Rectus turnover flaps for the reconstruction of large midline abdominal wall defects

Abdominal Wall Reconstruction Using Pedicled Antero Lateral Thigh Flap

Background

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

Methods

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

Results

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

Conclusion

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

Hinge Flap of Rectus Abdominis Muscle Combined with Component Separation Technique: Clinical Cases

Some techniques to reconstruct the abdominal wall have been published, including the component separation procedure. The contribution of the rectus abdominis flap in the reconstruction of a giant incisional hernia is reported. The authors report three clinical cases in which the component separation technique was insufficient to reconstruct a giant midline incisional hernia. As a salvage technique, the rectus abdominis flap was dissected in the form of a hinge. The postoperative period was successful in all patients, combining both techniques. The rectus abdominis hinge flap could be used as a complementary technique to component separation to reconstruct a giant midline incisional hernia. There are several options to reconstruct the abdominal wall, such as anterior transposition of the posterior rectus sheath,¹ or rotation of the anterior sheath toward the midline. This strategy is known as open book.² The rectus turnover flap is also used.³ The anterior component separation technique closes defects less than 20 cm width.⁴ If it is wider, the reconstruction is more difficult. When the operative plan fails in the operating room, an additional technique should be considered. We report on the cases in which we use the rectus abdominis hinge 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.

Management of the Sequelae of Severe Congenital Abdominal Wall Defects

Background

The survival rate of newborns with severe congenital abdominal wall defects has increased. After successfully addressing life-threatening complications, it is necessary to focus on the cosmetic and functional outcomes of the abdominal wall.

Methods

We performed a chart review of five cases treated in our institution.

Results

Five patients, ranging from seven to 18 years of age, underwent the following surgical approaches: simple approximation of the rectus abdominis fascia, the rectus abdominis sheath turnover flap, the placement of submuscular tissue expanders, mesh repair, or a combination of these techniques depending on the characteristics of each individual case.

Conclusions

Patients with severe congenital abdominal wall defects require individualized surgical treatment to address both the aesthetic and functional issues related to the sequelae of their defects.

Damage control abdomen: single-stage reconstruction using a vicryl mesh buttress

PURPOSE

Damage control laparotomy has become an accepted approach for patients with life-threatening abdominal conditions. This method compromises fascial integrity creating functionally and aesthetically debilitating hernias. The purpose of this study is to present our technique and outcomes with these complex abdominal wall reconstructions.

METHODS

A retrospective review was conducted on 56 patients with previous damage control laparotomies who underwent elective single-stage abdominal wall reconstruction between 1999 and 2006. Mean age was 42 years. Reconstruction consisted of a double-layer, subfascial Vicryl mesh buttress, combined with components separation and rectus muscle turnover flaps. Hernia recurrence and function were evaluated by clinical examinations and telephone surveys.

RESULTS

The major etiologies of abdominal hernias were gunshot wounds, motor vehicle accidents or blunt trauma, and sepsis or perforated bowel. The mean abdominal wall defect was 865 cm, and the average interval time to definitive repair was 17 months. The average length of follow-up was 29 months. Most patients (88%) had successful repair of their abdominal wall, with no hernia recurrence. There were 7 cases of hernia. Of these, 2 cases were from reopening of abdomen because of compartment syndrome that was not repaired, 3 were small asymptomatic hernias for which patients elected not to undergo further repair. Other complications include superficial skin dehiscence, all of which healed secondarily with daily wound care 12% (7 patients) and abdominal compartment syndrome 7.1% (4 patients), resulting in 2 postoperative mortalities in the initial part of the series. There were no mesh exposures, seromas, or fistulas. In all, 29% or 52% of patients were reached by telephone. Of those, 90% surveyed and who worked full-time prior to injury returned to their jobs, and 92% were functioning at premorbid activity levels.

CONCLUSION

Massive abdominal hernia following damage control laparotomy poses a great challenge to the reconstructive surgeon. This patient population is at significant risk for mortality and morbidity. We believe the use of a Vicryl mesh buttress is an important adjunctive tool in complex abdominal wall reconstruction. Functional results are excellent with most returning to work and preinjury activity levels.

