The tensor fasciae latae myocutaneous flap closure of major chest and abdominal wall defects

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.

The Free Myocutaneous Tensor Fasciae Latae Flap—A Workhorse Flap for Sternal Defect Reconstruction: A Single-Center Experience

Introduction: Deep sternal wound infections (DSWI) after cardiac surgery pose a significant challenge in reconstructive surgery. In this context, free flaps represent well-established options. The objective of this study was to investigate the clinical outcome after free myocutaneous tensor fasciae latae (TFL) flap reconstruction of sternal defects, with a special focus on surgical complications and donor-site morbidity. Methods: A retrospective chart review focused on patient demographics, operative details, and postoperative complications. Follow-up reexaminations included assessments of the range of motion and muscle strength at the donor-site. Patients completed the Quality of Life 36-item Short Form Health Survey (SF-36) as well as the Lower Extremity Functional Scale (LEFS) questionnaire and evaluated aesthetic and functional outcomes on a 6-point Likert scale. The Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scales (POSAS) were used to rate scar appearance. Results: A total of 46 patients (mean age: 67 ± 11 years) underwent sternal defect reconstruction with free TFL flaps between January 2010 and March 2021. The mean defect size was 194 ± 43 cm2. The mean operation time was 387 ± 120 min with a flap ischemia time of 63 ± 16 min. Acute microvascular complications due to flap pedicle thromboses occurred in three patients (7%). All flaps could be salvaged without complete flap loss. Partial flap loss of the distal TFL portion was observed in three patients (7%). All three patients required additional reconstruction with pedicled or local flaps. Upon follow-up, the range of motion (hip joint extension/flexion (p = 0.73), abduction/adduction (p = 0.29), and internal/external rotation (p = 0.07)) and muscle strength at the donor-sites did not differ from the contralateral sides (p = 0.25). Patient assessments of aesthetic and functional outcomes, as well as the median SF-36 (physical component summary (44, range of 33 to 57)) and LEFS (54, range if 35 to 65), showed good results with respect to patient comorbidities. The median VSS (3, range of 2 to 7) and POSAS (24, range of 18 to 34) showed satisfactory scar quality and scar appearance. Conclusion: The free TFL flap is a reliable, effective, and, therefore, valuable option for the reconstruction of extensive sternal defects in critically ill patients suffering from DSWIs. In addition, the TFL flap shows satisfactory functional and aesthetic results at the donor-site.

Repair of a large recurrent congenital lumbar hernia with free composite anterolateral thigh flap, tensor fascia lata flap, and vastus lateralis flap and meshes: A case report

Congenital lumbar hernia (LH) is a rare abdominal wall herniation and associated with lumbocostovertebral syndrome, including vertebral anomalies, costal defects and LH. There are reports using extraperitoneal placement of mesh, patches, and local flaps for repairing the LH. In this report we present a case of repair of a large recurrent congenital LH with free composite anterolateral thigh flap, tensor fascia lata flap and vastus lateralis flap (ALT-TFL-VL flap) and meshes. The patient underwent multiple cutaneous neurofibroma excisions before the treatment of LH. Recurrent neurofibroma and congenital aplasia of lumbar muscles at right flank may contribute to the patient's diffuse congenital LH development. Considering a large fascia defect (12 cm × 15 cm) with absence of lumbar muscles at the herniation site, using mesh alone is not strong enough to stop the herniation of bowel. Transposition of right pedicled ALT-TFL-VL flap (35 cm × 12 cm) with mesh was first attempted but proven to be futile, since the right lumbar wall bulged out from the distal border of previous reconstructed fascia. Thus, another free composite ALT-TFL-VL flap (35 cm × 15 cm) from left thigh was transferred on top of the previous pedicled flap, followed by delayed free flap advancement and surgical mesh addition. Post-operative course was smooth without complications. Twenty-one months after the surgery, computed tomography showed no recurrence of LH. Such case with large recurrent diffuse LH may be treated by a combination of conventional method with meshes and serial reconstruction with pedicled and free flaps for dynamic reconstruction of abdominal wall.

[Combined split ALT/TFL flap for soft tissue coverage in large thoracical defects]

BACKGROUND

Large, ulcerating tumors of the chestwall require soft tissue coverage after resection. Depending on size and location usually a latissimus dorsi flap, VRAM or TRAM flap is performed. In very large defects a combined split ALT/TFL flap is a new technique for coverage.

