Subtotal thigh flap and bioprosthetic mesh reconstruction for large, composite abdominal wall defects

The Past, Present, and Future of Perforator Flaps in Head and Neck Surgery

A perforator is a vessel that travels through muscle and perfuses the skin. Perforator flaps require intramuscular dissection and can be used as pedicled or free flap. With improved understanding of microvasculature, they can be tailored to have multiple skin paddles, multiple components, or shaped to conform to any defect. Reliable perforator flap-based reconstruction is a meticulous microvascular technique, ultimately allowing the surgeon to harvest any flap in a freestyle fashion and transplant to any recipient vessel. New technologies improve the safety and reproducibility of this type of reconstruction.

Re-Do Plastic Reconstruction for Locally Advanced and Recurrent Colorectal Cancer Following a beyond Total Mesorectal Excision (TME) Operation-Key Considerations

Innovation in surgery and pelvic oncology have redefined the boundaries of pelvic exenteration for CRC. However, surgical approaches and outcomes following repeat exenteration and reconstruction are not well described. The resulting defect from a second beyond Total Mesorectal Excision (TME) presents a challenge to the reconstructive surgeon. The aim of this study was to explore reconstructive options for patients undergoing repeat beyond TME for recurrent CRC following previous beyond TME and regional reconstruction. MEDLINE and Embase were searched for relevant articles, yielding 2353 studies. However, following full text review and the application of the inclusion criteria, all the studies were excluded. This study demonstrated the lack of reporting on re-do reconstruction techniques following repeat exenteration for recurrent CRC. Based on this finding, we conducted a point-by-point discussion of certain key aspects that should be taken into consideration when approaching this patient cohort.

Subtotal Thigh Flap for Large Abdominal Wall Defect Reconstruction in Patient With Recurrent Dermatofibrosarcoma Protuberans: A Case Report and Literature Review

BACKGROUND

Harvesting an adequate-sized flap is challenging for reconstructing large defects on the abdominal wall. A subtotal thigh flap would be one of the choices as it provides a well-vascularized large flap with muscle components. Moreover, dermatofibrosarcoma protuberans (DFSP) is a low-grade dermal neoplasm with a high recurrence rate. There is still no consensus on the extent of resection to prevent a recurrence.

OBJECTIVES

We present a case of a patient who underwent the reconstruction of a large abdominal wall defect with a subtotal thigh flap after the resection of recurrent DFSP.

MATERIALS AND METHODS

A 59-year-old man killed from a recurrent huge mass in the lower abdomen with an invasion of the small intestine. His baseline characteristics and records of operations, medications, and outcomes were reviewed.

RESULT

After tumor excision, a 28 × 30-cm subtotal thigh flap was harvested from his left thigh to reconstruct the abdominal defect. A microvascular anastomosis with left deep inferior epigastric vessels was made eventually. The flap was in good condition, and the donor site was covered with a split-thickness skin graft.

CONCLUSIONS

Subtotal thigh flap may be considered for large abdominal wall defect reconstruction as it allows good perfusion of relatively large skin paddles compared with other free flaps. Also, patients with DFSP need definite margin-free resection and close follow-up to prevent a recurrence.

Surgery for primary malignant tumors of the abdominal wall: experiences of three African surgical oncology units and review of the literature

BACKGROUND AND OBJECTIVES

Tumors of the abdominal wall are uncommon but diverse. The surgical challenge is double. The tumor must be completely removed and the abdominal wall repaired. Our aim was to describe the indications, techniques, and results of surgery on these tumors in an African context.

METHODS

Retrospective, multicentric and descriptive study conducted in three West African surgical oncology units. We included all abdominal wall tumors followed up between January 2010 and October 2022. Histological type, size, surgical procedure, and method of abdominal wall repair were considered. Survival was calculated using the Kaplan-Meier method and comparisons of proportions were made using the Student t test.