Local skin flap reconstruction for abdominal wound dehiscence after abdominal surgery with a stoma: report of two cases

Abdominal wound dehiscence is a serious complication of laparotomy, and fascial dehiscence in a patient with a stoma is especially difficult to manage. We describe how we performed local skin flap reconstruction for abdominal wound dehiscence in two patients with stomas. One patient underwent sigmoidectomy with a colostomy for peritonitis caused by perforated diverticulitis of the sigmoid colon. Postoperative fascial dehiscence was repaired by rhomboid flap reconstruction. The other patient underwent total gastrectomy, cholecystectomy, and splenectomy. An ileostomy was performed for digestive tract perforation, which was complicated by abdominal dehiscence with necrosis of the fascia. This was repaired by rotation flap reconstruction. The abdominal walls in both patients were repaired successfully without tension.

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.

Not all biologics are equal!

BACKGROUND

Although the efficacy of various biologic meshes in the abdominal reconstruction of complex ventral hernia has been shown, the performance profile of various biologic mesh scaffolds in terms of hernia-specific outcomes such as recurrence, mesh explantation, and mesh infections has not been examined.

AIM

To evaluate the clinical outcomes of patients who underwent complex ventral hernia repair with bioprosthetic material.

METHODS

This study is a retrospective analysis of the use of bioprosthetic material in complex ventral hernia at an academic institution from January 2002 to December 2007.

RESULTS

A total of 58 patients with a mean age of 57.2 years and mean body mass index (BMI) of 33.8 who underwent reconstruction of ventral abdominal defects with a bioprosthetic from January 2002 to February 2009 were included in the study. The study patients had about 4.8 previous surgeries and 43.1% of patients had reconstruction in a setting of enterocutaneous fistula, while 46.6% had a previous mesh infection. Complex ventral hernia was seen in 50 patients, while eight patients had ventral and parastomal hernia. The type of biologic used for reconstruction was human-derived (AlloDerm, 29), porcine cross-linked (CollaMend, 3; Permacol, 2), and non-cross-linked porcine (Surgisis, 16; Strattice, 8). At least one complication was seen in 72.4% of patients. Major complications noted were surgical wound infections (19.0%), seroma (8.6%), and abscess formation (5.2%). The one-year hernia recurrence rate was 27.9% and mesh explantation was needed in 17.2% of patients. AlloDerm was less likely to be explanted (13.8%) or become infected (37.9%) but more likely to recur (28.6%) compared to porcine cross-linked bioprosthesis. Porcine cross-linked biologics were more likely to become infected (60%) and explanted (40%) but less likely to recur (20%) compared to AlloDerm. Non-cross-linked porcine biologics were less likely to be explanted (16.7%) but had higher recurrence (29.4%) compared to cross-linked porcine biologics and a higher infection rate (54.2%) compared to AlloDerm.

CONCLUSIONS

The results from this study underscore the difficulty of repairing complex abdominal wall defects in contaminated fields. Cross-linked porcine biologics showed relatively higher infection and explantation rates. Equivalent recurrence and explantation rates were observed for the non-cross-linked porcine biologics and AlloDerm. These data indicate that there is currently no ideal biologic for complex ventral hernia repair.

Damage control surgery and open abdominal management: recent advances and our approach

The concept of damage control and improved understanding of the pathophysiology of abdominal compartment syndrome (ACS) have been proven to be great advances in the management of both traumatic and nontraumatic surgical conditions. The practice of damage control surgery includes 3 components: 1) abbreviated resuscitative surgery for rapid control of hemorrhage and abdominal contamination by gastrointestinal contents, followed by temporary abdominal wall closure for planned reoperation and prevention of ACS; 2) restoration of physiologic function, including rewarming and correction of coagulopathy and hemodynamic stabilization in the intensive care unit; and 3) re-exploration for the definitive management of injuries and abdominal wall closure. Although this new approach can decrease the mortality rate of patients with severe physiological derangement, the establishment of clearly defined indications is necessary. For patients who require damage control surgery, interventional radiology should be integrated into the strategy for achieving hemostasis. Angiographic evaluation and embolization should be considered immediately after initial operation, especially for patients with combined intraperitoneal and retroperitoneal hemorrhage, severe hepatic injury, or ongoing hemorrhage after damage control surgery. In many patients who require conventional open abdominal management following damage control surgery or decompressive laparotomy for ACS, the granulating abdominal contents are covered with only a skin graft, which is associated with a risk of enterocutaneous fistula. These patients will ultimately require complex abdominal wall reconstruction at a later stage. We have performed early fascial closure using an anterior rectus abdominis sheath turnover flap method. This technique may reduce the need for skin grafting and subsequent reconstruction and can be considered as an alternative method for the early management of patients with open abdomen.

