Full-thickness Abdominal Wall Defects Research Articles

Pedicled omental split skin graft: A novel method for reconstruction of full-thickness abdominal wall defect

Although rare in children, aggressive fibromatosis or desmoid tumors require wide surgical excision for durable relief. The resultant defect poses many challenges for reconstruction. The authors report reconstruction of such a wound using a pedicled omental split skin graft, which resulted from the excision of a locally recurrent desmoid tumor.

PAUL-Procedure

Treatment of small congenital abdominal wall defects (e.g. omphalocele and gastroschisis) can be performed by direct closure. In large defects non-resorbable artificial materials (e.g. Gore-Tex) are necessary to close the fascia. The aim of this study was to find out whether a new procedure, the PAUL pocedure, might be suitable for the treatment of large abdominal wall defects. A full thickness abdominal wall defect was created in young Wistar Rats. These defects were then closed by implantation of a 1x2 cm sized piece of PTFE (Dual-Mesh), a polypropylene mesh (Prolene(R)) or by using the PAUL procedure. Over a period of 6 weeks no wound infections or hernias were monitored. In contrast to PTFE the PAUL procedure showed only minimal adhesion to the intestine and a high stability of the implanted material. A xenogenic extracellular matrix, such as that used in the PAUL procedure, may induce an immune response, which is comparable with a remodeling reaction rather than rejection. Based on these good results a large animal model study (Goettinger mini-piglets) was performed. No wound infections or hernias could be observed throughout the experiment. Control laparoscopy after 3, 6, 9, and 12 months showed only minimal adhesion to the intestine. Our results indicate that the PAUL procedure can be used easily and successfully for the therapy of congenital abdominal wall defects.

Repair of Complex Abdominal Wall Defects From High-Voltage Electric Injury With Two Layers of Acellular Dermal Matrix: A Case Report

High-voltage electric burn causing full-thickness necrosis of the abdominal wall and exposure of visceral organs is a real clinical challenge. This article reports a case of high-voltage electric burn causing a giant full-thickness abdominal wall defect. Seeing that it was unable to repair the abdominal wall defect with the conventional method, we used two layers of allogenic acellular dermal matrix substitutes to reconstruct and repair the defected abdominal wall. A 1-year follow-up showed that the abdominal wall of the patient recovered strong tenacity and strength without the evidence of significant complications.

Closing gastroschisis: diagnosis, management, and outcomes

Purpose Gastroschisis (GS) is defined as a full-thickness abdominal wall defect (usually right-sided) with intestinal prolapse and occasionally other viscera. The defect itself may close around the viscera causing exit or entry level intestinal atresia and ischaemia or midgut infarction, previously described as closed GS. We now report the largest series of infants born with various stages of closing GS describing features, management, and outcome. Methods The study used a single-centre retrospective review of infants with GS and evidence of defect closure at birth. Results Nine infants (6 girls) with a median of 35 (range, 32-36) weeks of gestation fulfilled criteria for closing GS from a series of 146 (6%) infants born from August 1994 to December 2007. Delivery had been expedited in 6 based on increasing intraabdominal bowel dilatation and suspicion of closing GS on serial antenatal ultrasound. At delivery, 5 had compromised but viable bowel and required intestinal surgery. Three fetuses, all with midgut necrosis, had antenatal scans typical of GS with no additional features. After a variety of surgical procedures, 7 patients are now fully enterally fed, one is parenteral nutrition-dependent. One died of end-stage liver failure secondary to short bowel syndrome. The length of follow-up was 6 (range, 0.5-11) years. Conclusions Of infants with GS, 6% present with closing abdominal ring. Close antenatal monitoring may prevent severe bowel loss in some cases. After multiple surgical interventions, most have a favorable outcome.

Experimental comparison of abdominal wall repair using different methods of enhancement by small intestinal submucosa graft

To assess the biomechanical properties of full-thickness abdominal wall defects, either using Native tissues, with or without Overlay, and by substitution of the Defect by small intestinal submucosa mesh. Seventy-two rats were divided into three groups according to repair method (Native, Overlay or Defect). At 7, 14, 30, and 90 days, six rats were sacrificed to measure tensile strength, collagen ingrowth, and host response. Explants had comparable strength at 30 days, the majority rupturing at the interface. Afterwards, the Native group was more resistant than both small intestine submucosa (SIS) groups with a more organized fibrotic scar on histology at 90 days. SIS augmentation of native tissue repair does not increase strength. Replacement of abdominal wall by SIS is equally strong when compared to the SIS-augmented group; however, materials preferably rupture at the site of the implant itself.

