Role of tensor fasciae latae in abdominal wall reconstruction

Open Complex Abdominal Wall Reconstruction

This article provides an approach to open complex abdominal wall reconstruction. Herein, the authors discuss the purpose of component separation as well as its relevant indications. The techniques and anatomical considerations of both anterior and posterior component separation are described. In addition, patient selection criteria, preoperative adjuncts that may assist with fascial or soft tissue closure, and complications of component separation will be discussed.

Lateral femoral circumflex artery contribution to the articular and periarticular hip circulation: relevance to the anterior hip approach-a cadaveric study

BACKGROUND

The purpose of this cadaveric study was to anatomically demonstrate the contribution of the lateral femoral circumflex artery (LFCA) to the articular and peri-articular hip circulation with an emphasis on the vascularization of hip abductors specially tensor fasciae latae muscle (TFLM).

METHODS AND MATERIALS

Thirty hips from 26 fresh cadavers were dissected after injection of the aorta or common iliac artery by colored silicon, to study the contribution of the LFCA to the articular and periarticular hip circulation. Furthermore, the aorta was injected in another 18 fresh cadavers after unilaterally ligating the ascending branch of the LFCA (a-LFCA) as the vascular pedicle of the TFLM, to evaluate the collateral circulation to the TFLM, if available.

RESULTS

In all specimens but one, the a-LFCA was found as the single major vascular pedicle of the TFLM. When ligated, only 4 out of 18 hips demonstrated colored cast vessels in the cut surface of the muscle. The ascending branch had also consistent but variable contribution to the gluteus medius and gluteus minimus muscles in 80% of the hips. Furthermore, the a-LFCA consistently supplied the anterior and anterolateral aspects of the hip capsule. In 35% of hips, the a-LFCA contributed to the femoral head and neck circulation via one or two small anterior retinacular arteries.

CONCLUSION

LFCA contribution to the articular and periarticular hip circulation is only delivered by the ascending branch. The TFLM is specially perfused by the a-LFCA; its ligation significantly decreases the muscle perfusion. It is poorly supplied by the collateral circulation.

Prelamination of Vascularized Tensor Fascia Lata for Complex Abdominal Wall Reconstruction

ABSTRACT

There are 2 to 5 million laparotomies performed in the United States annually. Of these, 250,000 to 350,000 will undergo a ventral hernia repair. Repairs are often complicated by recurrence and infection. These risks are significantly increased in previously infected repairs, with reported recurrence rates varying from 17% to 28% after repair of infected ventral hernias, double the rates reported for first-time uninfected repairs. We describe here a novel treatment strategy involving the creation then use of bilateral prelaminated permanent mesh-reinforced tensor fascia latae flaps for abdominal wall reconstruction in patients who have recurrent ventral hernias and had undergone previous repairs complicated by infection. Previous repairs included anterior components separation, thereby making subsequent fascial release techniques and achievement of a reinforced repair extremely unlikely. Three patients were treated by a single surgeon using this 2-stage technique. There have been no incidences of recurrence and no infections after 2 to 10 years. In these patients, the only conventional option would have been a bridged repair with absorbable mesh. Combining the advantages of permanent mesh and well-vascularized autologous tissue optimizes the repair's tensile strength while mitigating the chance of recurrent infection associated with the use of permanent mesh. We propose that this strategy may be an appropriate treatment option for patients with recurrent ventral hernias that have not responded to other conventional modalities of treatment.

Use of Polypropylene Mesh in the Management of a Contaminated Large Ventral Hernia: A Contraindication or a Solution?

Management of contaminated large ventral hernias is still a challenge as a result of massive loss of muscular and fascial tissues in the abdominal wall, traditional contraindication to use of a prosthesis, and complicated perioperative management. This study aimed to provide a solution for this challenging dilemma using monofilament polypropylene mesh (Marlex; Bard) in the Sublay-Bridge fashion. Twenty-three consecutive patients with contaminated large ventral hernias from 2009 to 2011 were identified. Preoperatively, source of contamination at the surgical site was managed through oral antibiotics, wound débridement, and dressing change; the hernia content was reduced into the abdominal cavity gradually and an abdominal binder was applied. Marlex meshes in the Sublay-Bridge fashion were used in these patients. Demographic and perioperative data were collected. Fourteen males and nine females were included with a mean age of 52.5 ± 10.5 years and a mean body mass index of 25.2 ± 6.1 kg/m2. Twelve patients underwent ostomy takedown, which was the most common indication. Mean hernia size was 120.5 ± 18.5 cm2 and a mean mesh size was 380.0 ± 80.5 cm2. The mean operative time was 125.5 ± 35.5 minutes and the hospital stay was 10.0 ± 3.5 days. Twenty-three patients had a mean follow-up period of 12.5 ± 6.5 months. An iatrogenic bladder injury occurred because of severe prevesical adhesion attributed to previous prosthesis repair. There was no presentation of abdominal compartment syndrome. Four patients developed surgical site infection and managed with conservative therapy without mesh removal. Three patients had seromas and underwent aspiration guided by B-ultrasound. Three patients reported chronic foreign body sensation. No recurrence was followed up. Repair of contaminated large ventral hernia using a Marlex mesh in the Sublay-Bridge fashion is safe and efficient management. Perioperative management and operative technology play important roles in dealing with this problem.

Use of autologous dermal flap as mesh coverage in the treatment of large abdominal-wall defect in patients following massive weight loss: presentation of a novel surgical technique

PURPOSE

Reconstruction of large abdominal-wall defects (AWD) in patients after massive weight loss (MWL) can be challenging. Patients are left with a sizeable amount of excess skin and subcutaneous tissue which can serve as a natural and readily available source of mesh coverage. In this article, we present our experience in the reconstruction of large AWD in patients after MWL, using autogenous dermal flaps combined with a synthetic mesh.

