Abdominal wall reconstruction using a combination of free tensor fasciae lata and anterolateral thigh myocutaneous flap: a prospective study in 16 patients

The external oblique muscle flap technique for the reconstruction of abdominal wall defects

PURPOSE

Several modifications to the anterior component separation technique (ACST) have been reported to facilitate the closure of abdominal wall defects. In this study, the external oblique (EO) muscle flap for modified ACST during major abdominal wall defect reconstructions has been described.

METHODS

A retrospective review of consecutive patients undergoing modified ACST was conducted. The clinical data were collected and retrospectively analyzed.

RESULTS

Among the 36 patients admitted to our hospital from December 2014 to December 2020, 9 cases had rectus abdominis tumors, 1 case had rectus abdominis trauma, and 26 cases had incisional hernias. The average age was 61.17 ± 13.76 years, and the mean BMI was 24.25 ± 3.18 kg/m². The average width of the defect was 14.33 ± 2.90 cm. Unilateral EO muscle flap technique was used to reconstruct the abdominal wall. 3 cases of surgical site infection (8.3%), 4 cases of grade III or IV seroma (11.1%) and 2 cases of intestinal obstruction (5.5%)were reported postoperatively. Ischemic necrosis of the abdominal EO muscle flap, incision dehiscence, intestinal fistula, or other complications were not observed. 1 case of incisional hernia recurrence (2.8%) was reported. Recurrence of tumors or abdominal wall bulging were not noted during the follow-up period of 32.53 ± 14.21 months.

CONCLUTIONS

The EO muscle flap technique is associated with low postoperative morbidity and recurrence rate, which approves it a reliable technique for selected groups of patients. Further research are needed to confirm the effectiveness of this technique.

Abdominal Wall Reconstruction Using Pedicled Antero Lateral Thigh Flap

Background

Reconstructing abdominal wall defects has been a difficult task for surgeons. The abdominal wall defects range from defects of only soft tissue to full thickness defects including all the three layers of the abdomen. Only soft tissue defects are commonly caused by peritonitis and laparotomies, and full thickness defects can occur from en bloc resection of tumours as well as trauma. Treatment options available include component separation, partition technique, flap coverage, and more recently acellular dermal matrix.

Methods

This retrospective study done between 2016 and 2020 where 20 patients were operated for abdominal wall defect using Pedicled ALT flap in the Department of Plastic and Reconstructive Surgery, Sawai Man Singh Hospital, Jaipur, Rajasthan, India.

Results

The study consisted of total 20 patients, 14 males and 6 females. Eight patients were post electric burn, 5 patients had suffered trauma, 4 patients underwent resection of abdominal wall tumour and 3 patients were post laparotomy for peritonitis. Mean age of patients was 48 years (range from 36 to 62 years). Mean fascia defect size was 14.2 cm (range 12.2 to 16.4 cm). Mean operative time was 170 minutes (range from 140 minutes to 220 minutes). Postoperative hospital stay ranged from 8 days to 24 days (mean- 12 days).

Conclusion

Pedicled ALT flap has expanded the armamentarium of plastic surgeons for reconstruction of abdominal wall defects.

Evolving concepts in ventral hernia repair and physical therapy: prehabilitation, rehabilitation, and analogies to tendon reconstruction

PURPOSE

The abdominal wall and musculoskeletal tendons share many anatomic, physiologic, and functional characteristics. This review aims to highlight these similar characteristics and to present a rationale why the treatment principles of successful musculoskeletal tendon reconstruction, including principles of surgical technique and physical therapy, can be used in the treatment of complex abdominal wall reconstruction or ventral hernia repair.

METHODS

The MEDLINE/PubMed database was used to identify published literature relevant to the purpose of this review.

