Obesity is a chronic metabolic disorder increasingly encountered in children, adolescents, adults, and pregnant women [11]. It is an independent risk factor for the occurrence of SSIs following many types of surgical interventions [12, 13], particularly, following C-section. [13]. There exist alterations in the vascularisation of the subcutaneous adipose tissues, which in turn alters the normal healing process and enhances the occurence of seromas and hematomas after C-section and later on SSIs [14]. Finally, obesity especially at the level of the folds is responsible for a maceration that maintains the infection. Once there is an infection at the surgical site, its management meets the general principles of all wound infection management : wound debridement, cleansing, dressing and coverage (reconstruction) [15]. The optimization of the treatment of SSI also involves the management of risk factors which in our case is mainly maceration. The initial incision was a Pfannestiel, performed at the lower abdominal fold, an area where maceration is very high, given the grade III panniculus [16]. Therefore, limiting maceration in this area could be achieved by reducing the abdominal panniculus.

Panniculectomy is an integral part of plastic surgery procedures. It is increasingly practiced given the rise in incidence of obesity and bariatric surgery [17]. In this case, it corrects the silhouette or contours of the abdomen by resection of excess abdominal skin and subcutaneous tissues formed as a result of excessive weight loss [16, 18, 19]. Apart from the aesthetic aspect responsible for most of its indications, panniculectomy can be performed for medical reasons [20]. It is indicated in cases of an important panniculus (grade 3 or overhanging panniculus) and symptomatic [20], that is to say associated with a severe skin infection or persistent ulceration despite conventional treatment. It may be the first step of a digestive or gynecological abdominal surgery requiring a sufficient operative exposure or to facilitate access to the abdominal cavity [16, 21]. In our case, it was carried out as part of the management of a persistent and sustained SSI by maceration induced by the excessive adipose panniculus.

Abdominal panniculectomy is a technique of transverse abdominoplasty. This is a low transverse anterior lipectomy; the principle is a resection of the abdominal panniculus by an incision in an orange quarter under the umbilicus associated with a lowering of the upper abdominal flap [16, 17]. Transposition of the umbilicus can be carried out depending on the case [17,18,19]. During this procedure, a plasty of the fascia or muscles of the abdominal wall is not performed, which makes it possible to differentiate panniculectomy from other abdominoplasty procedures. Thus, some authors refer to panniculectomy as a miniabdominoplasty [22].

The operative technique of panniculectomy described in this case has several variants [18]. The elements to be taken into account are: the xipho-umbilical distance, the umbilico-pubic distance, the presence of an umbilical hernia, an incisional hernia, an associated diastasis recti, the level of skin distension and the elasticity of the supra-umbilical region [23]. In the case of our patient, besides the huge adipose panniculus, the upper flap was not very elastic. This condition limited the extent of the area to be resected with a risk of having sutures under tension. Our patient had not undergone any previous bariatric surgery nor liposuction, and therefore, did not have an adequate melting of the adipose tissue sufficient to obtain a relaxation of tissue. As such, a simultaneous liposuction could have been performed intraoperatively. However, the infectious context was a contraindication for the latter.

The most common postoperative complications of panniculectomy are [17,18,19]: hematomas, seromas, SSIs, flap necrosis (in case of sutures under tension), an inaesthetic scarring (due to the ascension of the pubic flap in case of an excessive traction on the tissues) and rarely, thromboembolic complications seen in 0.56% of panniculectomy cases [16]. In the above case presented, we note the occurrence of a seroma which resolved a few days later with simple bandages.

Prevention of deep infection of the surgical site in morbidly obese patients during gynecological interventions by laparotomy would involve performing a panniculectomy at the same time [24, 25]. This additional procedure does not significantly increase operative time or blood loss. However, it is more easily conceived in elective surgeries, whereas our patient’s first surgical intervention was an emergency to safe her foetus.

Standard management of morbidly obese surgical patients like ours entails a multidisplinary approach by all the specialties involved in the management of obesity [26, 27]. These generally includes the following measures; dietary control, regular physical exercise, pharmacological treatment, psychological support and bariatric surgery [26, 27]. Bariatric surgery is indicated in the absence of sufficient weight loss despite a well-conducted multidisciplinary medical management for 6 - 12 months [26, 27]. Other eligibility criteria for bariatric surgery are: patient age between 18 to 60 years; BMI ≥ 40 kg/m2 or ≥ 35 kg/m2 with at least one comorbidity or BMI > 30 kg/m2 with diabetes mellitus or metabolic syndrome that is difficult to control [26, 27]. Furthermore, the patient must be well informed in advance and should accept long-term medical and post-surgical follow-up. Surgery should be done after multidisciplinary evaluation, in a patient with an acceptable surgical risk [24, 25]. Overall, our setting being a surgical infrastructural environment with limited equipment and skills for bariatric surgery, panniculectomy seems to be a promising safe practical adapted efficacious therapeutic option with minimal postoperative complications and satisfactory cosmetic outcomes when used in a multidisciplinary anti-obesogenic approach.