METHOD

All patients with large AWD and MWL, diagnosed between January 2012 and December 2016, were considered to be candidates for the procedure. During the operation, an attempt was made to attain full closure of the defect above the mesh. In those patients for whom such closure was not possible, a dermal flap technique was used. Patients were closely monitored for at least 1 year. Outcome measures included early and late postoperative complications. Data are presented as mean ± standard deviation (SD).

RESULTS

Over the study period, a total of 14 patients underwent a surgery involving combined mesh and dermal flap technique. Early post-operative complications included three patients who suffered from minor wound disruption and were treated with local dressings. One patient had an abdominal-wall hematoma that required an evacuation. Two patients suffered from an epidermal cyst and chronic sinuses that required surgical debridement. None of the patients experienced intra-abdominal complication, respiratory failure, or required ICU treatment. No mesh contamination or hernia recurrence was observed during the follow-up period of 22.25 ± 6.4 months.

CONCLUSION

Autologous dermal flap combined with mesh technique may serve as an effective surgical alternative in patients after MWL with large AWD for whom full muscular coverage of the underlying prosthesis is not possible.

[Modified pedicled anterolateral thigh myocutaneous flap for large full-thickness abdominal defect reconstruction]

OBJECTIVE

To investigate the reconstructive methods and effectiveness of modified pedicled anterolateral thigh (ALT) myocutaneous flap for large full-thickness abdominal defect reconstruction.

METHODS

Between January 2016 and June 2018, 5 patients of large full-thickness abdominal defects were reconstructed with modified pedicled ALT myocutaneous flaps. There were 3 males and 2 females with an average age of 43.7 years (range, 32-65 years). Histologic diagnosis included desmoid tumor in 3 cases and sarcoma in 2 cases. The size of abdominal wall defect ranged from 20 cm×12 cm to 23 cm×16 cm. Peritoneum continuity was reconstructed with mesh; lateral vastus muscular flap was used to fill the dead space and rebuild the abdominal wall strength; skin grafting was applied on the muscular flap, the rest abdominal wall soft tissue defects were repaired with pedicled ALT flap. The size of lateral vastus muscular flap ranged from 20 cm×12 cm to 23 cm×16 cm, the size of ALT flap ranged from 20 cm×8 cm to 23 cm×10 cm. The donor site was closed directly.

RESULTS

All flaps and skin grafts survived totally, and incisions healed by first intention. All patients were followed up 6-36 months (mean, 14.7 months). No tumor recurrence occurred, and abdominal function and appearance were satisfying. No abdominal hernia was noted. Only linear scar left in the donor sites, and the function and appearance were satisfying.

CONCLUSION

Modified pedicled ALT myocutaneous flap is efficient for large full-thickness abdominal defect reconstruction, decrease the donor site morbidity, and improve the donor site and recipient site appearance.

Large Abdominal Wall Defect Reconstruction: Revoking and Modifying the Old Technique

The risk factors for abdominal wall hernia after surgery are an increase in body mass index, midline incision, incisional surgical-site infection, preoperative chemotherapy, blood transfusion, increasing age, female sex, and increasing thickness of subcutaneous tissue. Reconstructing the abdominal wall defect becomes a challenge in multiple risk factor patients. Many new mesh implants have been invented, but all fail in case of infections. We modified and re-evoked an old technique of fascia lata free graft reinforced with tensor fascia lata pedicled flap.

Reconstruction of Type II abdominal wall defects: Anterolateral thigh or tensor fascia lata myocutaneous flaps?

Introduction:

Reconstruction of complex abdominal wall defects is both challenging and technically demanding for plastic surgeon. Objectives in abdominal wall reconstruction are consistent and include restoration of abdominal wall integrity, protection of intra abdominal viscera and prevention of herniation.

Materials:

We conducted a retrospective study on five patients in whom lateral thigh flaps such as anterolateral thigh (ALT) flaps and tensor fascia lata (TFL) myocutaneous flaps as pedicled or free flaps were used for complex abdominal wall Type II defects over a 5- years period between 2007 and 2012.

Results:

In two patients, free flaps were used for reconstruction of the upper abdomen and both were ALT. In three patients of lower abdominal defects, one patient had bilateral pedicled ALT flaps, one pedicled TFL myocutaneous and one free TFL myocutaneous in view of ipsilateral electric burn scars. There were no flap losses. Patients were followed up beyond 6 months and found to have a good abdominal contour and only one of five had clinical evidence of herniation.

Conclusion:

It can be concluded that flap from the Lateral thigh (ALT or TFL) is flap of choice for large Type II abdominal defects. Including vascularised fascia in the flap maintains abdominal wall integrity and use of synthetic mesh is not necessary. Upper abdominal defects need free flaps and in lower abdominal defects a pedicled flap suffices.

Combined single-stage enterolysis with pedicle seromuscular bowel flaps, myocutaneous and fasciocutaneous flaps to repair recurrent enterocutaneous fistulas in complex abdominal Wall defects

INTRODUCTION

Reconstruction of abdominal wall defects with enterocutaneous fistulas (ECF) remains challenging. The purpose of this report is to describe a single-stage approach using combined microscopic enterolysis, pedicle seromuscular bowel flaps, mesh, fasciocutaneous, and myocutaneous flaps.

METHODS

Between 1990 and 2016 a retrospective review identified a total of 18 patients with an average age of 39 years (ranging 26-59 years). Thirteen cases were associated with trauma, four were complication of previous mesh repair, and one was after an aortic dissection. Average diameter of defect size was 22 cm (ranging 20-24 cm). Surgical technique involved enterolysis using microscope magnification, a pedicle seromuscular bowel flap to reinforce the bowel anastomosis, mesh, musculocutaneous, and fasciocutaneous flaps to reconstruct the abdominal wall.