Utilization of Human Cadaveric Acellular Dermis for Abdominal Hernia Reconstruction

BACKGROUND

Incisional hernias with history of recurrence or infection remain a challenge, with high postoperative morbidity and recurrence rates. The purpose of this study is to evaluate outcomes of patients treated with human cadaveric acellular dermis as an adjunct to abdominal wall reconstruction.

METHODS

We retrospectively reviewed 39 abdominal wall reconstructions with human cadaveric acellular dermis performed in 37 patients and compared them with 39 randomly selected cases.

RESULTS

There is a significant decrease in recurrence rates when human cadaveric acellular dermis is added as an overlay to primary closure plus rectus muscle advancement and imbrication in patients with medium-sized hernias. No differences were observed when adding human cadaveric acellular dermis as an overlay to patients with large-size hernias treated with underlay mesh. The use of human cadaveric acellular dermis did not increase postoperative morbidity rates.

CONCLUSIONS

Improved results with human cadaveric acellular dermis are obtained by achieving tension-free repairs.

Usefulness of the bilateral anterior rectus abdominis sheath turnover flap method for early fascial closure in patients requiring open abdominal management

BACKGROUND

Many patients requiring conventional open abdominal management need a postoperative intermediate period with a large ventral hernia. This situation, in which the granulated abdominal contents are covered only with a skin graft, carry with it a high risk of enterocutaneous fistula, and the patients ultimately require late-stage abdominal wall reconstruction. Early abdominal wall reconstruction in noncandidates for standard fascial closure has received little attention. In this study we used bilateral anterior rectus abdominis sheath turnover flaps for early fascial closure which, to date, has not been evaluated as a technique for early fascial closure.

METHODS

Eleven trauma and 18 nontrauma cases requiring open abdominal management over a 7-year period were reviewed. Bilateral anterior rectus abdominis sheath turnover flaps were created by longitudinal incisions along the lateral edge of the anterior rectus sheath, which were mobilized medially and approximated. The skin was closed primarily.

RESULTS

Twelve nontrauma and eight trauma patients survived. No enteric fistula or abdominal abscess occurred. Anterior rectus sheath turnover flaps were used in nine of the 18 nontrauma and two of the 11 trauma patients, all of whom were unsuitable for standard fascial closure of prolonged visceral edema; the respective mean intervals from initial laparotomy to fascial closure were 9.4 and 18 days. Of the 11 patients with flaps, ten survived without fascial dehiscence or herniation (maximum follow-up: 65 months).

CONCLUSIONS

Early fascial closure using the anterior rectus abdominis sheath turnover flap may reduce the need for skin grafting and subsequent abdominal wall reconstruction. This approach can be considered as an alternative technique in the early management of patients with open abdomen.

Updated algorithm for abdominal wall reconstruction

Like any clinical regime, the algorithm for abdominal wall reconstruction requires routine updating as new options and techniques become available. Increased experience and understanding of new applications have allowed for improvements to the approach to complex abdominal wall defects. These improvements have increased efficiency and decreased risk, particularly in the area of staged reconstruction. Surgeons have continued to rely heavily on autologous reconstruction and local tissue advancement for long-term dynamic support. The current approach to abdominal wall reconstruction is based on understanding the literature, clinical experience, and the type of patients seen in practice. This article provides surgeons with the basic guidelines to follow when faced with complex abdominal wall defects and the tools necessary to solve these difficult problems in a responsible and reliable way.

