The pararectus approach to harvest large scale of vascularized iliac crest. An anatomical study of feasibility

Abstract

The use of the vascularized iliac crest to reconstruct bone defect has been published in 1979 but has gained very little popularity in the fields of the reconstructive surgery of the extremities. The usual approach to harvest vascularized iliac crest goes through the inguinal ligament. Up to 10% of inguinal hernia and above 20% of sensory loss have been reported as complication with this approach. On the other hand, the iliac crest offers larger amount of rapidly integrated cancellous bone as compared to vascularized fibula. The pararectus approach has been initially used for internal fixation of acetabular fractures. This approach gives direct access to the branches of the external iliac artery without interruption of the inguinal ligament. In this anatomical study, 5 human specimens preserved with the Thiel-Method and injected with colored latex were harvested on both side with the pararectus approach. The goal of the study was to assess if this approach gives easily access to the deep circumflex iliac artery (DCIA) vascularizing the anterior iliac crest. The approach consisted into an incision of the rectus sheath at the lateral border of the rectus abdominis and then to a retrograde dissection the deep inferior epigastric vessels up to the external iliac artery and veins in the retroperitoneal space. In all specimens, the level of the origin of the deep circumflex iliac vessels coincided with the origin of the deep inferior epigastric vessels on the external and internal border of the external iliac vessels, respectively. To harvest large scale vascularized iliac crest the pararectus approach was extended to the supraumbilical level with incision of the anterior and posterior sheath of the rectus abdominis. With this approach, the maximum size of harvested bone was 8 × 5 cm, preserving the first 2 cm of the anterosuperior iliac spine. In all harvested sides, the anterograde dissection of the lateral femoral cutaneous nerve and of the genitofemoral nerve was easy and allowed a safe harvest of the deep cicumflex iliac vessels. In conclusion, the pararectus approach extended to the supraumbilical space give an easy access to the deep circumflex iliac vessels and very large size of vascularized iliac crest. This approach respects the inguinal ligament and is easy to close. We are now using this approach in a preliminary clinical study to harvest vascularized iliac crest of large scale.