RESULTS

Fifteen patients required rotational flaps with an average skin paddle area of 442.7 cm² (ranging 440 cm² -260 cm² ) and 10 patients required a serosal patch with an average length of 5 cm (ranging 4-6 cm). Complications included three wound dehiscence and one abdominal wall bulging. Flap survival was 100%. The majority of patients (12 out of 18) were able to resume normal activities, and the remaining (n = 6) were able to resume most activities. Functional outcome as assessed by 36-Item Short Form Survey (SF-36) physical function component questionnaire at 18-24 months follow up was 67.8% (ranging from 59 to 72%). Mean length of hospital stay was 2.2 weeks (ranging 1.4-2.7 weeks). Mean follow-up was 24 months (ranging 22-26 months) with clinical examination.

CONCLUSION

Microscopically assisted intra-abdominal dissection with resection of diseased bowel, replacement with well-vascularized tissue at the anastomosis site in, and reinforcement with mesh combined with pedicle musculocutaneous and fasciocutaneous flaps may be an alternative when other local reconstructive options have failed.

[Reconstruction using the tensor fasciae latae muscle flap]

OBJECTIVE

The tensor fasciae latae (TFL) muscle flap can be used for reconstruction of decubital ulcers in the trochanteric or ischial region.

INDICATIONS

Deep decubital ulcers in the gluteal or ischial area after debridement and exhaustion of conservative measures.

CONTRAINDICATIONS

Moribund or palliative patients who do not benefit from defect coverage and are likely to suffer a life-threatening complication. Noncompliant patients who cannot follow the postoperative recommendations or protocols in regard to positioning or recurrence prevention. The presence of extensive scars after previous operations in the donor area or irradiation of the donor area can lead to flap necrosis.

SURGICAL TECHNIQUE

The TFL flap is commonly used as a regional transposition flap. Rare cases of a free TFL flap have been described.

POSTOPERATIVE MANAGEMENT

Following surgery the patient needs to be positioned on the side or prone to prevent recurrence. Drains should be left for 5-7 days. Antibiotics are only needed in the case of persistent florid infection.

RESULTS

The TFL muscle flap is known to be a reliable flap for the coverage of ulcers in the ischial and trochanteric region following radical debridement. This flap can also be transferred with its sensitive nerve supply resulting in a reduced chance of a recurring ulcer.

Abdominal Wall Allograft: Preclinical Biomechanical Investigation of a Novel Reconstructive Adjunct

INTRODUCTION

Acellular dermal matrices have revolutionized abdominal wall reconstruction; however, device failure and hernia recurrence remain significant problems. Fascia grafts are a reconstructive adjunct with increased tensile strength compared with acellular dermal matrices; however, clinical use is limited by insufficient donor material and donor site morbidity. To this end, we investigate the biomechanical properties of human abdominal wall allografts (AWAs) consisting of the anterior rectus sheath from xiphoid to pubis.

METHODS

After cadaveric procurement of 6 human AWAs, the tissue was divided horizontally and a matched-sample study was performed with specimens randomized to 2 groups: fresh, unprocessed versus processed with gamma irradiation and decellularization. Specimens were evaluated for physical properties, DNA content, tensile strength, and electron microscopy.

RESULTS

All AWA donors were male, with a mean age of 55.2 years (range, 35-74 years). Procured AWAs had a mean length of 21.70 ± 1.8 cm, width of 14.30 ± 1.32 cm, and area of 318.50 cm, and processing resulted in a 98.3% reduction in DNA content. Ultimate tensile strength was significantly increased after tissue processing, and after subcutaneous implantation, processed AWA demonstrated 4-fold increased tensile strength compared with unprocessed AWAs.

CONCLUSIONS

Acellular AWAs represent a novel reconstructive adjunct for abdominal wall reconstruction with the potential of replacing "like with like" without additional donor site morbidity or antigenicity.

Abdominal Wall Reconstruction After Temporary Abdominal Closure: A Ten-Year Review

Abdominal wall reconstruction (AWR) is often required for hernias created after temporary abdominal closure (TAC). Demographic and clinical data from patients undergoing TAC and AWR between January 1, 1992, and December 31, 2002, were collected and univariate analysis performed. Temporary abdominal closure and AWR were performed in 21 patients. Complications developed in 12 patients (57.1%) after TAC; associated risk factors were mesh placement ( P = .04) and skin grafting ( P = .04). Successful AWR included mesh (n = 6), component separation (n = 6), primary repair (n = 4), and 3 combination techniques. Six patients (28.6%) developed intraoperative complications, and 14 (66.7%) developed postoperative complications. Intraoperative complications were increased in patients with tissue expanders ( P = .01). Postoperative complications ( P = .04) were less likely with component separation. The complication rate with TAC and AWR is high. Tissue expanders are associated with an increased risk of intraoperative complications with AWR, whereas component separation is associated with a reduction in postoperative complications.

Reconstruction of the Lower Abdominal Region Using Bilateral Pedicled Anterolateral Thigh Flaps Combined With Poly-Surgical Mesh: A Case Report

The en-bloc resection of neoplasms on the abdominal wall often causes extensive defects that are difficult to manage. The anterolateral thigh (ALT) flap is a widely used flap in reconstructive surgery of defects. In this article, we present a case using bilateral pedicle anterolateral thigh flaps combined with a surgical polymesh to repair a large defect (22 cm × 18 cm) caused by dissection of a recurrent fibromatosis with good functional and aesthetic effects. There were no obvious morbidities or complications during a 6-month follow-up period.We conclude that the bilateral pedicle anterolateral thigh flap is a good choice for reconstruction of large lower abdominal wall defects. It can afford sufficient soft tissue coverage without obvious donor site morbidity.