CONCLUSIONS

There are several anatomical and functional similarities between the linea alba and musculoskeletal tendons. Because of this reason, many of the surgical principles for musculoskeletal tendon repair and ventral hernia repair overlap. Distribution of tension is the main driving principle for both procedures. Suture material and configuration are chosen to maximize tension distribution among the tissue edges, as seen in the standard of care multistrand repairs for musculoskeletal tendons, as well as in the small bites for laparotomy technique described in the STITCH trial. Physical therapy is also one of the mainstays of tendon repair, but surprisingly, is not routine in ventral hernia repair. The evidence surrounding physical therapy prehabilitation and rehabilitation protocols in other disciplines is significant. This review challenges the fact that these protocols are not routinely implemented for ventral hernia repair, and presents the rationale and feasibility for the routine practice of physical therapy in ventral hernia repair.

Propeller Flaps for the Anterior Trunk

Various types of propeller flaps from multiple donor sites can be used to reconstruct anterior trunk skin defects. The actual selection depends on the condition and location of the recipient site, especially if it is to be the chest or abdomen that requires attention. Before surgery commences, it is always important to use an imaging analyses such as computed tomography angiography to examine and identify perforators that could perfuse a perforator-pedicled propeller flap (PPPF), as it is the most multifaceted imaging technique. Clusters of perforators that can be commonly used for the "workhorse" PPPFs for the thoracic and abdominal regions are the internal mammary artery perforator, the musculophrenic artery perforator, and the deep inferior epigastric perforator. These perforators are reliable and large enough to support long and large propeller flaps that will cover most defects in this region, while still allowing primary donor-site closure.

Autologous abdominal wall reconstruction using anterolateral thigh and iliotibial tract flap after extensive tumor resection: A case series study of 50 consecutive cases

BACKGROUND

The utility of anterolateral thigh (ALT) + iliotibial tract (ITT) flaps for the reconstruction of large abdominal wall defects has been reported, especially in cases with huge skin defects, surgical contamination, or a history of radiotherapy. However, previous reports have mainly described short-term results such as flap success rates or incidence of wound complications. The present study reviewed 50 consecutive cases of abdominal wall reconstruction using an ALT+ITT flap after extensive tumor resection and evaluated the durability of this approach (incidence of bulge or hernia) and the factors affecting the results.

PATIENTS AND METHODS

A detailed retrospective review of 50 consecutive cases was conducted. Computed tomography or magnetic resonance imaging findings were reviewed to assess the incidence of abdominal bulge or hernia. Items extracted as variables from patient records were subjected to univariate and multivariate logistic regression analyses to identify their relationship with postoperative abdominal bulge or hernia.

RESULTS

Forty-six cases that were followed up for more than six months were analyzed. Twenty-three patients (50.0%) developed abdominal bulge, while none (0%) developed hernia. The multivariate logistic regression analysis revealed that old age and a high body mass index were independently associated with abdominal bulge, while abdominal defect size was not.

CONCLUSIONS

Abdominal wall reconstruction using an ALT+ITT flap after extensive tumor resection was considered a reasonable option with a low risk of hernia despite a marked incidence of postoperative abdominal bulge; however, the usage of additional material may be considered depending on the situation.

Complex abdominal wall reconstruction, harnessing the power of a specialized multidisciplinary team to improve pain and quality of life

INTRODUCTION

Patients who require highly complex abdominal wall hernia repair with composite soft tissue free flap coverage represent the most challenging population, and the most difficult to definitively treat. For many, this combined procedure represents their last chance to restore any sense of normalcy to their lives. To date, patient reported post-operative outcomes have been limited in the literature, in particular, quality of life has been an under-reported component of successful management.

METHODS

Patient-reported outcomes were analyzed using the 12-question HerQLes survey, a validated hernia-related quality of life survey to assess patient function after complex abdominal wall reconstruction. Using synthetic mesh for structural stability, and microsurgical flaps for soft tissue coverage, ten consecutive heterogeneous patients underwent repair of massive abdominal wall defects. Baseline preoperative HerQLes and numerical pain scores were then compared to those obtained postoperatively (at or greater than 6 months).

RESULTS

All patients experienced improvement in their quality of life and pain scores post operatively with average follow-up at 15.9 months, even in those who experienced complications. All microsurgical flaps survived. There were no hernia recurrences.