Structural and Functional Anatomy of the Abdominal Wall

Multiple options exist for managing complex abdominal wall defects. These options range from the use of autologous tissue with rearrangement procedures to the use of prosthetic or bioprosthetic materials. All options rely on a thorough understanding of the structural and functional anatomy of the abdominal wall and the relationship of varying anatomical structures to provide the optimal reconstructive procedure. A successful reconstruction is achieved when the structural anatomy is integrated with understanding the dynamic function of the abdominal wall.

Reconstruction of the abdominal wall for incisional hernia repair

BACKGROUND

Abdominal wall reconstruction with mobilization of autologous tissue has evolved as a reliable option for patients with incisional hernias.

METHODS

With the aim of evaluating morbidity and recurrence rates in patients who underwent abdominal wall reconstruction for incisional hernia repair, we retrospectively reviewed the charts of 188 patients treated between 1996 and 2003.

RESULTS

Primary approximation of the fascial defect was achieved in 77% and was reinforced by either mesh placement or rectus muscle advancement. The remaining 23% were reconstructed either by mesh placement, components separation, or distant flap mobilization. Median follow-up was 15 months. Overall morbidity rate was 38%; recurrence rate was 13%. Dimensions of the hernia and intraoperative enterotomies were associated with postoperative complications. Lack of complete restoration of the myofascial abdominal wall continuity was associated with recurrence.

CONCLUSIONS

In patients with incisional hernias, techniques involving autologous tissue mobilization are safe and associated with low recurrence rates.

One-stage reconstruction of large midline abdominal wall defects using a composite free anterolateral thigh flap with vascularized fascia lata

OBJECTIVE

Large midline abdominal wall defects are continuously a challenge for reconstructive surgeons. Adequate skin coverage and fascia repair of the abdominal wall is necessary for achieving acceptable results. The purpose of this paper is to present a new approach to abdominal wall reconstruction using a free vascularized composite anterolateral thigh (ALT) flap with fascia lata.

METHODS

Seven patients with large full-thickness abdominal wall defects were successfully reconstructed by means of a composite ALT flap combined with vascularized fascia lata. The size of the skin islands ranged from 20 to 32 cm in length and 10 to 22 cm in width, and the vascularized fascia lata sheath measured 14 to 28 cm and 8 to 18 cm, respectively. Functional outcome of the abdominal wall strength and donor thigh morbidity were investigated by using a Cybex kinetic dynamometer.

RESULTS

All flaps survived. No postoperative ventral hernia occurred except for one mild inguinal incision hernia. Subjectively there were no significant donor site problems. Objective assessment was performed in 4 patients 2 years postoperatively. In the reconstructed abdomen, isokinetic concentric and eccentric measurements of extension/flexion ratios of the abdominal wall strength showed no apparent decrease compared with other references. Functional evaluation of quadriceps femoris muscle contraction forces after free ALT composite flap harvest showed an averaged deficit of 30% as compared with the contralateral legs. However, no difficulties in daily ambulating were reported by the patients.

CONCLUSION

The free composite ALT myocutaneous flap with vascularized fascia lata provides an alternative option for a stable repair in complex abdominal wall defects.

The use of a subfascial vicryl mesh buttress to aid in the closure of massive ventral hernias following damage-control laparotomy

