Flap Reconstruction of the Abdominal Wall

Contemporary Abdominal Wall Reconstruction: Emerging Techniques and Trends

Abdominal wall reconstruction is a common and necessary surgery, two factors that drive innovation. This review article examines recent developments in ventral hernia repair including primary fascial closure, mesh selection between biologic, permanent synthetic, and biosynthetic meshes, component separation, and functional abdominal wall reconstruction from a plastic surgery perspective, exploring the full range of hernia repair's own reconstructive ladder. New materials and techniques are examined to explore the ever-increasing options available to surgeons who work within the sphere of ventral hernia repair and provide updates for evolving trends in the field.

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.

Distinctive characteristics of granulation tissue in laparotomy wounds with underlying oncological processes

This study aimed to investigate the effects of malignant neoplasms on the morphological characteristics of laparotomy wound granulation tissue in the muscular-aponeurotic layer. The study involved a sample of 34 deceased individuals who had undergone abdominal organ surgery. Biopsy samples were taken from the muscular-aponeurotic layer of the anterior abdominal wall and subjected to histological examination, including staining with hematoxylin and eosin and methylene blue/Chromotrope 2B using N.Z. Slinchenko's method. Descriptive methods and morphometry were used to evaluate pathomorphological changes. The results suggest that malignant neoplasms significantly impede and decelerate the maturation of laparotomy wound granulation tissue. Surgeries performed at the late stages of abdominal organ malignant neoplasms result in an uneven and slow maturation of the tissue, characterized by a higher prevalence of lymphoid cells, increased blood vessel volume, reduced optical density of stained collagen fibers, and pronounced chromotropophilia of collagen fibers. These distinct features should be considered to prevent postoperative eventration, a complication that is more likely to occur in this patient group. Clinicians should be aware of the possible consequences of malignant neoplasms on laparotomy wound granulation tissue, which may require additional measures to prevent postoperative complications in these patients.

Double-layer biodegradable temporising matrix reconstruction for abdominal skin and soft-tissue reconstruction

Dermatofibrosarcoma protuberans (DFSP) is a rare, locally invasive dermal sarcoma. The management is generally surgical, with wide local excision (WLE) forming the mainstay of treatment. Large abdominal wall defects are most aesthetically reconstructed using pedicled or free flaps; however, these require tumour-free surgical margins, and are off-set by donor site morbidity. We describe an alternative, aesthetic and low-morbidity technique for reconstruction of a subfascial defect following WLE of DFSP in a young woman in her early 20s, using two layers of a novel synthetic dermal matrix (NovoSorbBTM). To our knowledge, a double-layer reconstruction using an artificial dermal matrix has never been described for trunk reconstruction. We found that double-layer biodegradable temporising matrix can restore the inherent thickness and pliability of skin in a partial-thickness abdominal wall defect and offers improved durability and cosmesis compared with skin grafting or indeed single layer skin substitutes alone.

Tension-reduced closure of large abdominal wall defect caused by shotgun wound: A case report

BACKGROUND

Large abdominal wall defect (LAWD) caused by shotgun wound is rarely reported.

CASE SUMMARY

Herein, we describe a case of LAWD caused by a gunshot wound in which the abdominal wall was reconstructed in stages, including debridement, tension-reduced closure (TRC), and reconstruction with mesh and a free musculocutaneous flap. During a 3-year follow-up, the patient recovered well without hernia or other problems.

CONCLUSION

TRC is a practical approach for the temporary closure of LAWD, particularly in cases when one-stage abdominal wall restoration is unfeasible due to significant comorbidities.

Abdominal Wall Skin Loss Defects Reconstruction Using Pedicled Anterolateral Thigh Flap

It was extremely difficult to deal with the complex full-thickness abdominal wall defect post serious trauma. The pedicled anterolateral thigh flap had been reported to be applied in reconstructing full-thickness abdominal wall defect in lower abdomen and groin. However, less cases in upper abdominal wall defect reconstructed by anterolateral thigh flap were reported due to some limitations. The aim of this study was to introduce our experiences in applying anterolateral thigh flap in upper abdominal wall defect reconstructing. In this study, seven patients with a large area of upper full-thickness defect in abdominal wall complicated with multiple organ damage were retrospectively identified due to acute trauma. Immediate organ-repair surgeries were performed. Meanwhile, the patients underwent complete debridement in the zone of abdominal wall defect, together with anti-infective treatment. Then, the appropriate timing was chosen to perform pedicled anterolateral thigh flap for reconstructing large area of full-thickness defect involving the upper abdomen. Postoperative follow-up data demonstrated that all the flaps survived, with no hernia complications or other discomforts. The outcome of the patients was also good. Thus, we conclude that pedicled anterolateral thigh flap was feasible to repair full-thickness defect in upper abdominal wall as long as well designed.