GABBY: Anex vivomodel for learning and refining the technique of preformed silo application in the management of gastroschisis

Gastroschisis (GS) is a congenital full-thickness defect of the anterior abdominal wall, whose incidence is increasing. Traditional postnatal management options include primary reduction and closure under general anaesthetic or operative silo construction for defects judged to be unsuitable for immediate repair. The cot-side application of the preformed silo (PFS) with delayed abdominal wall closure has recently been advocated as the management method of choice for infants with GS. We report a novel trainer designed to facilitate acquisition and refinement of the skills to apply the PFS. A model of an infant with GS was constructed to allow application of a PFS. Each step of the clinical application of a PFS could be simulated. Paediatric surgeons at a regional meeting participated in evaluating the model. This cohort was surveyed with regards to previous clinical experience applying the PFS, invited to apply the silo on the model and then resurveyed with regard to the technique, ease of the application of the PFS on the model, its robustness and potential use as a training tool. Seventeen paediatric surgeons completed the surveys and applications of the PFS on the model. Under supervision, each step of the procedure was completed by all participants. Feedback was enthusiastic and positive and participants judged the model to be realistic and potentially very useful as a training tool (median score 8 out of 10). We have developed and evaluated a reproducible, low-cost model of an infant with GS. This ex vivo trainer may be a useful adjunct in the acquisition and refinement of the skills of surgeons who manage GS using a PFS.

Blood vessel matrix: a new alternative for abdominal wall reconstruction

Biologic matrices offer a new approach to the management of abdominal wall defects when the use of other foreign material is not ideal. A member of our team (GEA) developed a biological decellularized matrix generated from harvested blood vessels of swine blood vessel matrix (BVMx). The aim of our study was to investigate whether this novel collagen-based biological matrix is safe and effective for the repair of abdominal wall hernia defects in a rat model. Full thickness abdominal wall defects were created in rats and repaired with our BVMx. After implantation as an underlay for 30 and 90 days, animals were sacrificed and the implanted material evaluated for herniation, adhesions, breaking strength, inflammation, and revascularization. No evidence of herniation was noted at 30 (n = 7) or 90 (n = 7) days after repair. Adhesions, if present, were filmy and easily separated. The mean area of visceral adhesions to the BVMx was 18.9 +/- 11.0% at 30 days and 7.1 +/- 3.1% at 90 days post implantation (P = 0.33). The breaking strength of the BVMx-fascial interface was 4.5 +/- 0.8 N at 30 days and 4.5 +/- 2.4 N at 90 days post implantation (P = 0.98). Histologic analysis demonstrated that the BVMx elicited a mild transient inflammatory response and supported fibroblast migration, deposition of newly formed collagen, and neovascularization. These data confirm that this BVMx supports vascular ingrowth and provides adequate strength for the repair of abdominal wall defects. Future studies in a large animal model are required to assess its validity for human application.

Fate of collagen-based implants used in pelvic floor surgery: A 2-year follow-up study in a rabbit model

The purpose of this study was to compare the long-term host response to 2 different collagen matrices versus macroporous polypropylene mesh. Four full-thickness abdominal wall defects in 35 rabbits were reconstructed with either polypropylene (Prolene), porcine dermal (Pelvicol), or small intestine submucosal collagen matrix (SIS). Animals were sacrificed on day 30, 60, 90, 180, 365, 540, and 720 days to evaluate morphologic and biomechanical properties of explants. Prolene provoked a fibrotic reaction within 30 days. SIS was entirely replaced by a thin fibrotic layer within 60 days. Pelvicol was encapsulated, remaining structurally unchanged up to 180 days. Thereafter, half underwent degradation by a foreign body reaction. Prolene was integrated by an increasingly organised fibrotic scar while SIS was entirely remodelled within 60 days. Pelvicol implants underwent late onset (> or = 180 days) degradation. After 2 years of implantation there were no differences in tensiometric strength between the 3 different materials.

