound examination. At that end of the procedure, the binder is stored in a zip lock bag with appropriate identification information tying that binder to the specific patient. A single binder can be used multiple times for each individual patient.

Our office has found that use of the abdominal binder has greatly reduced patient preparation time, decreased staff fatigue, eliminated the need for abdominal wall taping and provided a more dignified patient experience. Surgical and ultrasound exposure are noted to be increased; eliminating the need for manual retraction and freeing hands for procedures.

We have found that use of the three-panel abdominal binder is less humiliating than tape or straps; and with reduced prep time and clinician involvement, high BMI patients will think this is a normal part of any procedure.

Application and removal are both quick and easy and will not damage the patient’s skin. The binder costs range from $9-$15 depending on the manufacturer. The binder is reproducible, can be adjusted and is readily covered by sterile drapes, thus decreasing the risk of contamination during a surgical procedure.  VTN

ABOUT THE AUTHORS

James E. White, MD, FACS, who is board certified in general surgery, phlebology and cosmetic surgery, owns Advanced Surgical Concepts, in Chattanooga, Tenn., a practice in phlebology and cosmetic surgery. He was graduated Magna Cum Laude from the Medical College of Georgia in 1990. He then completed a General surgery residency at the University of Tennessee, Chattanooga in 1996. He is a Diplomat with the American Board of Phlebology and the American Academy of Cosmetic Surgery.

Casi White, RDMS, is the office administrator at Advanced Surgical Concepts. She has degrees in radiologic technology with credentials: RT-Registered Radiologic Technologist, RT-M– Registered in Mammography, RDMS-Registered Diagnostic Medical Sonographer, as well as, CPC-Certified Professional Coder.