Combined Use of Anterolateral Thigh and Gluteal Fold Flaps for Complex Groin Reconstruction

We present a case of an epithelioid sarcoma of the right groin in which wide resection resulted in a complex groin defect involving the full thickness of the abdominal wall and the perineum. We reconstructed the defect using a combination of pedicled anterolateral thigh (ALT) flap and gluteal fold flap. The functional and aesthetic results were satisfactory. The ALT flap with a robust iliotibial tract is the flap of choice for abdominal wall reconstruction; however, the area covered by the skin island of the flap is restricted because the skin island is tethered to the iliotibial tract. In such cases, a gluteal fold flap is ideal for an ALT flap. Therefore, using a combination of a pedicled ALT flap and a gluteal fold flap could be a reliable option for the reconstruction of a complex groin defect.

Complex abdominal wall defect reconstruction using a latissimus dorsi free flap with mesh after malignant tumor resection

PURPOSE

Extended and full-thickness abdominal wall defects are commonly reconstructed using free flaps. Published surgical outcomes involving the latissimus dorsi (LD) free flap procedure are limited and are less numerous than those with free flaps involving the thigh. The aim of this report was to describe the immediate and long-term evaluation of complex abdominal wall reconstruction using a LD free flap with mesh.

PATIENTS AND METHODS

Between 2005 and 2013, nine patients with extended malignant tumors of the abdominal wall underwent surgeries. After the surgical resection, the mean defect size was 385 cm² (range: 190-650 cm² ). Full-thickness abdominal wall reconstruction was performed with a combination of LD free flaps and meshes. The immediate and long-term outcomes were assessed regarding the complications, sustainable strength of the abdominal wall and cancer recurrence.

RESULTS

The meshes measured 927 cm² in average (range: 500-1036 cm² ). Eight Parietex Composite® and 1 Bard Collamend Implant® were used. No donor site complications occurred, and complete LD flap survival was achieved without partial necrosis or thrombosis. One obese patient who received a porcine dermis mesh developed an eventration four days postoperatively and exhibited a limited amount of abdominal skin necrosis around the flap. Two patients died from cancer evolution. After a mean follow-up of 60.4 months (range: 29-94 months), clinical evaluation of the abdomen revealed 2 patients without anomalies, 4 cases of abdominal bulging without functional discomfort and 1 case of major abdominal distension.

CONCLUSIONS

Complex abdominal reconstruction with LD free flap and mesh allows extended satisfactory coverage with a low incidence of flap and donor site complications. However, patients should be advised of the significant risk of abdominal bulging. © 2014 Wiley Periodicals, Inc. Microsurgery 37:38-43, 2017.

Use of Acellular Dermal Matrix Combined with a Component Separation Technique for Repair of Contaminated Large Ventral Hernias: A Possible Ideal Solution for this Clinical Challenge

Repair of large contaminated ventral hernias is always challenging because of massive loss of muscular and fascial tissues, high risk of surgical infection and recurrence, and contraindication to use of a permanent prosthesis. This study reviewed retrospectively data of 35 patients with contaminated large ventral hernias who received repair using acellular dermal matrix combined with a component separation technique from 2009 to 2011. Twenty-one males and 14 females were identified with a mean age of 45.5 ± 12.5 years and a mean body mass index of 22.5 ± 5.8 kg/m2. Simultaneously, nine patients underwent bowel fistula resection, 13 patients underwent ostomy takedown, five patients underwent recurrent colon cancer dissection, and eight patients underwent infectious permanent mesh removal and wound débridement. Mean defect size was 125.0 ± 23.5 cm2. The aponeurosis of the external oblique muscle was transected and separated from internal oblique muscle to reach abdominal closure. A cellular dermal matrix was placed in an onlay fashion and mean mesh size was 300.0 ± 65.0 cm2. Thirty-five patients had a mean follow-up period of 36.5 ± 12.5 months. Wound bleeding and partial dehiscence occurred at 36 hours post-operatively. Five patients reported abdominal wall pain during the first postoperative month. Five patients developed surgical site infection. Four patients were detected to develop seroma with volume more than 20 mL by B-ultrasound examination. No recurrence and chronic foreign body sensation were followed up. Use of acellular dermal matrix combined with a component separation technique is safe and efficient management for repair of contaminated large ventral hernia, in which permanent prosthesis placement is contraindicated.

Combined therapy of NPWT and bipedicled flap as an alternative approach for giant abdominal wall defect with significant visceral edema: report of a case

Open abdomen management is commonly used for the critically injured patients to avoid abdominal compartment syndrome. But it usually continues for days to weeks and finally results in abdominal wall defect that is too wide to close at once. This article presents an alternative approach to close the giant abdominal wall defect by using the combination of bipedicled flaps with the components separation technique and V.A.C.® system.

Versatility of pedicled tensor fascia lata flap: a useful and reliable technique for reconstruction of different anatomical districts

Aims and Objectives. The aim of this study was to evaluate the versatility of pedicled tensor fascia lata flap for reconstruction of various anatomical regions. Materials and Methods. In this retrospective study a total of 34 patients with defects over various anatomical regions were included. The defects were located over the trochanter (n = 12), groin (n = 8), perineum (n = 6), lower anterior abdomen (n = 6), gluteal region (n = 1), and ischial region (n = 1). The etiology of defects included trauma (n = 12), infection (n = 8), pressure sores (n = 8), and malignancy (n = 6). Reconstruction was performed using pedicled tensor fascia lata flaps. Patients were evaluated in terms of viability of the flap and donor site morbidity. The technical details of the operative procedure have also been outlined. Results. All the flaps survived well except 5 patients in which minor complications were noted and 1 who experienced complete flap loss. Of those with minor complications, 1 patient developed distal marginal necrosis and 1 developed infection which subsided within three days by dressings and antibiotics and in 2 patients partial loss of the skin graft occurred at the donor site out of which 1 required regrafting and another one healed completely with dressing and antibiotics. All the patients were followed up for an average period of 6 months, ranging from 1 to 12 months. Donor site morbidity was minimal. Conclusion. It was concluded that the pedicled tensor fascia lata flap is a versatile, reliable, easy, and less time consuming procedure for the coverage of defects around trochanter, groin, lower anterior abdomen, perineum, and ischial region.

