The repair of large full-thickness post-excisional defects of the abdominal wall

Reconstruction of large thoracoabdominal defects using two-stage free tissue transfers and prosthetic materials

Very large full thickness defects of the thorax or abdomen after tumoral resections commonly need to be reconstructed with free tissue transfers. We retrospectively analysed the protocol of performing the free tissue transfer before the wide excision in 15 patients (mean age of 48) with large tumours of the thorax and abdomen. During the first stage, the flap was folded on itself in a strategic position close to the future resection site and microsurgical anastomoses performed. The second stage surgery consisted of the full thickness excision and definitive reconstruction of the defect by unfolding the flap over prosthetic material. The inclusion criteria were: large thoracoabdominal resections exposing lung or bowel and requiring the use of prosthetic material as part of the reconstruction after resection for locally aggressive tumours such as dermatofibrosarcoma protuberans. In 8/10 patients, vein grafts were used in the arterial anastomosis. The mean time interval between the first and the second stage was 17 days (7-50 days). Flap survival was one hundred percent on first attempt. In one patient who had presented with a large abdominal haemangioma, pulmonary embolism occurred during the second stage. In another patient, an infection under the flap occurred 3 years after reconstruction. Results of this series of patients support our belief that a two-stage microsurgical strategy can be useful in selected patients where large free flaps (with grafted pedicle) in combination with prosthetic materials have to be performed for reconstruction of full thickness defects of the trunk or the abdomen.

Osseous and chondral fixation of polypropylene mesh

Fixation of polypropylene (Marlex) mesh in the epigastrium and at the iliac crest can be ineffective because of insufficient local fascia; however, two techniques have been described to obtain firm and durable attachment of polypropylene grafts at these sites. Perichondral slips at the costal margin permit very satisfactory attachment with excellent long-term results. Stainless steel wire fixation of the mesh to the iliac crest has satisfied the need for osseous fixation in that area. Long-term repair of difficult and recurrent hernias has been described in three patients for whom other tactics for abdominal wall repairs were not available.

Abdominal wall resection and reconstruction with the aid of Marlex mesh

Treatment of malignant tumours of the abdominal wall is primarily surgical and should consist of ample excision with margin of 4-6 cm into the adjacent healthy tissue. When primary closure of the defect in the abdominal wall is not feasible, it can be repaired with the aid of Marlex mesh, combined if necessary with a pedicled omentum flap and free skin grafts. Major resections of the abdominal wall are thus made possible.