Damage control laparotomy for life-threatening abdominal conditions has gained wide acceptance in the management of exsanguinating trauma patients as well as septic patients with acute abdomen. Survivors considered too ill to undergo definitive abdominal wall closure are temporized, often with skin grafting on granulated viscera. These maneuvers compromise the integrity of the anterior abdominal wall and result in a subset of patients with loss of abdominal domain and massive, debilitating ventral hernias. A retrospective review was conducted of 21 such patients (16 men, five women) who underwent elective abdominal wall reconstruction at the Hospital of the University of Pennsylvania between November of 1998 and October of 2000. The purpose of this study was to report the authors' experience with these complex abdominal wall reconstructions. A double-layer, subfascial Vicryl mesh buttress was used in all repairs to aid in reestablishing abdominal wall integrity. The mean hernia size was 813 cm2 (range, 75 to 1836 cm2), and the average interval to definitive repair was 24.4 months (range, 3 weeks to 11 years). Mean follow-up was 13.5 months (range, 1 month to 40 months). Twenty patients (95 percent) had successful ventral hernia repair. Four patients with massive hernias (924 to 1836 cm2) required submuscular Marlex mesh implantation. Two patients (10 percent) developed abdominal compartment syndrome that required surgical decompression. One patient (5 percent) developed an incisional hernia at a prior colostomy site. Four patients (19 percent) had superficial skin dehiscence that healed secondarily with daily wound care. There were no mesh infections. In most cases, successful single-stage repair of large ventral hernias following damage control laparotomy can be achieved using a subfascial Vicryl mesh buttress in combination with other established reconstructive techniques. Massive defects exceeding 900 cm2 typically require permanent mesh implantation to achieve fascial closure and to minimize the risk of postoperative abdominal compartment syndrome and recurrent herniation. This technique represents an improved solution to a complicated problem and optimizes the aesthetic and functional outcome for these debilitated patients.

The “Open-Book” Variation of Component Separation for Repair of Massive Midline Abdominal Wall Hernia

The reconstruction of massive midline abdominal wall defects as a result of intra-abdominal catastrophes has long challenged the reconstructive surgeon. Previously, the lack of autogenous tissue often forced the surgeon to resort to synthetic materials, which may be complicated by adhesions, enterocutaneous fistulas, and infection. The introduction of the “components of anatomic separation” technique by Ramirez et al. in 1990 allowed for autogenous reconstruction using bipedicle rectus flaps. This technique was far superior to any previous option, but it had its limitations. The authors report a modification to the component separation technique which may allow larger defects to be closed as well as diminish the weakness left below the arcuate line found in some of the previously reported techniques. Ten patients are discussed for which this modified technique of component separation was employed. The follow-up ranges from 5 weeks to 53 months.

Abdominal wall partitioning (the accordion effect) for reconstruction of major defects: a retrospective review of 10 patients

Ten patients underwent abdominal wall reconstruction using the technique of abdominal wall partitioning. All defects were closed in the midline by approximating fascia to fascia with the assistance of a general surgeon. One patient had skin grafted small bowel. Five patients had chronically infected mesh and previous failed attempts at repair. Four patients had large ventral hernias following gastric reduction operations and massive weight loss. No defect in any dimension was less than 20 cm. All patients had secure abdominal wall repair by reconstruction of a midline anchor for the abdominal wall musculature. One patient was lost to follow-up after 3 weeks. The average follow-up time for the remaining nine patients was 18.6 months (range, 6 months to 4.7 years). One patient required readmission to the hospital for management of a limited area of skin necrosis. Two patients had minor wound infections, and three patients had subcutaneous seromas, all of which were managed on an outpatient basis. One patient developed a 2 x 2-cm subxiphoid hernia recurrence. Technical details include subcutaneous undermining of the abdominal skin to the anterior axillary lines bilaterally, mobilization of the viscera to expose the white lines of Toldt bilaterally, and parallel, parasagittal, staggered releases of the transversalis fascia, transversalis muscle, external oblique fascia, external oblique muscle, and rectus fascia. These multiple releases allow expansion and translation of the abdominal wall by an accordion-like effect. This accordion-like effect allows closure of abdominal wall defects that are substantially larger than what can be closed with current techniques.

Abdominoplasty repair for abdominal wall hernias

The objectives of abdominal hernial repair are to reconstruct the structural integrity of the abdominal wall while minimizing morbidity. Current techniques include primary closure, staged repair, and the use of prosthetic materials. Techniques for abdominoplasty include the use of the transverse lower abdominal incision and the resection of excess skin. By incorporating these aspects into hernial repairs, the procedures are made safer and the results are improved. The medical records were reviewed of 123 consecutive patients who underwent hernial repair. Seventy-six of these patients underwent a total of 82 herniorrhaphies using an abdominoplasty approach. This included using a transverse lower abdominal incision with or without extending it into an inverted-T incision. The hernial defect was then identified and isolated. Repair was obtained with primary fascial closure and plication, primary fascial approximation and reinforcement with absorbable Vicryl mesh, or placement of permanent mesh with or without fascial approximation. Overall, 8 of 82 hernias recurred. Most complications were minor and could be managed with local wound care only. Major complications included one enterocutaneous fistula, one occurrence of skin flap necrosis requiring operative debridement and skin grafting, and one delayed permanent mesh extrusion 2 years after repair. The abdominoplasty approach isolates the incision from the hernial defect and repair. This technique is safe with a low risk of complications and a low rate of recurrence. It is particularly helpful in obese patients, in patients with multiple hernias, and in those patients with recurrent hernias.

