Dynamic Abdominal Wall Research Articles

Intersection-splitting Deep Inferior Epigastric Perforator Flap.

Summary:Preserving a dynamic abdominal wall is the premise behind the evolution of TRAM flaps into deep inferior epigastric perforators (DIEPs). Performing a true DIEP flap requires a highly refined surgical technique and often times involves a tedious intramuscular dissection which may account for the slow, albeit steady adaptation of DIEPs in breast reconstruction. This article intends to address a scenario in which an additional perforator from a different row is needed. Based on our current knowledge of the abdominal wall and its embryology, we propose splitting the rectus abdominis muscle through the intersections while recruiting a second perforator instead of converting the procedure into MS-TRAM or performing a second anastomosis through the perforator exchange technique, APEX. This potentially saves time and simplifies the procedure while maintaining the integrity of the abdominal wall.

Innervated Pedicled Gracilis Flap for Dynamic Abdominal Wall Reconstruction.

Abdominal wall reconstruction for full-thickness defects is a challenging procedure that usually requires the use of flaps. The gracilis flap is known to be used in hernia repair in which the abdominal muscles are still intact, but there are no reports in literature describing the use of an innervated gracilis for dynamic abdominal wall reconstruction after tissue loss due to severe trauma. We present a surgical technique in which the gracilis is harvested preserving the neurovascular pedicle, then tunneled underneath the adductor longus to cover the lower abdominal defect and provide it with basal muscle tone without tension on the pedicle. This results in restored integrity of the musculofascial abdominal wall and dynamic muscle function and support. The gracilis flap has been proven to be useful and versatile in reconstructive surgery with great potential in abdominal wall reconstruction having minimal donor-site morbidity and hernia recurrence risk.

Open abdomen management by vacuum with and without dynamic abdominal wall traction

Open abdomen management by vacuum with and without dynamic abdominal wall traction

Delayed dynamic abdominal wall closure following multi-visceral transplantation

INTRODUCTIONPrimary closure of the abdominal wall following intestinal transplantation or multivisceral transplantation could become a challenging problem in a significant number of patients. PRESENTATION OF CASEA 38-year-old woman with familial adenomatous polyposis (FAP) underwent a multi-visceral transplantation for short gut syndrome. She subsequently developed acute graft rejection that proved resistant to conventional treatment. She was relisted and underwent re-transplantation along with kidney transplantation. Abdominal wall closure could not be achieved because of the large size of the graft and bowel oedema. The wound was initially managed with laparostomy followed by insertion of the delayed dynamic abdominal closure (DDAC) device (Abdominal Retraction Anchor – ABRA® system). Continuous dynamic traction to the wound edges resulted in gradual approximation and complete closure of the abdominal wound was achieved within 3 weeks. DISCUSSIONSuccessful abdominal closure after multivisceral transplantation or isolated intestinal transplantation often requires biological mesh, vascularised flaps or abdominal wall transplantation. DDAC eliminated the need for a prosthetic mesh or skin graft and provided an excellent cosmetic result. Adjustment of the dynamic traction at the bedside minimised the need for multiple returns to the operating theatre. It resulted in a well-healed linear scar without a hernia. CONCLUSIONDynamic traction allows delayed closure of laparotomy resulting in strong and cosmetically sound wound healing with native tissue.