The influence of porosity on the integration histology of two polypropylene meshes for the treatment of abdominal wall defects in dogs

Two types of monofilament polypropylene mesh with different pore sizes, mass densities and burst strengths were used to repair two identical paired full-thickness abdominal wall defects in ten dogs, in order to compare their integration histology 90 days after implantation. On one side a standard mesh, Prolene (Ethicon), was sutured to the borders of the defect, while on the other a new ultralightweight macroporous mesh, Mpathy mesh, was used. There was a significantly greater densitometric proportion of mature (type I) collagen (58.38%) for Mpathy mesh compared to Prolene (34.05%, P=0.01). Although Prolene has 3.6 times the burst strength of Mpathy mesh, the implanted tissue strength was marginally greater for Mpathy mesh. We conclude that Mpathy mesh gives a surgical repair that is at least as strong as that provided by Prolene, along with a higher concentration of mature collagen and less fibrosis (P=0.07), in this canine histology model.

Risk stratification of 4344 patients with gastroschisis into simple and complex categories

Background Gastroschisis is a congenital full-thickness abdominal wall defect characterized by the protrusion of intraabdominal organs outside the abdominal domain that requires surgical management in the early neonatal period. The goal of this study was to validate a previous risk stratification classification of infants born with this defect. Methods A retrospective analysis of a nonoverlapping combination of the databases National Inpatient Sample and Kids' Inpatient Database (1988-2003) was performed. These combined databases contain information from nearly 93 million discharges in the United States. Infants with gastroschisis were identified by an International Classification of Diseases, Ninth Revision procedure code of 54.71 (repair of gastroschisis) and an age at admission of less than 8 days. Infants were divided into simple and complex categories based on the absence or presence of intestinal atresia, stenosis, perforation, necrosis, or volvulus. Variables of sex, race, geographic region, coexisting diagnoses, hospital type and charges adjusted to 2005 dollars, length of stay, inpatient mortality, and complications were collected. Comparison between the 2 groups was performed using Pearson χ 2 for categorical outcomes and the Kruskal-Wallis test for non-normally distributed continuous variables. Results A total of 4344 infants with gastroschisis were identified and divided into simple and complex categories. Simple gastroschisis represented 89.1% (n = 3870) of the group, whereas 10.9% (n = 474) had complex disease. Simple and complex patients differed in coexisting cardiac disease (8.3% vs 11.8%, P = .01), hospital type (78.7% vs 84.1% treated at urban teaching centers, P < .01), median length of stay (28 vs 67 days, P < .01), median inflation-adjusted hospital charges ($90,788 vs $197,871; P < .01), and inpatient mortality (2.9% vs 8.7%, P < .01). Gastrointestinal (14.4% vs 83.5%, P < .01), respiratory (2.6% vs 4.6%, P = .01), and infectious disease complications (24.3% vs 45.4%, P < .01) also differed between the groups. Conclusions These data use the largest data set to date to validate the risk stratification of infants with gastroschisis. This analysis improves the characterization and understanding of clinical subsets of infants in whom this congenital condition is diagnosed.

Evaluation of a new composite prosthesis for the repair of abdominal wall defects

The degree of integration of biomaterials used in the repair of abdominal wall defects seems to depend upon the structure of the prosthesis. The present investigation evaluates the behaviour in terms of adhesion formation and integration of a new composite prosthesis that could be employed in this clinical application. Full-thickness abdominal wall defects (7 x 5 cm) were created in 16 anaesthetized New Zealand white rabbits and the prosthesis were placed in direct contact with the visceral peritoneum during the experiment. The defects were repaired with a composite prosthesis or pure polypropylene mesh to establish two study groups (n = 8 each). The composite device was constituted by a polypropylene mesh physically attached to a poly(ether)urethane-polydimethylsiloxane laminar sheet. Animals were sacrificed 7, 14, 21 and 30 days after implant and prosthesis/surrounding tissue specimens subjected to light and electron microscopy. Firm adhesions were detected in the polypropylene implants, while they were not present in the composite implants. The excellent behaviour of the composite prosthesis shown in this study warrants further investigation on its use for the repair of abdominal wall defects when a prosthetic device needs to be placed in contact with the intestinal loops.

Definitive reconstruction of full-thickness abdominal wall defects initially treated with skin grafting of exposed intestines

The reconstruction of wide, full-thickness abdominal wall defects of the midline presents a continuing challenge, and consensus concerning the appropriate surgical treatment is lacking. In this retrospective review, we describe a simple method of reconstruction in full-thickness defects initially treated with skin grafting directly on to the surface of the intestines. Instead of removing the split-thickness grafts from the surface of the intestines, the abdominal wall was reconstructed by inverting the grafted area and advancing the rectus muscles towards the midline. Four patients with full-thickness transverse defects larger than 10 cm at the level of the waist and extending from the xiphoid to the suprapubic region were operated with this method. All healed uneventfully. In one case, microscopic examination of the inverted skin showed transformation to normal connective tissue. Reconstruction of abdominal wall defects previously treated with skin grafting directly on to the intestines can be safely done by reposition of the skin-grafted intestines into the abdominal cavity and realignment of the rectus muscles in the midline.