PATIENT AND METHODS

In 4 patients (3 female, 1 male) a soft tissue reconstruction after tumor resection was necessary. The mean age was 54 years. The mean size of the defect was 656 cm(2).

RESULTS

In 3 cases the coverage was achieved by a unilateral, and in 1 case a bilateral combined split ALT/TFL flap. All flaps healed without flap loss. The donor site closure was achieved primarily in 2 cases. In 3 cases a small split skin graft was needed.

CONCLUSION

The indications for combined split ALT/TFL flaps are large defects which cannot be covered by one single flap. The combination of these two long-known flaps on one pedicle is a new development.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Autologous tissue repair of large abdominal wall defects

Background and method

Techniques for autologous repair of abdominal wall defects that could not be closed primarily are reviewed. Medline and PubMed were searched for English or German publications using the following keywords: components separation technique (CST), Ramirez, da Silva, fascia lata, tensor fasciae latae, latissimus dorsi, rectus femoris, myocutaneous flap, ((auto)dermal) graft, dermoplasty, cutisplasty, hernia, abdominal wall defect, or combinations thereof. Publications were analysed for methodological quality, and data on surgical technique, mortality, morbidity and reherniation were abstracted.

Results and conclusions

The CST is the best documented procedure; it is associated with a high morbidity rate of 24·0 per cent and a recurrence rate of 18·2 per cent. Although the results of the da Silva technique are good (morbidity 5–20 per cent and reherniation 0–3 per cent), the poor methodological quality of the studies precludes firm conclusions. Repair with free fascia lata or dermal grafts is an alternative if the above techniques cannot be used, but wound complications affect 42 per cent of patients and recurrent hernia up to 29 per cent. Pedicled or free vascularized flaps are reserved for complex situations.

The role of bovine preserved peritoneum in rats ventral hernia: a histological evaluation

PURPOSE: To assess the role of preserved bovine parietal peritoneum as a material for hernia repair in a rat ventral hernia model. METHODS: An abdominal wall defect (15mm x 25mm) was created in Wistar male rats (n=40). Control animals (n=20) had the polypropylene (PP) mesh sutured into the defect, whereas bovine preserved peritoneum (BPP) was used in experimental group (n=20). After 7 and 28 days, the abdominal wall was taken off and histological studies of the amount of collagen by Sirius Red stain and morphometric evaluation consisted in quantitative analysis of the collagen by using specific software (Imagelab®). The Mann-Whitney, Kruskal-Wallis and ANOVA tests were applied for statistical analysis (pd"0.05). RESULTS: Histological examination revealed no difference between the BPP and PP groups (p = 0.55 NS). CONCLUSION: BPP is suitable for the closure of ventral hernias in rat model as shown by its morphological properties.

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.

Peritônio bovino conservado na correção de hérnia ventral em ratos: uma alternativa para tela cirúrgica biológica

OBJETIVO: Verificar a possibilidade de implantação e a capacidade de resistência tênsil do peritônio parietal bovino como tela cirúrgica na correção de hérnia ventral em um modelo animal de experimentação. MÉTODO: Utilizando 57 ratos machos Wistar, comparou-se o implante do peritônio bovino com a tela de polipropileno na correção de um defeito provocado na parede abdominal do animal. Após sete (sub-grupo A) e 28 (sub-grupo B) dias de observação, as peças foram retiradas e procedeu-se a avaliação da resistência à tração em Máquina Universal de Ensaios. Um grupo sem implante de material protético foi utilizado como controle nos testes de força tênsil. Os testes de Mann-Whitney e de Kruskal-Wallis foram utilizados e estabeleceu-se em 0,05 o nível para rejeição da hipótese de nulidade. RESULTADOS: Os testes de resistência à tração, com valores expressos em Newton, não mostraram diferenças estatísticas entre os grupos estudados, tanto no 7º quanto no 28º dia de pós-operatório, e ambos foram menos resistentes que a parede abdominal normal (p = 0,003). CONCLUSÃO: O peritônio parietal bovino apresentou resistência tênsil semelhante a da tela de polipropileno em um modelo de correção de hérnia ventral em ratos.

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.