Reverse flap of distal latissimus dorsi for diaphragm reconstruction in the adult: specification of the technical procedure and report on six cases

A Surgical Alternative in the Treatment of Recurrent Diaphragmatic Hernia after Total Gastrectomy

Treament of hiatal hernia remains a challenge for surgeons. The techniques for treatment started with cruroplasty, which was later associated with extensive mobilization of the esophagus, with or without fundoplication. Other solutions included the use of synthetic or biological mesh and autologous tissue reinforcement. Despite these therapeutic strategies, the recurrence rate for hiatal hernia is significant, and no existing treatments have had much success in reducing this rate. Total gastrectomy, as in this case, represents an additional challenge because of the absence of gastric tissue, which can buttress the pillars’ repair. This case report introduces a novel approach for the treatment of recurrent hiatal hernia, using a pedicled vertical rectus abdominis myocutaneous flap.

Complications, pitfalls, and outcomes after chest wall reconstruction

Chest wall and mediastinal wounds may be life-threatening. Although modern reconstruction methods with various muscle flaps have reduced morbidity and mortality, chest wall reconstruction presents unique challenges. Major categories of adverse outcomes include (1) persistent infection; (2) interference with respiratory mechanics; (3) functional deficits of the shoulder; and (4) hernias. Persistent infection may be resolved by providing coverage via muscle or omental flap, performing thorough debridement, filling the "dead space" with adequate volume, buttressing repair of visceral fistulae, and covering exposed prosthetic material with vascularized flaps. Potential deficits in respiratory mechanics and shoulder function may be avoided by stabilizing the chest wall skeleton and decreasing donor muscle functional loss. Hernias may be minimized by maintaining visceral "right of domain" to the chest and abdominal cavities. Complex reconstructive cases represent an intricate interplay of physiology, structural protection, and aesthetic considerations and require integration of several management principles.

Chest reconstruction: I. Anterior and anterolateral chest wall and wounds affecting respiratory function

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe the indications for chest wall reconstruction. 2. Understand the function of the chest wall and implications for both reconstruction and the chest wall itself when components are missing or used for reconstruction. 3. List the reconstructive requirements of chest wall wounds. 4. Identify flaps for regional reconstruction of the chest wall. 5. Describe the role of microvascular surgery in chest wall reconstruction.

BACKGROUND

Chest wall and mediastinum wounds may be life-threatening. They interfere with respiratory mechanics and may also be contaminated with exposed vital structures. Consideration is given to flap choice to restore function, resolve infection, and maintain suitable aesthetics.

METHODS

Literature search as well as the authors' personal experience enabled preparation of this article.

RESULTS

Where necessary, skeletal integrity must be restored, generally with prosthetic material, and then covered with well-vascularized soft tissue. "Living tissue" is required to help combat infection, buttress visceral repairs, and fill dead space. Soft-tissue deficiency must occasionally be augmented with large distant microvascular flaps.

CONCLUSION

Flap reconstruction has reduced morbidity and mortality of these complex problems without undue donor-site impairment of respiratory and upper extremity function.

Hemidiaphragmatic reconstruction with a transversus abdominis muscle flap after resection of a solitary diaphragmatic mesothelioma in a dog

CASE DESCRIPTION

A 2-year-old Siberian Husky was evaluated because of a 2-week history of coughing and gagging and decreased appetite and activity level.

CLINICAL FINDINGS

Radiography, surgery, and immunohistochemical examination revealed a solitary sclerosing mesothelioma extending from the left thoracic diaphragmatic surface that was adherent to the pericardium and the caudal mediastinum.

TREATMENT AND OUTCOME

The tumor was resected along with most of the left hemidiaphragm, and the left transversus abdominis muscle was used to reconstruct the diaphragm. The 13th rib formed the base of the muscle flap. The muscle flap was transposed into the defect so that the mesothelium-lined surface faced the thoracic cavity and the deep aspect of the muscle formed the abdominal surface of the diaphragm. To minimize risk of adhesions, the exposed raw aspect of the abdominal surface was covered with porcine small intestinal submucosa. Recovery was uncomplicated, and the dog's appetite and activity level soon returned to normal. Evaluation 54 days after surgery revealed 2 subcutaneous masses on the thorax and masses in the liver and both kidneys; histologic and immunohistochemical analyses revealed metastasis of the original tumor. The dog was euthanatized.

CLINICAL RELEVANCE

Hemidiaphragmatic reconstruction with a transversus abdominis muscle flap after resection of a diaphragmatic tumor was successful. The muscle flap was easily harvested and transposed into the diaphragmatic defect.

Autologous diaphragm reconstruction with the pedicled latissimus dorsi flap

The latissimus dorsi (LD) muscle has been previously described to repair diaphragmatic defects, but as a "reverse" flap, relying on secondary blood supply from the perforating lumbar vessels rather than primary inflow from the dominant thoracodorsal artery. We report resection of a retroperitoneal synovial sarcoma, with reconstruction of the hemidiaphragm using the LD rotated on its primary neurovascular bundle. By using the dominant pedicle, the vascularity of the flap is improved, minimizing the chance of flap tip loss. Maintaining an intact nerve supply prevents atrophy. As the distal origin of the LD is broad and flat, it is ideally suited for diaphragm repair. A latissimus-sparing thoracotomy incision is required to enable this method of diaphragm reconstruction.

Turnover TRAM Flap as a Diaphragmatic Patch

A hole in the diaphragm requiring an exogenous material for repair is exceedingly unusual. Unfortunately, many nearby potential flap options for this role have frequently already been violated by prior thoracotomies. The ipsilateral superior-pedicled lower transverse rectus abdominis musculocutaneous (TRAM) flap could then be an important maneuver for salvage. Via a tunnel leading into the chest cavity, a deepithelialized TRAM flap can readily reach basilar thoracic defects, and[U0292] thus is particularly suited as an autogenous patch for the diaphragm.