Abdominal Wall Vascularized Composite Allotransplantation: A Scoping Review

BACKGROUND

 Abdominal wall vascularized composite allotransplantation (AW-VCA) is a novel reconstructive technique used for large abdominal wall defects in combination with intestinal transplantation (ITx) or multivisceral abdominal transplantation (MVTx). Since the introduction of this procedure, several studies have been published reporting their experience. This study aims to present a scoping review looking at all available evidence-based medicine information to understand the most current surgical techniques and clinical outcomes.

METHODS

 This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) extension for scoping reviews checklist. A comprehensive research strategy of several databases was conducted.

RESULTS

 A total of 31 studies were included in this review, which comprised animal, cadaveric, and human studies. In human studies, four surgical techniques with high flap survival rates and low complication rates were found. In cadaveric studies, it was shown that the use of iliofemoral cuff-based flaps provided adequate tissue perfusion to the abdominal wall graft. Also, the use of thoracolumbar nerves have been described to provide functionality to the AW-VCA and prevent long-term muscle atrophy.

CONCLUSION

 AW-VCA is a safe and efficient alternative for patients with large and complex abdominal wall defects. The future holds a promising evolution of a functional AW-VCA, though surgeons must face and overcome the challenge of distorted anatomy frequently present in this population. Forthcoming studies with a better level of evidence are required to evaluate functionality and differences between surgical techniques.

Composite Anterolateral Thigh and Fascia Lata Free Flap for Abdominal and Groin Reconstruction in a Pediatric Patient

Large abdominal wall and groin defects present complex reconstructive challenges. These defects typically require free flap reconstruction to bring in healthy vascularized tissue and recreate the complex full-thickness defect. A 6-year-old previously healthy girl presented to our trauma center after sustaining a close-range shotgun injury resulting in a full-thickness defect to the inferior hemi-abdomen and groin. A composite anterolateral thigh flap with fascia lata free flap was performed to reconstruct the myofascial, skin, and subcutaneous tissue of the abdomen and groin. We present the first composite anterolateral thigh flap with fascia lata for full-thickness abdominal wall and groin reconstruction in a pediatric patient.

Reconstruction of Complex Abdominal Wall Defect With Autogenous Pedicled Demucosalized Seromuscular Flap

Abdominal wall reconstruction is indicated when 1 or more of the abdominal wall components (skin, fascia, or muscle) are either injured or absent. When faced with defects requiring flap reconstruction, the decision regarding flap choice should take into consideration the volume of soft tissue required, the extent of the defect, donor site morbidity, and prior surgical scars that affect flap vascularity. We present a case of an abdominal wall defect with limited reconstructive options in which a spare ileal bowel segment was filleted to create a seromuscular flap for improving the abdominal wall blood supply. The postoperative course was complicated by abdominal fluid collection, which resolved following an ultrasound-guided drain. The patient had normal wound healing and recovery without further postoperative complications at the 7-month follow-up. Seromuscular flaps are a practical option in the armamentarium of plastic surgeons performing abdominal wall reconstruction, especially when other alternatives are limited.

The Anatomic Feasibility of a Functional Chimeric Flap in Complex Abdominal Wall Reconstruction

BACKGROUND

Dynamic and functional abdominal wall reconstruction (FAWR) remains a complex challenge. The ideal flap should have a minimal donor-site morbidity and cover a large surface area with motor and sensory capabilities. The goal was to investigate the feasibility of using a free chimeric flap with anterolateral thigh (ALT) and rectus femoris (RF) components pedicled only on the motor nerve branch.

METHODS

Ten fresh cadavers were dissected with a designed chimeric thigh flap including ALT and RF flaps. Anterolateral thigh was designed and raised with the lateral femoral cutaneous nerve integrated, and the descending branch of the lateral circumflex femoral artery was preserved. Rectus femoris was elevated and the common pedicle was dissected up to the femoral origin. Accompanying motor nerve branches were carefully dissected to their femoral origin.

RESULTS

Twenty RF flaps were dissected and 9 were harvested as a true chimeric flap with ALT. The mean number of neurovascular bundles associated with RF flap was 2.11 ± 0.47, and the mean primary motor nerve average length was 9.40 ± 2.42 cm. The common vascular bundle in all 9 chimeric flaps was ligated, and the flap was rotated toward the abdomen pedicled only by primary motor nerve of the RF muscle. Nerve length was adequate for reach up to xiphoid area in all 20 flaps.

CONCLUSIONS

This study demonstrates the feasibility of the chimeric ALT/RF muscle free flap pedicled only by the motor nerve branch, with adequate flap rotation. Even with the limitations in a live patient, this flap would be an excellent option for FAWR in the right patient.