Combined serratus anterior and latissimus dorsi myocutaneous flap for obliteration of an irradiated pelvic exenteration defect and simultaneous site for colostomy revision

Background

Usually, several surgical methods are used, with re-suturing, free skin grafting and local flaps, for the reconstruction of wall defects after abdominoperineal resection. However, or larger defects, free flaps have been preferred because they can provide a large area of well-vascularized soft tissue, which is suitable for defect repair. We present the case of a large abdominal wall defect, which was treated with a free combined serratus anterior and latissimus dorsi myocutaneous flap, resulting in a successful outcome.

Case presentation

A 38-year-old female originally had squamous cell carcinoma of the cervix uteri, and had undergone radical hysterectomy and oophorectomy followed by radiotherapy. She had a recurrence of the cervical cancer after 13 years, and underwent pelvic exenteration. However, the mid-abdominal wound developed dehiscence and an abdominal full-thickness defect communicating with the pelvic cavity. Furthermore, the adhered colon developed necrosis, which drained stools into the pelvic cavity, resulting in chronic peritonitis. During surgery, the empty pelvic cavity was filled with a combined serratus anterior and latissimus dorsi myocutaneous flap to prevent chronic peritonitis, to create a new stoma in the skin paddle of the flap for the necrotic colon, and to separate the pelvic cavity from the drained stools. The patient could walk in the absence of abdominal hernia formation and relapse of infection.

Conclusions

A combined serratus anterior and latissimus dorsi myocutaneous free flap was applied to cover the raw surface and reinforce the abdominal wall and to fashion a new colostomy, as well as successfully filling the pelvic cavity with a large muscle body and long vascular pedicle. This is the optimal method for reconstructing severe abdominal wall defects that have many complications.

Repair of giant ventral hernias

Repair of huge ventral hernias is technically challenging for the surgeon and a major operation for the patient and should be performed by experienced surgeons in centers that are used to caring for patients who are commonly massively obese with significant comorbidities. Preoperative medical optimization of patients is an important part in the overall management of these large hernias. Conventional component separation with retromuscular mesh repair is the workhorse operation, which successfully deals with many giant ventral hernias, but multiple alternative strategies must be available to address situations in which myofascial elements are completely deficient or there is significant loss of domain The complexity of this surgery is reflected by recurrence rates ranging from 10% to 30% and wound complication rates as high as 40% to 50% in experienced centers.

Reconstruction of extensive abdominal wall defect using an eccentric perforator-based pedicled anterolateral thigh flap: a case report

Reconstruction of extensive abdominal wall defects is a challenge for reconstructive surgeons. In this report, a case of reconstruction of a large abdominal wall defect using an eccentric perforator-based pedicled anterolateral thigh (ALT) flap is presented. A 30-year-old man presented with recurrent desmoid-type fibromatosis in the abdominal wall. The recurrent tumor was radically excised, and the en bloc excision resulted in a full-thickness, large abdominal wall defect (25 cm × 20 cm). An eccentric perforator-based pedicled ALT flap, including wide fascial extension, was transferred to the abdominal defect; fascial portions were sutured to the remnant abdominal fascia. Plication of the fascia along the sutured portion was performed to relieve the skin tension between the flap and the marginal skin of the abdominal defect. Eight months after surgery, the reconstructed abdomen had an acceptable esthetic appearance without tumor recurrence or hernia. The use of an eccentric perforator-based pedicled ALT flap may be an alternative method for the reconstruction of extensive abdominal wall defects.

Abdominal wall reconstruction with mesh and components separation

Incisional hernias in the abdominal wall are a by-product of multiple previous laparotomies. Unfortunately, the incidence of incisional hernias has risen, as we have progressed with new surgical techniques in the treatment of abdominal pathologies. Many methods have been attempted in the past to achieve a better and more durable repair, namely using components separation to bring the fascia into the midline, and reinforce incisional hernias with different mesh materials. The authors review the recent literature regarding the efficacy of these synthetic materials and biomaterials in incisional hernia repair, as well as share their experience in treating complex abdominal wall defects using components separation and biologic mesh.

[Hypogastric abdominal wall reconstruction with a pedicled anterolateral thigh flap]

Looking at a full-thickness abdominal wall defect, it is necessary to use reconstructive surgery techniques. The authors present an original case of reconstruction of the abdominal wall, using an anterolateral thigh flap (ALT) harvested with vascularised fascia lata. We describe the advantages of this technique, which has rarely been used for this indication. An 80-year-old woman presenting a full-thickness abdominal wall defect of 15×18cm was reconstructed by a pedicled ALT flap. Skin wound healing was obtained within 15 days, with no complication. There was no donor site sequela. The pedicled ALT flap appears to be a good solution for hypogastric abdominal wall defect in a one step procedure. Vacularised fascia lata bring with the cutaneous flap is useful to reconstruct the abdominal fascia.