[About the rational use of intrathoracic transfers. Anatomical and surgical bases for the selection of twelve different muscular and omental flaps]

Because of their rich blood supply and of their original detersive and filling properties, the muscular pedicled flaps harvested from the trunk or the omental flap elevated from the abdomen may be very usefull to treat large defects or major septic problems in pleural, pericardic or mediastinal cavities. We here describe the main principles to be followed in such intrathoracic reconstructions performed in order to control severe mediastinites, aortic prosthetic infections, pleural empyemas and broncho-pleural, tracheo-esophageal or broncho-esophageal fistulas. In all these circumstances, the muscular or omental flaps which are transferred into the chest are selected according to the recipient field and to their respective access to the upper, middle and lower portions of the pleural space or mediastinum. Twelve different flaps so appear available to achieve the adequate reconstruction, filling or coverage of nine distinct topographic sites. Their rational use, based on various anatomical guidelines, allows to prevent or to cure efficiently 90% of the infectious or fistular complications frequently observed in the postoperative course of aggressive, functional or oncological, intrathoracic surgical procedures.

Reversed latissimus dorsi muscle flap for repair of recurrent congenital diaphragmatic hernia

BACKGROUND/PURPOSE

Neonates with large congenital diaphragmatic hernias (CDH) require prosthetic patch closure of the defect because of the paucity of native diaphragmatic tissue. As the child grows, patch separation can occur necessitating reoperation. Use of vascularized autologous tissue may decrease the incidence of reherniation as tissue incorporation and growth may be improved. The authors report our early experience using a local muscle advancement flap with microneural anastomosis for those children in whom reherniation develops after prosthetic patch placement.

METHODS

Seven patients with CDH (6 left and 1 right) whose synthetic diaphragmatic patch separated from the chest wall resulting in a clinically significant recurrent hernia were followed up with prospectively. After dissecting the ipsilateral latissimus dorsi off the chest wall and dividing the thoracodorsal neurovascular bundle (based on its lumbar blood supply), the synthetic patch was removed via an eighth intercostal incision. The muscle flap was placed into the hemithorax through the bed of the tenth rib and sutured in place over a Vicryl mesh scaffold. The thoracodorsal nerve was anastomosed to the phrenic nerve. Functional analysis of the flap was performed in 4 patients.

RESULTS

Age at placement of the muscle graft ranged from 2 months to 48 months (median, 24 months). There has been no evidence of reherniation after placement of the muscle graft. Long-term outcome and functional analysis of the flap was available in 4 patients (mean, 19 months). Two infants had fluoroscopic and sonographic evidence of nonparadoxical neodiaphragmatic motion. In one of these, electromyographic evidence of function was documented with a phrenic nerve conduction velocity of 22 meters per second. The third infant showed no evidence of neodiaphragmatic motion, and the fourth infant had paradoxical motion.

CONCLUSIONS

This is the first direct documentation of phrenic nerve function in an infant with CDH. An innervated reversed latissimus dorsi (RLD) flap reconstruction for recurrent CDH provides an alternative to prosthetic patch repair. This technique offers the advantages of autologous vascularized tissue with potential phrenic nerve innervation and physiologic neodiaphragmatic motion.

Reconstruction of diaphragm using autologous fascia lata: an experimental study in dogs

BACKGROUND

We investigated whether fascia lata is an appropriate material for reconstruction of the diaphragm.

METHODS

A diaphragmatic defect (2 cm by 5 cm) was reconstructed with a patch of autologous fascia lata in the experimental group (n = 12) and with expanded polytetrafluoroethylene in the control group (n = 12). Maximal tensile strength at the sutured region was measured serially.

RESULTS

The maximal tensile strength at the sutured region reconstructed with the fascia lata was 1.14 +/- 0.50 kgf 15 days and 2.04 +/- 0.94 kgf 30 days after operation. The values were higher than those of expanded polytetrafluoroethylene (p < 0.0001). These values of fascia lata were close to the original maximal tensile strength of the muscular region of the diaphragm (1.52 to 1.66 kgf).

CONCLUSIONS

Reconstruction of diaphragm using autologous fascia lata is safe, easy, and inexpensive, and provides smooth wound healing. The only disadvantage is the necessity of a femoral incision for harvest; nevertheless, it may be worthwhile to use fascia lata in clinical trials to further assess its suitability as a reconstruction material.

Latissimus dorsi reverse flap to substitute the diaphragm after extrapleural pneumonectomy

BACKGROUND

The standard procedure for diaphragm reconstruction after extrapleural pneumonectomy for a malignancy consists of the use of prosthetic patches. Our original technique utilizing the reverse flap of the latissimus dorsi is evaluated.

METHODS

Once the extrapleural pneumonectomy is performed, the distal portion of the latissimus dorsi, which has been divided with a standard posterolateral thoracotomy at the level of the fifth to sixth rib, is elevated into the chest through the passage obtained by resection of the tenth rib and sutured to the lower pericardium and to the chest wall. Nine patients were evaluated.

RESULTS

No operative death occurred. No flap-related complication nor infection was postoperatively assessed. Six patients received adjuvant radiotherapy. No late complication was observed.

CONCLUSIONS

The distal latissimus dorsi can be used for total reconstruction of one hemidiaphragm, ensuring a watertight separation between the pleural and peritoneal cavities and avoiding paradoxical respiratory motion. In our opinion, the technique was easier, faster, and more reliable than the standard procedure employing prosthetic materials. We recommend that the procedure be integrated with the standard technique of extrapleural pneumonectomy.