Catastrophic appendicitis operation, successful repair in tertiary limited resources hospital: A case report

Introduction

Acute appendicitis is one of the most common surgical diseases. Perforated appendicitis resulting in catastrophic complication because of a burst abdomen with necrotizing fasciitis of the abdominal wall is exceedingly a rare case.

Presentation of case

A 13-year-old girl with perforated appendicitis who had undergone laparotomy had to experience a burst abdomen with necrotizing fasciitis of the abdominal wall. The patient has temporarily closed the abdominal cavity with a urine bag (modified Bogota bag). After 23 times replacement of the Bogota bag and the condition of the sepsis and nutrition had improved, the abdominal wall reconstruction was performed by carrying out two random rotational flaps to close the abdominal defect. One year later, the patient came for ileocolostomy closure; then the patient was sent home with uneventful condition.

Discussion

Perforated appendicitis is a type of acute appendicitis with a low morbidity rate. Compared to other complications, burst abdomen and necrotizing fasciitis (NF) in perforated appendicitis are exceptionally rare events. Surgery with sepsis and recurrent intra-abdominal abscesses as a result of previous surgery are the causes of burst abdomen. The use of abdominal drainage has also been shown to cause NF. Both of these conditions will increase the cost and length of stay, and reduce the quality of life. The rotational flap procedure is the procedure of choice for a large burst abdomen.

Conclusion

Surgeons should and have to perform a meticulous operation to prevent catastrophic complication and to increase the quality of life.

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Acute appendicitis is one of the most common surgical diseases.

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Perforated appendicitis resulting in catastrophic complication as burst abdomen with necrotizing fasciitis is very rare.

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Sepsis, intraabdominal abscesses, use of abdominal drainage had been shown to cause burst abdomen and necrotizing fasciitis.

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Used Bogota bag to temporarily closed abdominal wall and rotational flap is the selected procedure for large burst abdomen.

Chinese expert consensus on adult ventral abdominal wall defect repair and reconstruction

BACKGROUND

Surgical management of patients with ventral abdominal wall defects, especially complex abdominal wall defects, remains a challenging problem for abdominal wall reconstructive surgeons. Effective surgical treatment requires appropriate preoperative assessment, surgical planning, and correct operative procedure in order to improve postoperative clinical outcomes and minimize complications. Although substantial advances have been made in surgical techniques and prosthetic technologies, there is still insufficient high-level evidence favoring a specific technique. Broad variability in existing practice patterns, including clinical pre-operative evaluation, surgical techniques and surgical procedure selection, are still common.

DATA SOURCES

With the purpose of providing a best practice algorithm, a comprehensive search was conducted in Medline and PubMed. Sixty-four surgeons considered as experts on abdominal wall defect repair and reconstruction in China were solicited to develop a Chinese consensus and give recommendations to help surgeons standardize their techniques and improve clinical results.

CONCLUSIONS

This consensus serves as a starting point to provide recommendations for adult ventral abdominal wall repair and reconstruction in China and may help build opportunities for international cooperation to refine AWR practice.

Application of double circular suturing technique (DCST) in the repair of large abdominal wall defects after resection of abdominal wall tumor

Background

The aim of this study was to investigate the clinical effects of repairing large defects using the double circular suturing technique (DCST) after resection of abdominal wall tumor.

Methods

The clinical data of 62 patients (25 men, 37 women; average age 41.7±22.4 years) who underwent DCST between October 2010 and November 2018 for the repair of large abdominal wall defects with anti-adhesion underlay mesh after resection of abdominal wall tumor were retrospectively analyzed. The maximum diameter of abdominal wall defect after resection of abdominal wall tumor was 10.4±5.6 cm. The course of disease was 1–341 months, and the average was 32.4 months. Operative time, postoperative hospitalization time, perioperative complications, tumor recurrence in situ, incidence of postoperative chronic pain, and hernia were recorded.

Results

All 62 operations were completed successfully. The operative time was 73.2±31.4 minutes, and the mean postoperative hospitalization time was 9.6 days (range, 2–20 days). In total, 54 patients were followed up postoperatively for a median 6.7 years (range, 0.9–9.0 years). Partial splitting of incisions occurred in 2 patients, fat liquefaction of incisions occurred in 3 patients, and chronic pain occurred in 4 patients. No tumor in situ recurrence, hernia, or other complications were found in any cases in the follow-up. Tumor metastasis occurred in 9 patients with 6 of these patients dying of tumour progression.

Conclusions

With simple operations, short procedure time, few complications, low tumor recurrence rate, and low incidence of postoperative chronic pain, application of DCST in the repair of large abdominal wall defects is effective after resection of abdominal wall tumor.