RESULTS

We registered 62 tumors of the abdominal wall and we operated on 41 (66.1%). The mean size of the tumors was 14.3 ± 26 cm. Dermatofibrosarcoma and desmoid tumor were present in 33 and 3 cases respectively. In 31.7% of cases in addition to the tumour, the resections carried away the muscular aponeurotic plane. Parietal resections required the use of a two-sided prosthesis in 6 cases. In 13 cases, we used skin flaps. The resections margins were invaded in 5 cases and revision surgery was performed in all of them. Incisional hernia was noticed in 2 cases. The tumor recurrence rate was 12.2% with an average time of 13 months until occurrence. Overall survival at 3 years was 80%.

CONCLUSIONS

Surgery is the mainstay of treatment for abdominal wall tumors. It must combine tumor resections and parietal repair. Cancer surgeons need to be trained in abdominal wall repair.

Microvascular Free Tissue Transfer for Reconstruction of Complex Abdominal Wall Defects

SUMMARY

Patients with significant loss of abdominal wall soft tissue represent a reconstructive challenge. The purpose of this study was to describe the authors' experience using microvascular free tissue transfer to repair complex abdominal wall defects with insufficient overlying soft tissue. In this report, the authors highlight their techniques and experiences in performing microvascular free tissue transfer to the abdominal wall for these massive, complex defects. In total, 14 patients who underwent 16 free-flap reconstructions were included in the series. The patients' mean age was 50 ± 14 years, and mean body mass index was 27 ± 5 kg/m2. The mean hernia defect size was 412 ± 149 cm2. Ten flaps were fasciocutaneous anterolateral thigh flaps, one myocutaneous anterolateral thigh flap, two subtotal thigh flaps, one myocutaneous latissimus dorsi flap, one parascapular/latissimus dorsi flap, and one free filet of the lower leg. Five cases (36 percent) developed hernia recurrence, and seven developed surgical site complications. All flaps survived, with no total flap loss. This report highlights that microsurgical free tissue transfer in combination with mesh repair is a safe and reliable method for restoring complex, large, full-thickness abdominal wall defects. This case series illustrates a number of techniques and considerations that are of importance to achieve a favorable outcome when faced with these complex defects.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Individually Tailored Approach to Reconstruction of Complex Defects Using Versatility of the Lateral Circumflex Femoral Artery System-Based Pedicled Flaps

Lateral circumflex femoral artery (LCFA) system is one of the most versatile donor sites in the body. We present our experience with pedicled flaps from the LCFA system, including different components for a wide variety of etiologies and locations. Twenty-three consecutive pedicled flaps were performed on 22 patients (10 females and 12 males; age 4-71 years) between 2007 and 2015 by a single surgeon. Flap size, type, and composition were tailored according to the requirements of the defects, including (1) location; (2) surface area; (3) depth; (4) number of defects; (5) presence of exposed critical structures; (6) presence of exposed foreign bodies; (7) prior use of other options; (8) history of radiation; and (9) other comorbidities. Defect locations were 10 abdominal wall (including groin and pubis), 9 ischio-gluteo-trochanteric and 4 perineal. Defect sizes ranged from 6 × 6 to 30 × 35 cm. Maximum depth of wounds ranged between 7 and 18 cm. The flap sizes ranged from 9 × 6 to 38 × 20 cm. Two flaps were fasciocutaneous perforator, 4 were myocutaneous with "muscle sparing" vastus lateralis, 10 were myocutaneous with "segmental" vastus lateralis, 5 were myocutaneous "tri-muscle," 1 was "tri-muscle," and 1 was rectus femoris only. Donor sites were closed primarily in 20 cases and with split thickness skin grafting in 3 cases. All flaps survived completely without any partial loss or congestion. Pedicled flaps from the LCFA system can be tailored individually for a wide variety of etiologies and locations. Muscles can be harvested and used as "muscle sparing," "segmental," and "tri-muscle" to accommodate the requirements of the defects.

Fasciocutaneous anterolateral thigh flaps for complex abdominal wall reconstruction after resection of enterocutaneous fistulas and the role of indocyanine green angiography: a pilot study

Purpose

No previous study reported the use of a fasciocutaneous anterolateral thigh (ALT) flap combined with a biological mesh for abdominal wall reconstruction (AWR) after enterocutaneous fistula (ECF) in a single-staged procedure and the use of Indocyanine Green Angiography (ICGA) intraoperatively. The purpose of this study was to determine the feasibility and safety of this procedure and to examine the added value of ICGA in minimizing postoperative complications.