Rotation flap of the anterior rectus abdominis sheath for hernia prevention in TRAM breast reconstruction

Prevention of hernia or bulge of the abdominal wall after TRAM breast reconstruction has been a challenge for the reconstruction surgeon. Different techniques have been described to avoid this complication. The use of anterior rectus abdominis sheath (ARAS) for the repair of various abdominal wall hernias has been well described in the literature and is the basis of the authors' technique. The authors present the use of ARAS flap in TRAM breast reconstruction. It is a simple and safe technique using autologous tissues for hernia or bulge prevention.

Complex abdominal wall reconstruction: a comparison of flap and mesh closure

OBJECTIVE

To analyze a series of patients treated for recurrent or chronic abdominal wall hernias and determine a treatment protocol for defect reconstruction.

SUMMARY BACKGROUND DATA

Complex or recurrent abdominal wall defects may be the result of a failed prior attempt at closure, trauma, infection, radiation necrosis, or tumor resection. The use of prosthetic mesh as a fascial substitute or reinforcement has been widely reported. In wounds with unstable soft tissue coverage, however, the use of prosthetic mesh poses an increased risk for extrusion or infection, and vascularized autogenous tissue may be required to achieve herniorrhaphy and stable coverage.

METHODS

Patients undergoing abdominal wall reconstruction for 106 recurrent or complex defects (104 patients) were retrospectively analyzed. For each patient, hernia etiology, size and location, average time present, technique of reconstruction, and postoperative results, including recurrence and complication rates, were reviewed. Patients were divided into two groups based on defect components: Type I defects with intact or stable skin coverage over hernia defect, and Type II defects with unstable or absent skin coverage over hernia defect. The defects were also assigned to one of the following zones based on primary defect location to assist in the selection and evaluation of their treatment: Zone 1A, upper midline; Zone IB, lower midline; Zone 2, upper quadrant; Zone 3, lower quadrant.

RESULTS

A majority of the defects (68%) were incisional hernias. Of 50 Type I defects, 10 (20%) were repaired directly, 28 (56%) were repaired with mesh only, and 12 (24%) required flap reconstruction. For the 56 Type II defects reconstructed, flaps were used in the majority of patients (n = 48; 80%). The overall complication and recurrence rates for the series were 29% and 8%, respectively.

CONCLUSIONS

For Type I hernias with stable skin coverage, intraperitoneal placement of Prolene mesh is preferred, and has not been associated with visceral complications or failure of hernia repair. For Type II defects, the use of flaps is advisable, with tensor fascia lata representing the flap of choice, particularly in the lower abdomen. Rectus advancement procedures may be used for well-selected midline defects of either type. The concept of tissue expansion to increase both the fascial dimensions of the flap and zones safely reached by flap transposition is introduced. Overall failure is often is due to primary closure under tension, extraperitoneal placement of mesh, flap use for inappropriate zone, or technical error in flap use. With use of the proposed algorithm based on defect analysis and location, abdominal wall reconstruction has been achieved in 92% of patients with complex abdominal defects.

An algorithm for abdominal wall reconstruction

Acquired abdominal wall defects result from trauma, previous surgery, infection, and tumor resection. The correction of complex defects is a challenge to both plastic and reconstructive and general surgeons. The anatomy of the abdominal wall, as well as considerations in patient assessment and surgical planning, are discussed. A simple classification of abdominal wall defects based on size, depth, and location is provided. Publications regarding the various abdominal reconstruction techniques are reviewed and summarized to familiarize the reader with the treatment options for each particular defect. Finally, an algorithm is presented to guide the surgeon in selecting the optimal reconstructive technique.