Análise da rejeição do transplante de aponeurose em coelhos

OBJETIVO: Estudar a viabilidade de aponeurose heteróloga para fechar parede abdominal de coelhos, com ênfase no processo de rejeição. MÉTODOS: Este projeto foi aprovado pelo Comitê de Cuidados Animais da Faculdade de Ciências Médicas da Santa Casa de São Paulo e realizado na Unidade Técnica e Cirurgia Experimental. Quatro coelhas vermelhas trocaram aponeurose da parede abdominal com outros quatro animais machos brancos. Em dois coelhos, foi retirada e substituída a aponeurose como controle do processo cicatricial. Eles foram avaliados 1 vez por dia e sacrificados após 7 dias. Foi realizada a imunoistoquímica com CD20 e CD79. RESULTADOS: Os animais não tiveram celulite, abscesso, hematoma, deiscência da ferida ou hérnia. O local do enxerto mostrou hiperemia intensa. A análise histológica mostrou um processo inflamatório, com a presença de miofibroblastos em amadurecimento e colágeno, que variou de incipiente a moderado. O número de vasos estava reduzido e as células inflamatórias foram, em sua maioria, células plasmáticas e macrófagos. Não havia sinais morfológicos da rejeição aguda com a agressão do endotélio vascular. O músculo adjacente mostrou sinais de degeneração, com reação inflamatória dos núcleos e condensação do citoplasma. A análise imunoistoquímica (CD20 e CD79) mostrou que o processo inflamatório não foi mediado por linfócitos. O teste não paramétrico de Mann-Whitney mostrou que não se pode rejeitar a hipótese de igualdade (p>0,05). CONCLUSÃO: Não houve complicações pós-operatórias (fístulas, deiscência etc.) e a análise histológica revelou processo inflamatório inespecífico. A análise imunoistoquímica mostrou que o processo inflamatório não foi em razão de uma possível rejeição.

Autologous dermal grafts for rectus sheath reconstruction and application in closure of ventral myofascial defects

Ventral abdominal hernias pose a reconstructive challenge, with recurrence rates after primary closure exceeding 50 % and synthetic options at high risk for infection. We describe our experience with using autologous dermis, sourced from the redundant overlying abdominal skin, for reconstruction of ventral abdominal wall defects. We describe the surgical technique, applied anatomy and an analysis of short- and long-term outcomes. Twelve consecutive patients undergoing repair of medium-large size, reducible abdominal wall defects were recruited. The dermal graft technique was used in each case, utilizing an autologous running strip of abdominal skin for reconstruction. Both short- and long-term outcomes were assessed prospectively. Scores were given on a scale of 1-10, with 1 = least/worst and 10 = most/best. The described technique was successfully undertaken in all patients. Long-term follow-up demonstrated a 100 % resumption of normal activities, with an improvement in quality of life and physical activity scores postoperatively, and no recurrences. Short-term complications were notable, with five patients requiring postoperative intensive care unit admission, and seven patients requiring respiratory support. In conclusion, the use of autologous rectus sheath reinforcement may achieve good surgical outcomes and high patient satisfaction. While early respiratory complications should be noted, the potential utility of this technique is worthy of future investigation.

Radical tumor excision and immediate abdominal wall reconstruction in patients with aggressive neoplasm compromised full-thickness lower abdominal wall

BACKGROUND

Radical tumor resection and immediate lower abdominal wall reconstruction in patients with aggressive neoplasm invading full-thickness abdominal wall are challenging because of their close proximity and possible invasion to bone and great vessels, as well as consequent giant defect.

METHODS

Data on 16 patients were reviewed retrospectively. Radical neoplasm resection and immediate abdominal wall reconstruction using the combined technique of intraperitoneal mesh placement, sublay technique, pedicled great omentum flap, and rotation skin graft were performed.

RESULTS

Sixteen patients underwent radical abdominal wall neoplasm resection, achieving clear margin of >3 cm. The mean size of consequent giant defect was 226.5 ± 65.5 cm(2), with a mean polypropylene mesh size of 160.7 ± 40.5 cm(2) and a mean compound mesh size of 330.8 ± 100.2 cm(2). Sixteen patients had a mean follow-up duration of 32.5 ± 12.5 months. Four patients developed incisional infections, and 1 patient died of several metastatic lesions 24 months postoperatively. No ventral hernia and abdominal wall recurrence were observed.

CONCLUSIONS

Radical neoplasm resection and immediate abdominal wall reconstruction are appropriate for patients with aggressive neoplasm in the lower abdominal wall.

Autologous reconstruction of massive enteroatmospheric fistulation with a pedicled subtotal lateral thigh flap

Background

Reconstruction of massive contaminated abdominal wall defects associated with enteroatmospheric fistulation represents a technical challenge. An effective technique that allows closure of intestinal fistulas and reconstruction of the abdominal wall, with a good functional and cosmetic result, has yet to be described. The present study is a retrospective review of simultaneous reconstruction of extensive gastrointestinal tract fistulation and large full-thickness abdominal wall defects, using a novel pedicled subtotal thigh flap.

Methods

The flap, based on branches of the lateral circumflex femoral artery, was used to reconstruct the abdominal wall in six patients who were dependent on artificial nutritional support, with a median (range) of 4·5 (3–23) separate intestinal fistulas, within open abdominal wounds with a surface area of 564·5 (204–792) cm2. Intestinal reconstruction was staged, with delayed closure of a loop jejunostomy. Median follow-up was 93·5 (10–174) weeks.

Results

Successful healing occurred in all patients, with no flap loss or gastrointestinal complications. One patient died from complications of sepsis unrelated to the surgical treatment. All surviving patients gained complete nutritional autonomy following closure of the loop jejunostomy.