Prosthetic mesh for infected abdominal wall defects? Report of a patient with a large full thickness abdominal wall defect and colostomy due to a gunshot wound

Reconstruction of large, infected abdominal wall defects is often difficult. Local factors, such as defect size, presence of infection, adequate skin coverage and presence of enteric fistulae dictate the reconstructive method that can be used. Placement of prosthetic mesh materials into infected defects was generally not recommended due to a high rate of extrusion and fistulae. We present a patient with a large infected abdominal wall defect, exposed intestines and colostomy due to a gunshot wound that was successfully treated with a polypropylene mesh reinforcement and free latissimus dorsi muscle flap coverage. Twelve months following abdominal wall reconstruction with stable soft tissue cover, the patient is without any signs of hernia or infection. We conclude that prosthetic mesh repair of infected abdominal wall defects of such characteristics that preclude other reconstructive procedures can be attempted provided there is coverage with a well vascularised tissue.

Effect of Preservation Methods on the Performance of Bovine Pericardium Graft in a Rat Model

This study investigates the effect of preservation methods on the performance of bovine parietal pericardium grafts in a rat model. Mid-ventral full thickness abdominal wall defects of 3 x 2.5 cm in size were created in 90 male Sprague-Dawley rats (300-400 g), which were divided into three groups of 30 rats each. The abdominal defects of group one and two were repaired with lyophilized and glycerolized bovine pericardium grafts, while the defects of group three were repaired with expanded polytetrafluoroethylene (ePTFE) Mycro Mesh as a positive control. Another group of 30 rats underwent sham operation and was used for comparison as negative control. Each group of rats (n = 30) was divided into five subgroups (n = 6) and killed at 1, 3, 6, 9 and 18 weeks post-surgery for gross and morphological evaluations. The rats tolerated the surgical procedure well with a total mortality of 0.05%. No serious post-operative clinical complications or signs of rejection were encountered. Adhesions between the grafts and the underlying visceral organs observed in the study were mostly results of post-surgical complications. Glycerol preservation delayed degradation and replacement of the grafts, whereas lyophilization caused early resorption and replacement of the grafts. The glycerolized grafts were replaced with thick dense fibrous tissue, and the lyophilized grafts were replaced with thin loose fibrous tissue. The healing characteristic of the bovine pericardium grafts was similar to those of the sham-operated group, and quite different from those of the ePTFE Mycro Mesh. The outcome of the present study confirmed the superiority of glycerolized bovine pericardium grafts over its lyophilized counter part.

Bilateral anterior abdominal bipedicle flap with permanent prosthesis for the massive abdominal skin-grafted hernia

Background Fascial closure after damage control or decompression laparotomy is not always possible. The result is a ventral hernia covered with skin grafts. Massive hernias impair bowel, bladder, and respiratory function and are displeasing aesthetically. Most repair methods provide inadequate closure of large full-thickness abdominal wall defects. We describe our method of repair using bilateral anterior abdominal bipedicle flaps over permanent mesh. Methods We reviewed 6 patients who underwent this repair method. This staged repair first involves flap elevation followed by delay. In the next stage, the hernia skin graft is excised, mesh is placed, and flaps are advanced to midline to cover the mesh. Results The average hernia size was 885 ± 274 cm 2 (28-cm wide × 31-cm vertical), with a range of up to 37-cm wide. An average of 3 surgeries were required for closure, with a mean hospital stay of 22 days. No patients developed hernia recurrence with a mean follow-up period of 23 months. Conclusions This method provides successful and durable closure of massive skin-grafted hernias.