Modified components separation technique for TRAM flap donor site closure

Sir, Components separation is a method of abdominal closure for complex abdominal wall defects first described by Ramirez et al. in 1990 [1]. Since then several modifications have been described [2–4], and these methods achieve local fascial approximation whilst maintaining dynamic abdominal wall function. The most common method involves transection of the external oblique aponeurosis just lateral to the linea semilunaris, with separation of the external oblique from the internal oblique muscle laterally (Fig. 1). This plane is relatively aneurovascular, preserving vascularity and innervation to the anterior abdominal wall. When required, further gain can be achieved by additional separation of the posterior rectus sheath from the rectus abdominal muscle or by releasing the external oblique muscle laterally. The defect created is then usually reinforced with prosthetic mesh repair. Following transverse rectus abdominis musculocutaneous (TRAM) flap harvest, direct fascial approximation is desirable as it results in a low risk of abdominal bulge and hernia formation [5], however where this is not possible, techniques such as inlay of prosthetic mesh or acellular dermal matrix are required to achieve abdominal closure. We have found a novel technique of limited components separation to have great utility following free muscle-sparing TRAM flap harvest without any bulges or hernias occurring to date. The linea semilunaris is first incised along the lateral border of the defect and the external oblique aponeurosis mobilized (Fig. 2a, b). The extent of the undermining is sufficient to allow advancement to gain direct fascial closure without tension (Fig. 3a). The external oblique aponeurosis is then reapproximated with the anterior lamina of the internal oblique aponeurosis at the linea semilunaris with horizontal mattress nonabsorbable sutures to restore normal anatomy and to ensure that fascial closure is tensionless (Fig. 3b). The fascial defect is then closed using horizontal mattress nonabsorbable sutures. A prosthetic mesh inlay may be utilized in addition to further reinforce the closure, assessed on an individual case basis, which is fully covered with vascularized tissue, which we consider desirable and may help to reduce the potential for infection. This simple modification of the components separation technique extends the range over which direct fascial approximation at the donor site may be achieved whilst simultaneously reducing tension at the site of primary fascial repair. In addition we advocate reconstruction of M. Schaverien (*) Department of Plastic Surgery, Ninewells Hospital, Dundee DD1 9SY, UK e-mail: markschaverien@fastmail.fm

Tissue Compression Analysis for Magnetically Anchored Cautery Dissector During Single-Site Laparoscopic Cholecystectomy

IntroductionThe purpose of this study was to evaluate the histological effects of dynamic abdominal wall compression using the magnetic anchoring and guidance system (MAGS) platform. MethodsCholecystectomy was performed in two nonsurvival and two survival pigs using a single-site laparoscopic (SSL) approach. A deployable MAGS cautery dissector was used to perform the entire dissection in conjunction with a laparoscope and other instruments. The abdominal wall areas corresponding to the region occupied by the MAGS platform were examined grossly and microscopically for signs of tissue damage. Gallbladder dissection time was 36 min with no complications. Compressed abdominal wall thickness was 1.4 cm. ResultsIn all four animals, a very mild skin erythema was noted immediately postprocedure but was nonvisible within 20 min. Mild peritoneal blanching was noted in two animals, and one animal exhibited a 5-mm area of petechiae. Necropsy demonstrated no adhesions. Light microscopy documented no evidence of tissue injury for all specimens. DiscussionThis study demonstrated that the use of the MAGS cautery dissector for a SSL cholecystectomy was advantageous in providing triangulation and did not result in any significant gross or microscopic tissue damage despite the thin abdominal wall of the porcine model.

Early Results of Midline Hernia Repair Using a Minimally Invasive Component Separation Technique

A minimally invasive component separation may lead to a dynamic abdominal wall after hernia repair, with reduced complications. We present early results of our patients undergoing this technique. Five patients were selected for open midline repairs; three with chronic infections, one with a prior midline skin graft, and one who desired a primary, tension-free repair. These three males and two females had a mean age of 50.8 +/- 21.1 years and body mass index of 30.9 +/- 6.2. The mean number of previous abdominal operations was 7 +/- 3.4 and previous attempted hernia repairs were 4 +/- 2.7. All patients had a midline laparotomy with lysis of adhesions. An endoscopic component separation was then performed bilaterally. Drains were left in the dissection bed. All patients had the midline closed; four received biologic mesh underlays. Mean operative time was 227 minutes +/- 49. Mean length of stay (LOS) was 9.2 days +/- 3.6. Early median follow-up was 6 months (range 0.25-9). Two patients required postop transfusions, and two patients had mild complications of the midline wound (hematoma, infection). To date, one recurrence was diagnosed by CT scan. Early evaluation of adopting the minimally invasive (MIS) component separation demonstrates minimal complications and good initial outcomes.

Use of Abdominal Wall Allotransplantation as an Alternative for the Management of End Stage Abdominal Wall Failure in a Porcine Model