Conclusion

Replacement of almost the entire native abdominal wall in patients with massive contaminated abdominal wall defects is possible, without the need for prosthetic material or microvascular free flaps. The subtotal pedicled thigh flap is a safe and effective method of providing definitive treatment for patients with massive enteroatmospheric fistulation.

Violation of the rectus complex is not a contraindication to component separation for abdominal wall reconstruction

BACKGROUND

Component separation (CS) is an effective technique for reconstructing complex abdominal wall defects. Violation of the rectus abdominis complex is considered a contraindication for CS, but we hypothesized that patients have similar outcomes with or without rectus complex violation.

STUDY DESIGN

We retrospectively studied all consecutive patients who underwent CS for abdominal wall reconstruction during 8 years and compared outcomes of patients with and without rectus violation. Primary outcomes measures included complications and hernia recurrence. Logistic regression analysis identified potential associations between patient, defect, and reconstructive characteristics and surgical outcomes.

RESULTS

One hundred sixty-nine patients were included: 115 (68%) with and 54 (32%) without rectus violation. Mean follow-up was 21.3 ± 14.5 months. Patient and defect characteristics were similar, except for the rectus violation group having a higher body mass index. Overall complication rates were similar in the violation (24.3%) and nonviolation (24.0%) groups, as were the respective rates of recurrent hernia (7.8% vs 9.2%; p = 0.79), abdominal bulge (3.5% vs 5.6%; p = 0.71), skin dehiscence (20.0% vs 22.2%; p = 0.74), skin necrosis (6.1% vs 3.7%; p = 0.72), cellulitis (7.8% vs 9.2%; p = 0.75), and abscess (12.3% vs 9.2%; p = 0.58). Regression analysis demonstrated body mass index to be the only factor predictive of complications.

CONCLUSIONS

CS surgical outcomes were similar whether or not the rectus complex was violated. To our knowledge, this study is the first to evaluate the effects of rectus violation on surgical outcomes in CS patients. Surgeons should not routinely avoid CS when the rectus complex is violated.

Complex abdominal wall repair using a porcine dermal matrix

Management of complex abdominal defects remains a significant challenge for many surgeons, especially in contaminated fields. Currently, available biosynthetic grafts include human cadaveric dermis (AlloDerm), porcine dermal (Permacol and Strattice), and submucosal (Surgisis) sources. All these grafts are composed of an acellular collagen scaffold to provide a bridge for tissue incorporation and neovascularization. The authors describe a case report of a woman who required dual mesh explantation and successive reparative surgery using a porcine dermal matrix for a complex and infected abdominal wound. Twelve months postdischarge the patient remains well, she is pain free, and she returned home to full activities with complete wound closure and without any evidence of residual or recurrent hernia. The patient was satisfied with her cosmetic results. In conclusion, the authors' experience shows that the use of Permacol, a porcine dermal matrix, has been successful in treating an infected abdomen and a vast abdominal wall defect.

Management of enterocutaneous fistulas

Management of enterocutaneous fistulas (ECFs) involves (1) recognition and stabilization, (2) anatomic definition and decision, and (3) definitive operation. Phase 1 encompasses correction of fluid and electrolyte imbalance, skin protection, and nutritional support. Abdominal imaging defines the anatomy of the fistula in phase 2. ECFs that do not heal spontaneously require segmental resection of the bowel segment communicating with the fistula and restoration of intestinal continuity in phase 3. The enteroatmospheric fistula (EAF) is a malevolent condition requiring prolonged wound care and nutritional support. Complex abdominal wall reconstruction immediately following fistula resection is necessary for all EAFs.

Outcome of components separation for contaminated complex abdominal wall defects

BACKGROUND

Contaminated large abdominal wall defects can pose a formidable challenge to the surgeon. This study compared the outcome of components separation (CS) for complex ventral defects with or without contamination.

METHODS

A retrospective review was conducted of all patients who underwent CS over an 8-year period. Pre-operative factors such as the presence/absence of contamination were analyzed for their effect on length of hospitalization, readmission rate, post-operative complications, re-intervention rate, and long-term recurrence.

RESULTS

A total of 34 patients was analyzed. There were 18 males (53%) with a mean age of 57 years. Mean body mass index was 31 kg/m(2). Seventeen patients (50%) had prior repair (mean 2.1 repairs per patient, median 2). Mean size of abdominal defect was 255 cm(2). Out of the 34 patients, 13 had infected or contaminated defects, including 5 patients with infected mesh. Length of stay was longer in the contaminated group (11.1 vs 3.1 days, P < 0.01). A higher complication rate was noted in the setting of contamination (77 vs 38%, P = 0.03). During a mean follow-up of 47 months, no difference was noted in the re-intervention rate (38 vs 29%, P = 0.70) or long-term recurrence rate of the defect (8 vs 5%, P = 1.0) (contaminated vs non-contaminated group, respectively).

CONCLUSIONS

CS is a good option for closure of large contaminated complex abdominal wall defects. Despite an increased risk of postoperative complications and longer hospitalization length, long-term outcomes are favorable.

Reconstruction of Complex Abdominal Wall Defects

INTRODUCTION

Reconstruction of large abdominal wall defects not amenable to primary closure remains a challenging problem. These defects result from trauma, previous surgery, infection and tumour resection. The primary objectives of abdominal wall reconstructions are to protect abdominal contents and provide functional support. The abdominal wall reconstruction aims at providing basic component parts, i.e. skin, soft tissue and fascia. For large soft tissue defects, pedicled or free flap closure can be used. In clean wounds, fascial replacement is accomplished with synthetic mesh provided there is adequate soft tissue coverage.