Long-lasting bioresorbable poly(lactic acid) (PLA94) mesh: a new approach for soft tissue reinforcement based on an experimental pilot study

The purpose of this study was to evaluate host response and soft-tissue regeneration after poly(lactic acid) (PLA) mesh implantation in a rat model, in comparison with light-weight polypropylene (PPL) and poly(glycolic acid) (PGA) meshes. Full-thickness abdominal wall defects were created in 45 Wistar rats and reconstructed with 15 PLA(94), 15 PPL and 15 PGA meshes. Animals were killed on days 7, 30 and 90 to evaluate the presence of adhesions and changes in tensile strength of the implants. Histopathology and immunohistochemistry were performed to evaluate the collagen deposition and the inflammatory response. Statistics were done using unpaired Student's t-test, Mann-Whitney rank sum test, Student-Newman-Keuls test and Bonferroni (Dunn) t-test. The inflammatory response induced by the PLA mesh implantation was significantly milder than after PPL mesh. In PLA, vascularity and collagen organization was significantly higher than in PPL and PGA at 30 and 90 days, and collagen composition score was significantly higher than in PPL at 7 and 30 days. In PLA, shrinkage was significantly lower than in PPL and PGA at 7 and 30 days. Elongation at break and tensile strength were comparable between PLA and PPL over the 90-day period. The PLA mesh induces a milder inflammatory response, more orderly collagen deposition than PPL, and preserved comparable tensile strength after 90 days.

Repair of a full-thickness abdominal wall defect with an innervated latissimus dorsi free flap

A 38-year-old man developed an infection that led to necrosis of the abdominal wall after perforation of a gastric ulcer. A split-thickness skin graft over the abdominal viscera was used to achieve temporary primary closure. After full systemic and local stabilisation, it was reconstructed with a free innervated latissimus dorsi myocutaneous flap.

Tensile strength and host response towards different polypropylene implant materials used for augmentation of fascial repair in a rat model

We compared inflammatory response, fibrosis and biomechanical properties of different polypropylene materials from one manufacturer (Tyco Healthcare) in a rat model for primary fascial repair. Full-thickness abdominal wall defects were primarily repaired using 'overlay' technique. Multifilament implants were Surgipro SPM and SPMW, the latter a wider-weave type of the former. Monofilament SPMM implants and polypropylene suture repair (Surgipro II) served as controls. Explants were evaluated macroscopically and changes in thickness, shrinkage and tensile strength were measured. Inflammatory and connective tissue response was assessed on haematoxylin-eosin and Movat stains. Immunohistochemistry was done to localise rat macrophages/monocytes. Multifilament materials induced a shorter acute inflammatory response and more pronounced chronic inflammatory reaction compared to monofilament implants. Macrophages could be found deep in interstices 7.5 by 12.5 microm. No difference in collagen deposition and neovascularisation was observed. At 90 days time point, explants reconstructed with tighter woven multifilament SPM were weaker than sutured or SPMM controls. Overall shrinkage of 10% was comparable for all groups.

Acellular dermal graft for repair of abdominal wall defects in rabbits

Sixteen clinically healthy New Zealand white rabbits of either sex were divided into 2 equal groups (I and II) of 8 animals each. Under thiopental sodium (2.5%) anaesthesia a 2 x 3 cm full-thickness abdominal wall defect in the mid-ventral abdominal wall was created and repaired with an acellular dermal graft (ADG) in all the animals of group I (test group). In animals of group II (control group) a full-thickness linear midline abdominal muscular wall incision was made and repaired with a continuous suture pattern using 2-0 nylon.

Myoblast–Acellular Skeletal Muscle Matrix Constructs Guarantee a Long-Term Repair of Experimental Full-Thickness Abdominal Wall Defects

To obtain a valuable treatment of congenital muscle defect, cell-matrix constructs composed of satellite cell-derived myoblasts (XY karyotype) seeded on muscle acellular matrices were used to repair a previously created full-thickness defect of abdominal wall of 18 1-month-old female Lewis rats. Acellular abdominal matrices, obtained by a detergent-enzymatic method, were positive for both basic fibroblast growth factor and transforming growth factor-beta, and were able to support in vitro cell adhesion. All animals survived the surgery, without signs of infection or implant rejection, and were humanely killed at 1, 3, or 9 months after surgery. The implants appeared well preserved, were integrated in the host tissue, and maintained their original dimension and thickness until 9 months. Vesicular acetylcholine transporter was expressed on the surface of muscle fibers from 1 month postsurgery. Finally, implanted male myoblasts were present inside the patches until 9 months, as demonstrated by the expression of SrY mRNA and by the presence of Y chromosome probe signal. These results allow us to conclude that cell-matrix constructs could represent a promising approach to the repair of muscle defects, because they are repopulated in vivo by skeletal muscle cells and nervous elements and maintain their structural integrity over the long term.