Methods

A single-institution review of a prospectively maintained database was conducted at Maastricht University Medical Center. To evaluate the feasibility and safety of this procedure, early (≤ 30 days) and late (> 30 days) postoperative complications were assessed. ECF recurrence was considered the primary outcome. To examine the added value of ICGA, complications in the ICGA group and the non-ICGA group were compared descriptively.

Results

Ten consecutive patients, with a mean age of 66.7 years, underwent a single-staged AWR with fasciocutaneous ALT flaps. Mean follow-up was 17.4 months (4.3–28.2). Two early ECF recurrences were observed. Both restored without the need for reoperation. A lower rate of early complications was observed in the ICGA group compared to the non-ICGA group.

Conclusion

The combination of a biological mesh and fasciocutaneous ALT flap is feasible and safe in AWR after ECF repair in a single-staged approach, with an acceptable complication rate in a cohort of complex patients operated in a dedicated center. ECF closure was achieved in all patients. ICGA seems to be of great added value in minimizing postoperative complications during AWR.

Electronic supplementary material

The online version of this article (10.1007/s10029-020-02167-w) contains supplementary material, which is available to authorized users.

[Application of pedicled anterolateral thigh myocutaneous flap for full-thickness abdominal wall reconstruction after tumor resection]

OBJECTIVE

To explore the effectiveness of pedicled anterolateral thigh myocutaneous flap for full-thickness abdominal wall reconstruction after tumor resection.

METHODS

Between September 2010 and December 2017, 18 patients with abdominal wall tumors were collected. There were 11 males and 7 females, with an average age of 45.2 years (range, 29-68 years). Histologic diagnosis included desmoid tumor in 8 cases, sarcomas in 6 cases, malignant teratoma in 2 cases, and colon adenocarcinoma in 2 cases. All abdominal wall defects were full-thickness defects. Peritoneum continuity was reconstructed with mesh; the lateral vastus muscular flaps were used to fill the dead space and rebuild the abdominal wall strength; the abdominal wall soft tissue defects were repaired with pedicled anterolateral thigh flaps. The size of abdominal wall defects ranged from 15 cm×6 cm to 25 cm×22 cm; the size of lateral vastus muscular flap ranged from 10 cm×8 cm to 22 cm×10 cm; the size of anterolateral thigh flap ranged from 14.0 cm×8.0 cm to 21.0 cm×8.5 cm. The bilateral pedicled anterolateral thigh myocutaneous flaps were harvested to repair the extensive abdominal wall defects in 2 cases. All donor sites were sutured directly.

RESULTS

All wounds healed smoothly and all flaps survived totally. All donor sites healed smoothly. The mean follow-up time was 22.5 months (range, 11-56 months). No tumor recurrence occurred, the abdominal function and appearance were satisfactory, no abdominal hernia was noted. Only linear scar left at the donor sites.

CONCLUSION

Pedicled anterolateral thigh myocutaneous flap combined with mesh is fit for large full-thickness abdominal defect reconstruction.

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.

Complex Open Abdominal Wall Reconstruction: Management of the Skin and Subcutaneous Tissue

Optimal skin and soft tissue management in complex open abdominal wall reconstruction is an integral element of the operation to achieve optimal outcomes. Failure to provide stable, well-vascularized soft tissue coverage over the hernia repair can jeopardize the reconstruction through association with nonhealing wounds, mesh exposure, and even possible hernia recurrence. The literature has shown that careful attention to the skin and soft tissue, especially when part of a multidisciplinary approach to complex abdominal wall reconstruction, improves patient outcomes significantly.

Reconstruction of the Abdominal Wall after Oncologic Resection: Defect Classification and Management Strategies

Compared with conventional ventral hernia repair, there are several additional considerations germane to the oncologic abdominal wall reconstruction, including the management of radiation soft-tissue injury, the management of bacterial contamination, and the location and extent of the defect. Herein, we review some of the unique challenges associated with oncologic abdominal wall reconstruction and introduce a new classification schema to assist the reconstructive surgeon in performing these complex cases.