METHODS

We treated a total of 20 consecutive patients with complex abdominal wall defects utilizing various reconstructive procedures. There were 15 males (75%) and 5 females (25%). The aetiology included dehiscence of laparotomy wounds in eight (40%), following ablative surgery for malignant tumours in seven (35%), trauma in three (15%) and congenital defects in two (10%) cases. The reconstructive procedures consisted of onlay prolene mesh in seven (35%), Gore-Tex (PTFE) dual mesh both as inlay and onlay in five (25%), facial partition release technique in three (15%), inlay prolene mesh covered with omentum and split skin graft in two (10%), inlay prolene mesh covered with expanded skin in two (10%), and Gore-Tex dual mesh covered with latissimus dorsi myocutaneous flap in one (5%) case. Postoperatively none developed mesh infection or extrusion. Three patients with malignant aetiology received postoperative radiotherapy. During follow up, one patient developed ventral hernia cephalad to the repair and one died due to recurrence of abdominal wall malignancy.

CONCLUSION

The reconstruction of an abdominal wall defect requires a comprehensive plan of preoperative and post operative care of the patient and aims toward restoration of abdominal structural integrity by a variety of procedures. The use of new biomaterials and tissue expanders provides reliable and durable abdominal wall closure along with good aesthetic results.

Abdominal ventral hernia repair with current biological prostheses: an experimental large animal model

Biologic prostheses have emerged to address the limitations of synthetic materials for ventral hernia repairs; however, they lack experimental comparative data. Fifteen swine were randomly assigned to 1 of 3 bioprosthetic groups (DermaMatrix, AlloDerm, and Permacol) after creation of a full thickness ventral fascial defect. At 15 weeks, host incorporation, hernia recurrence, adhesion formation, neovascularization, inflammation, and biomechanical properties were assessed. No animals had hernia recurrence or eventration. DermaMatrix and Alloderm implants demonstrated more adhesions, greater inflammatory infiltration, and more longitudinal laxity, but near identical neovascularization and tensile strength to Permacol. We found that porcine acellular dermal products (Permacol) contain following essential properties of an ideal ventral hernia repair material: low inflammation, less elastin and stretch, lower adhesion rates and cost, and more contracture. The addition of lower cost xenogeneic acellular dermal products to the repertoire of available acellular dermal products demonstrates promise, but requires long-term clinical studies to verify advantages and efficacy.

Tunnelled tensor fascia lata flap for complex abdominal wall reconstruction

This study describes the treatment of two patients with recurrent, infected abdominal wall defects using bilateral delayed and tunnelled pedicled tensor fascia lata (TFL) myofascial flaps. TFL flaps were elevated and delayed for 4 weeks in both cases. In the second case, Parietex Composite mesh was positioned underneath the TFL flap and allowed to incorporate. After a delay of 4 weeks, the flaps were harvested and tunnelled subcutaneously to repair the abdominal wall defect. Both patients have stable repairs but had donor site seromas requiring drainage. Cadaver dissection was also performed to identify structures related to TFL flap harvest. We identified a variant of lateral femoral cutaneous nerve that traversed the TFL flap, necessitating meticulous dissection during surgery. In summary, we describe a new technique of incorporating mesh into the TFL prior to flap harvest for reconstruction of complex abdominal wall.

Human acellular dermal matrix for ventral hernia repair reduces morbidity in transplant patients

PURPOSE

Organ transplantation is widely accepted as the treatment of choice for native organ failure. Due to required immunosuppression, however, organ recipients are prone to wound infections, incisional hernias, and fascial dehiscence. These complications are especially dangerous in this patient population, as they can compromise the survival of the transplanted organ. Various methods have been employed to repair ventral and incisional hernias in these patients. These include primary repair, synthetic mesh, biologic mesh, tensor fascia lata grafts (TFL), component separation, flaps from the thighs, or a combination of these. The goal of this study was to review the experience at our institution with ventral hernia repair in transplant patients and to compare outcomes of the various repair techniques.

METHODS

Patients with liver, renal, or pancreas transplants requiring immunosuppression who underwent a ventral or incisional hernia repair at the University of Maryland from 2000-2005 were reviewed retrospectively. Factors examined include type and location of hernia, type of repair, post operative infection, hernia recurrence, reoperation, mesh removal, and length of follow up. Complication rates were compared using odds ratio and chi-square.

RESULTS

A total of 104 patients met the criteria with a mean length of follow up of 26 months. Of these, 34 patients had repair with human acellular dermal matrix (HADM), 26 had synthetic mesh, 25 had primary repair, and 9 had TFL. Rates of wound infection in these groups were 15, 65, 8, and 11% respectively (χ (2) = 28, P < 0.001). Rates of recurrence were 24, 77, 36, and 11% respectively (χ (2) = 22, P < 0.001). The rate of mesh removal with HADM and synthetic mesh were 12 and 69%, respectively (χ (2) = 14, P < 0.001). When comparing HADM and synthetic mesh, the odds ratio for wound infection is 11 (95% CI 3.2-38) and for mesh removal is 8.7 (95% CI 2.6-28).

CONCLUSION

When repairing ventral or incisional hernias in immunosuppressed transplant patients, HADM provides significantly reduced morbidity from reduced rates of infection, recurrence, and need for operative removal of mesh.

Latissimus dorsi free flap for reconstruction of extensive full-thickness abdominal wall defect. A case of desmoid tumor

Desmoid tumor is a rare, benign fibroblastic tumor that is characterized by highly aggressive local invasiveness. The authors report the case of a 35-year-old male who presented with a 20 cm para-umbilical tumor invading the right rectus abdominis muscle. This required a wide excision of the abdominal wall. The resulting defect was closed with a single-stage latissimus dorsi myocutaneous free flap in combination with a prosthetic mesh reconstruction. The authors discuss the therapeutic options for management of these rare tumors and the variety of available techniques for coverage and reconstruction after extensive parietal loss of substance.