We describe a novel approach for treating end stage abdominal wall failure using isolated abdominal wall allotransplantation in a porcine model. Full thickness abdominal wall transplants were performed in 13 pairs of genetically mismatched pigs. All recipients received daily immunosuppresion after transplantation. Rejection was assessed by visual inspection and skin biopsies. At the end of the 28 d study period, thickness, stiffness, and tensile strength of the transplanted rectus muscle was measured and compared with native rectus muscle. Eight grafts were viable and showed no signs of herniation. Four grafts failed within the first week secondary to vascular thrombosis. One animal had viable graft but was euthanized due to an incarcerated inguinal hernia. Rejection was minimal in six of the eight recipients. At necropsy, the gross thickness of the transplanted muscle flap was reduced compared with the native muscle (4.3 mm versus 7.7 mm, P < 0.001). Histologically, the diameter of the muscle fiber decreased from 0.15 mm to 0.09 mm (P < 0.0001). While the stiffness measurements between the transplanted and native muscles were comparable, the transplanted muscles had significantly lower tensile strength than the native muscles. This study demonstrates the feasibility of isolated abdominal wall allotransplantation to provide a potential solution for end stage abdominal wall failure. Based on the model set forth, future work will evaluate the biomechanical properties of the composite allograft to provide a suitable dynamic abdominal wall replacement.

Recalcitrant abdominal wall hernias: long-term superiority of autologous tissue repair.

Secondary repair of recurrent ventral hernia is difficult, and success depends on re-establishing the functional integrity of the abdominal wall. Current techniques used for closure of these defects have documented recurrence rates as high as 54 percent. The authors' 8-year experience utilizing variations of the components separation technique for autologous tissue repair of recalcitrant hernias emphasizes that recurrent or recalcitrant hernias benefit from the creation of a dynamic abdominal wall. A total of 389 patients were retrospectively identified as having abdominal wall defects, and 284 of these patients met the selection criteria. Study patients were grouped according to the type of surgical repair used. The recurrence rate was 20.7 percent over all study groups and was directly related to the extent of repair required. Group 1 patients (wide tissue undermining) had a recurrence rate of only 15 percent, while in group 2 (complete components separation), the recurrence rate was 22 percent. Group 3 patients (interpositional fascia lata graft) had a 29 percent recurrence rate. Time to recurrence was also significantly different across treatment groups, with study group 3 experiencing earlier hernia recurrence. The most frequent postoperative complication was wound infection, which was directly related to the repair performed. The relative odds of recurrence versus the risk factors of age, sex, perioperative steroid use, wound infection, defect size, and the presence of enterocutaneous fistula were studied with a logistic regression analysis. These factors did not possess statistical significance for predicting hernia recurrence. The preoperative presence of mesh was independently significant for hernia recurrence, increasing the relative odds 2.2 times (p = 0.01). Similarly, when other risk factors were controlled for, increasing the complexity of the treatment group, from study group 1 (wide tissue undermining) to study group 3 (interpositional fascia lata graft), also increased the odds of hernia recurrence 1.5-fold per group (p = 0.04). Average inpatient cost was $24,488. The length of inpatient stay ranged from 2 to 172 days (average, 12.8 days). The length of inpatient stay and costs were directly related to the extent of repair required. Using the analysis of variance test for multiple factors, the presence of an enterocutaneous fistula (p = 0.0014) or a postoperative wound infection (p = 0.008) independently increased the length of inpatient stay and hospital costs. A total of 108 successfully repaired patients were contacted by telephone and agreed to participate in a self-reported satisfaction survey. The patients noticed improvements in the appearance of their abdomen, in their postoperative emotional state, and in their ability to lift objects, arise from a chair or a bed, and exercise. These results suggest that recalcitrant hernia defects should be solved, when possible, by reconstructing a dynamic abdominal wall.

Reconstruction of abdominal-wall midline defects--The Abdominal-Wall Components Separation

The recurrence rate of midline defects like incisional hernias is high. Alloplastic material in sublay or onlay technique is often be used if the suture tension is to high for a primary closure. Free or pedicled musculocutaneous flaps transfer denervated muscle and lack dynamic resistance against the intraabdominal pressure. The separation of the lateral abdominal wall achieves autogenous, dynamic material for a tension free closure in small and moderate midline defects. In 1990 Ramirez described a technique, which separates parts of the lateral abdominal wall and advances it towards the midline. The innervation and blood supply of the advanced part is maintained. With this technique it is possible to close defects tension free with dynamic abdominal wall. 9 patients were treated with this technique and followed up. Midline defects up to 16 cm at the waistline could be closed without tension. There were no major complications (one small delayed wound healing). There were no recurrences in a follow up time of 14.2 months. The separation of parts of the lateral abdominal wall can achieve tension free closure of e.g. incisional hernias of small and moderate size. The advancement of the medial component provides well innervated muscle for dynamic resistance against the abdominal pressure.