CONCLUSION

Despite the extraordinary preoperative morbidity of massive abdominal wall defects, with an experienced General Surgery and Plastic Surgery multidisciplinary team, these highly complex patients are able to achieve a significant improvement in their pain and quality of life following repair and reconstruction with complex mesh hernia repair and microsurgical free tissue transfer.

Collapsed wall: destructive and reconstructive surgery of anterior abdominal wall tumour in a young girl

Natural history of abdominal wall soft tissue sarcoma is still poorly understood due to its rarity. In unpublished data of our institution, only seven cases of abdominal wall soft sarcoma with ICD-10 coding of 49.4 were found for past 10 years. We illustrate a case of juvenile fibrosarcoma of anterior abdominal wall. This is a case of young girl with anterior abdominal wall tumour, underwent wide local excision with immediate reconstruction. There are few options of surgical treatment for this case, but which is the best. It is always a challenge in managing young patient with giant abdominal wall defect in view of long term effect namely weakened abdominal wall, pregnancy related issue and risk of herniation and surgical site recurrence as well.

Successful Pregnancy and Delivery after Autologous Abdominal Wall Reconstruction using Anterolateral-Thigh and Iliotibial-Tract Flap

The surgical management of abdominal wall tumor in women with childbearing potential is a thorny issue. A synthetic mesh is widely used for abdominal wall reconstruction but not necessarily applicable in case of women of childbearing potential because it has been reported to cause severe pain during pregnancy. Autologous reconstruction is usually considered a feasible option for such cases; however, there is no consensus on this approach and almost no evidence to support it. In the present 2 cases, 2 female patients (age, 17 years and 35 years) with abdominal wall desmoid tumor underwent primary radical resection and autologous reconstruction of an abdominal wall defect in the lateral oblique muscle area (defect size, 13 × 5 cm and 8 × 6 cm) using an anterolateral thigh and iliotibial tract flap. The postoperative course was uneventful. Both patients achieved pregnancy and a full-term delivery without complications with the exception of a feeling of mild stretching in the area of the operation. Magnetic resonance imaging and a clinical examination after the delivery revealed no signs of abdominal wall hernia or bulging. Normal pregnancy and full-term delivery could be obtained after abdominal wall resection and autologous reconstruction using an anterolateral thigh + iliotibial tract flap. This reconstructive method is considered to be a versatile option for the management of abdominal wall tumor in women with childbearing potential; however, further evidence should be accumulated on the reconstruction of wider and central abdominal wall defects.

Sliding free transverse rectus abdominis myocutaneous flap for closure of a massive abdominal wall defect: A case report

Despite considerable advances in reconstructive surgery, massive abdominal wall defects continue to pose a significant surgical challenge. We report the case of a 72-year-old morbidly obese female patient with Clostridium septicum-related gas gangrene of the abdominal wall. After multidisciplinary treatment and multiple extensive debridements, a massive full-thickness defect (40 cm × 35 cm) of the right abdominal wall was present. The abdominal contents were covered with a resorbable mesh to prevent evisceration. Finally, the composite defect was successfully reconstructed through a contralateral extended free transverse rectus abdominis myocutaneus (TRAM) flap (50 cm × 38 cm). An arterio-venous loop to the superficial femoral vessels using the great saphenous vein was necessary to allow the flap to reach the defect. Postoperatively, a minor wound healing disorder of the flap was successfully treated with split skin grafting. Six month after surgery, the patient presented with a completely healed flap coverage area and a small abdominal hernia without the need of further surgical revision. This case illustrates the use of a sliding free TRAM flap for closure of a massive abdominal wall defect.

Early laparotomy and timely reconstruction for patients with abdominal electrical injury: Five Case Reports and Literature Review

INTRODUCTION

High-tension electricity can cause devastating injuries that may result in abdominal wall loss, visceral damage, and sometimes major threat to life. The visceral organ may be exposed after debridement and require flap cover, but the tensile strength of abdominal wall may be lack even if flap transplanted.

METHODS

From April 2007 through May 2015, 5 patients with severe abdominal electrical injury were treated at our hospital. Exploratory laparotomy was performed based on their clinical manifestations and debridement findings of abdominal wall at early stage, and decision regarding technique for reconstruction of abdominal wall was based on an assessment of the location and extent of the defect. Medical records were reviewed for these data.