Flap Reconstruction of the Abdominal Wall

Due to the abundant and lax tissue of the abdominal wall, most ventral trunk defects are amenable to local soft tissue closure. However, when abdominal defects are accompanied by a lack of soft tissue, the surgeon faces a more complex subset of reconstructions. Three important principles guide the reconstruction of these wounds: timing of closure, careful assessment of the true extent of the wound, and the components of the defect. This article focuses on these three guiding principles and suggests the authors' preferred technique for these difficult 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.

Management of skin and subcutaneous tissue in complex open abdominal wall reconstruction

PURPOSE

Open abdominal wall reconstruction is often a complex endeavor, usually performed on patients with multiple risk factors and co-morbidities.

METHODS

In this article, we review soft tissue management techniques that can optimize the skin and subcutaneous tissue, with the goal of reducing surgical-site occurrences.

RESULTS

Regardless of the hernia repair technique used, outcomes can be highly dependent on the appropriate management of the skin and subcutaneous tissue. Indeed, dehiscence and surgical-site infection can jeopardize the entire reconstruction, especially in cases where synthetic mesh might become exposed and/or infected, setting up a "vicious cycle" (Holihan et al. in J Am Coll Surg 221:478-485, 2015).

CONCLUSION

Multidisciplinary cooperation between the general and plastic surgeon is useful in cases of tenuous blood supply to the abdominal skin, in cases of redundant, marginal or excessive skin, and in cases of deficient skin.

An uncommon case of sarcomatoid urothelial carcinoma in covered bladder exstrophy

We report a case of a woman affected by covered exstrophy, uterus didelphys and external genital malformation presenting with advanced bladder cancer. After neoadjuvant therapy and anterior pelvic exenteration, the abdominal wall was reconstructed with a pedicled myocutaneous muscle-sparing vastus lateralis flap.

Degloving injuries of the abdominal wall

OBJECTIVE

To stress the local, regional and global impact of degloving injuries of abdominal wall based on which the surgeon can design the management protocol.

METHOD

A retrospective series of seven cases who met with high velocity run-over accidents between the year 2002 to 2007. All patients were clinically examined and the findings confirmed radiologically, which guided the management.

RESULTS

Out of the seven patients treated, six survived. All patients had open degloving injury of abdominal wall and in different areas of the lower limbs, while three had an additional closed degloving in the back, thighs and gluteal regions. All of them had pelvic fractures of various types. Three patients had peritoneal injury, of whom one had additional diaphragmatic injury. None of them had hollow viscus perforation or injury to solid viscera despite the varied severity of injuries to the abdominal wall, pelvic bone and diaphragm.

CONCLUSION

Degloving injuries of the abdominal wall are rarely encountered in our practice. The associated morbidity and mortality are very high. However, the prognosis can be improved by successful revival and rehabilitation of these patients, which is possible by early resuscitation, recognition of all bony and soft tissue injuries, early debridement and coverage.

Adipose-derived stem-cell-seeded non-cross-linked porcine acellular dermal matrix increases cellular infiltration, vascular infiltration, and mechanical strength of ventral hernia repairs

