Tissue Engineered Abdominal wall repair of Cloacal Exstrophy

Abstract

PURPOSE Cloacal exstrophy (CE) patients have severe abdominal wall reconstructive problems due to pelvic skeletal malformation, deficiency of abdominal wall tissue, and a small shallow abdominal cavity. This can result in would dehiscence, hernias, stomal prolapse, and abdominal compartment syndrome. In order to close the abdominal wall defect and to internalize the GI and urinary tracts these tissues must be removed from the abdominal wall leaving a significant tissue shortage. We present a novel approach to safely close the abdominal cavity using tissue engineered fascial substitute and a rectus muscle flap. MATERIAL AND METHODS Nine CE patients were reconstructed in a variety of methods. Once the bladder and gut were closed all had a severe deficiency of abdominal wall tissue. Three patients were treated with fascial replacement and rectus muscle flaps designed to add tissue to the abdominal wall. RESULTS Eight patients had 9 episodes of wound dehiscence or bladder prolapse, 5 large incisional hernias, and 8 significant ostomy prolapses. One suffered life threatening abdominal compartment syndrome. 21 of 25 attempts to close the abdominal wall were unsuccessful due to inadequate abdominal wall tissue and despite the use of pelvic osteotomies, rectus muscle flaps, relaxing incisions, and in one case a small SIS graft. Only three procedures were successful (no dehiscence, no prolapse, no incisional hernia, no necrosis) and all utilized extensive commercially available tissue engineered fascial substitutes (Alloderm) and pedicle rectus muscle flaps to provide blood supply to the graft. CONCLUSIONS CE patients benefit from having uneventful and early internalization of their abdominal viscera. Large abdominal wall defects resulting from closing viscera continue to be a major source of morbidity. Repair with commercially available tissue engineered fascial substitutes and rectus muscle flaps seems to be an efficient and safe method of reconstructing the abdominal wall in children with cloacal exstrophy.