RESULTS

Clinical evaluation and debridement findings of the abdomen revealed 4 patients with suspicious visceral damage. Laparotomy was performed in 4 cases, and revealed obvious lesion in 3 cases, including segmental necrosis of small intestine, partial necrosis of diaphragm, left liver and gastric wall, and greater omentum. Five patients underwent abdominal wall reconstruction using island retrograde latissimus dorsi myocutaneous flap or free/island composite anterolateral thigh myocutaneous flap. All flaps survived, abdominal bulging occurred in 3 cases after follow-up of 12 to 36 months.

CONCLUSIONS

The clinical manifestations and wound features of abdomen collectively suggest a possible requirement of laparotomy for severe abdominal electrical burns. Retrograde latissimus dorsi myocutaneous flap or composite anterolateral thigh myocutaneous flap is an effective option for reconstruction of abdominal wall loss, the long-term complication of abdominal bulging, however, remains a significant clinical challenge.

A fascia lata free flap in pelvic exenteration for Fournier gangrene due to advanced rectal cancer: a case report

Background

Fournier gangrene due to advanced rectal cancer is a rapidly progressive gangrene of the perineum and buttocks. Emergency surgical debridement of necrotic tissue is crucial, and secondary surgery to resect tumors is necessary for wound healing. However, pelvic exenteration damages the pelvic floor, increasing the likelihood of herniation of internal organs into the infectious wound. The management of pelvic exenteration for rectal cancer with Fournier gangrene has not yet been established. We herein describe the use of a fascia lata free flap in pelvic exenteration for rectal cancer with Fournier gangrene.

Case presentation

A 66-year-old male who had undergone colostomy for large bowel obstruction due to advanced rectal cancer and continued chemotherapy was referred to our hospital for Fournier gangrene resulting from chemotherapy. Emergency surgical debridement was performed, and the infectious wound around the rectal cancer was treated with intravenous antibiotic agents postoperatively. However, the tumor was exposed by the wound, and exudate persisted. Pelvic exenteration was performed due to tumor infiltration into the bladder and prostate. Tumor resection resulted in a defect in the pelvic floor. A fascia lata free flap (15 × 9 cm) obtained from the left thigh was fixed to the edge of the peritoneum and ileal conduit to close the defect in the pelvic floor and prevent small bowel herniation into the resected space. There was no intraabdominal inflammation or bowel obstruction postoperatively, and outpatient chemotherapy was continued.

Conclusions

Surgical repair with a fascia lata free flap to close the defect in the pelvic floor led to a good clinical outcome for pelvic exenteration in a patient with Fournier gangrene due to advanced rectal cancer.

The Marriage of Sartorius and Tensor Fasciae Latae in Treating Vascular Prosthetic Graft Infections

Background:

Vascular prosthetic graft infection in the groin is associated with high morbidity and mortality. This article presents a case series on the use of 2 flaps in the treatment of this condition.

Methods:

Five patients, mean age 65 years (range, 49–74 years), with significant comorbidity were treated for an exposed and infected vascular prosthetic graft in the groin with a combination of sartorius muscle (SM) flap and tensor fascia lata (TFL) myocutaneous flap after debridement and start of microbiologic culture–guided antibiotic treatment. The SM flap was used to cover the exposed graft. To obtain stable wound coverage, the SM and remaining groin defect were closed with a pedicle TFL flap.

Results:

All flaps survived, with only 1 TFL flap suffering a small tip necrosis. All patients obtained stable wound coverage. Donor-site morbidity was minimal. During the follow-up, mean 46 months (range, 15–79 months), 1 patient had a recurrence after 15 months due to a kink in the elongated prosthetic graft that protruded through the skin alongside the SM and TFL flaps.

Conclusions:

The combination of SM and TFL flaps could be a new treatment option for patients who have an exposed and infected vascular prosthetic graft in the groin. This flap combination could also be used as a prophylactic procedure for those patients with a high risk to develop such a serious complication.