Adipose-derived stem cells (ASCs) facilitate wound healing by improving cellular and vascular recruitment to the wound site. Therefore, we investigated whether ASCs would augment a clinically relevant bioprosthetic mesh-non-cross-linked porcine acellular dermal matrix (ncl-PADM)-used for ventral hernia repairs in a syngeneic animal model. ASCs were isolated from the subcutaneous adipose tissue of Brown Norway rats, expanded, and labeled with green fluorescent protein. ASCs were seeded (2.5×10(4) cells/cm(2)) onto ncl-PADM for 24 h before surgery. In vitro ASC adhesion to ncl-PADM was assessed at 0.5, 1, and 2 h after seeding, and cell morphology on ncl-PADM was visualized by scanning electron microscopy. Ventral hernia defects (2×4 cm) were created and repaired with ASC-seeded (n=31) and control (n=32) ncl-PADM. Explants were harvested at 1, 2, and 4 weeks after surgery. Explant remodeling outcomes were evaluated using gross evaluation (bowel adhesions, surface area, and grade), histological analysis (hematoxylin and eosin and Masson's trichrome staining), immunohistochemical analysis (von Willebrand factor VIII), fluorescent microscopy, and mechanical strength measurement at the tissue-bioprosthetic mesh interface. Stem cell markers CD29, CD90, CD44, and P4HB were highly expressed in cultured ASCs, whereas endothelial and hematopoietic cell markers, such as CD31, CD90, and CD45 had low expression. Approximately 85% of seeded ASCs adhered to ncl-PADM within 2 h after seeding, which was further confirmed by scanning electron microcopy examination. Gross evaluation of the hernia repairs revealed weak omental adhesion in all groups. Ultimate tensile strength was not significantly different in control and treatment groups. Conversely, elastic modulus was significantly greater at 4 weeks postsurgery in the ASC-seeded group (p<0.001). Cellular infiltration was significantly higher in the ASC-seeded group at all time points (p<0.05). Vascular infiltration was significantly greater at 4 weeks postsurgery in the ASC-seeded group (p<0.001). The presence of ASCs improved remodeling outcomes by yielding an increase in cellular infiltration and vascularization of ncl-PADM and enhanced the elastic modulus at the ncl-PADM-tissue interface. With the ease of harvesting adipose tissues that are rich in ASCs, this strategy may be clinically translatable for improving ncl-PADM ventral hernia repair outcomes.

Abdominal wall defect with large duodenal disruption treated by a free tissue flap with a help of temporary expandable metallic stent

Abdominal wall defect with large duodenal disruption after penetrating abdominal injury is a rare emergency situation that can result in life-threatening complications. We report on a 64-year-old man who had abdominal wall defect with large duodenal disruption after penetrating abdominal injury. The patient presented with intra-abdominal exsanguinating bleeding, duodenal disruption, and multiple small bowel perforation. The rarity of this complex injury and its initial presentation as a posttraumatic large duodenal disruption with abdominal wall defect warrant its description. The present case indicates that combining a free tissue flap with a covered expandable metallic stent can effectively and successfully repair an abdominal wall defect that is associated with a large duodenal disruption.

Soft tissue coverage in abdominal wall reconstruction

Abdominal wall defects requiring soft tissue coverage can be either partial-thickness defects or full-thickness composite defects. Soft tissue flap reconstruction offers significant advantages in defects that cannot be closed primarily. Flap reconstruction is performed in a single-stage procedure obviating chronic wound management. If the defect size exceeds the availability of local soft tissue for coverage, regional pedicled flaps can be delivered into the abdominal wall while maintaining blood supply from their donor site. Microsurgical free tissue transfer increases the capacity to provide soft tissue coverage for abdominal wall defects that are not amenable to either local or regional flap coverage.

Considerations in abdominal wall reconstruction

Reconstruction of complex defects of the central abdomen is both challenging and technically demanding for plastic surgeons. Advancements in the use of pedicle and free tissue transfer along with the use of bioprosthetic and synthetic meshes have provided for novel approaches to these complex defects. Accordingly, detailed knowledge of abdominal wall and lower extremity anatomy in combination with insight into the design, implementation, and limitations of various flaps is essential to solve these complex clinical problems. Although these defects can be attributed to a myriad of etiologic factors, the objectives in abdominal wall reconstruction are consistent and include the restoration of abdominal wall integrity, protection of intraabdominal viscera, and the prevention of herniation. In this article, it is our goal to review pertinent anatomy, pre- and postoperative care regimens, and the various local, regional, and distant flaps that can be utilized in the reconstruction of these complex clinical cases of the central abdomen.

Delayed abdominal wall reconstruction of giant ventral hernias using the anterolateral thigh free flap for skin coverage

Delayed abdominal wall reconstruction for extremely large ventral hernias can be exceedingly difficult if there is a concomitant skin deficiency. In the past decade, six such patients after restoration of the integrity of the musculofascial layer required vascularized tissues to accomplish closure of huge mid-abdominal defects using in all cases the anterolateral thigh free flap. As with all perforator flaps, this ensures function preservation of the intrinsic abdominal muscles to provide a reliable solution to a difficult challenge.

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.