Dynamic reconstruction of complex abdominal wall defects with the pedicled innervated vastus lateralis and anterolateral thigh PIVA flap

Abstract

Reconstruction of large and chronically infected recurrent abdominal wall defects with exposed bowel in a scarred wound environment, when component release has been previously performed but failed, is a veritable challenge. We use a pedicled innervated vastus lateralis muscle with a fasciocutaneous anterolateral thigh flap (PIVA flap) to restore the continuity of the abdominal wall with vascularised tissues and create a dynamic component that improves the functional outcome. A one-stage PIVA flap was used in 15 patients with grade 4 transmural chronically infected defects. They had a mean of 4.53 previous laparotomies and important co-morbidities. We determined post-operative reconstructive abdominal wall strength using a validated quality-of-life (QoL) hernia-related questionnaire and modified it to quantify donor-site morbidity at the thigh. We measured the maximal force generated at 60°/s and the force velocity at 120°/s by isokinetic dynamometric analysis at 3 and 12 months. Electromyography (EMG) was performed 12 months after the reconstruction to analyse the contractile integrity of the vastus lateralis segment. A two-sided sign test was used to analyse data. All transmural chronic wounds healed without recurrence. Dynamometric strength increased significantly in the abdominal wall musculature (p<0.016) and in the donor thigh (p<0.023) between 3 months and 12 months after the intervention, which reflected in the EMG outcome and the high scores in the QoL measurements after 12 months. The PIVA flap revascularises the scarred milieu, adds a dynamic component to improve function and may reach up to the xiphoid process. Donor-site morbidity is limited.