Large Abdominal Wall Defects Research Articles

Predictors of hernia recurrence after Rives-Stoppa repair in the treatment of incisional hernias: a retrospective cohort.

Rives-Stoppa retromuscular repair (RSR) has been traditionally used to provide adequate coverage for large abdominal wall defects and appears to be more advantageous compared to other surgical techniques concerning complications and recurrence rates. The aim of this study was to identify the independent predictors associated to hernia recurrence after RSR in the treatment of incisional hernias. This is a retrospective observational study of 213 patients who underwent RSR between June 2007 and January 2014 at a tertiary centre. Main inclusion criteria were adults with midline hernia classified as M1, M2, M3, M4, or M5, according to EHS classification. All the cases presented a transverse hernia defect measurement greater than 5cm (grades W2 and W3). Recurrence rate was determined by clinical examination plus confirmation by abdominal CT scan. At a median of 57.6 months (range 46-75 months) of postoperative follow-up, we reported 15 cases of recurrence (7.1%). Recurrences occurred after a mean period of 19.4 months (range 2-49 months). On multivariate analysis, steroid or immunosuppressive drugs use (OR 2.02; CI 1.16-3.95, p = 0.004), the development of postoperative hematoma (OR 2.9; CI 1.55-4.10, p = 0.001), and needing surgery for the hematoma (OR 2.1; CI 1.21-3.29, p = 0.004) were predictors of recurrence after RSR. There was no significant difference in recurrence rate among obesity, smoking, urgent repair, type of mesh fixation, operative time, type of prosthesis, or concomitant procedures. In our current study, using immunosuppressive drugs, the development of postoperative hematoma and needing surgery for the hematoma were associated with increased risk of hernia recurrence after RSR.

Reconstruction of a Large Infected Midline Abdominal Wall Defect Using a Latissimus Dorsi Free Flap

Managing large infected midline abdominal defects are clinically challenging and technically demanding. The alloplastic materials, regional flaps, and component separation are usually infeasible because of the size, location, depth, and state of the defects. In these cases, the free flap is the only option with a large well-vascularized tissue that is free to inset regardless of the location. Herein, we report a case of 44-year-old man with a large infected midline abdominal wall defect who was completely treated with a latissimus dorsi myocutaeous free flap followed by negative pressure wound therapy.

Cantrell’s pentalogy: long-term survival and repair of a large abdominal wall defect

Cantrell’s pentalogy: long-term survival and repair of a large abdominal wall defect

Giant Omphalocele with skeletal deformities: a case report

Omphalocele is an anterior abdominal wall defect at the base of the umbilical cord, with herniation of the abdominal contents which are covered by a membrane and associated with a very high incidence of structural and chromosomal anomalies including heart defect, vesical, genital or diaphragmatic malformations. A 1000 gm preterm neonate was born vaginally, to a non-consanguineously married primi mother with uneventful pregnancy. On examination baby had a large anterior abdominal wall defect covered by a thin membrane with widely open and bulging anterior fontanellae. Eyes, ears and lips were well developed but eyelids were fused. Liver, spleen and intestine were visible under a thin transparent membrane. Rib cage was formed, and ribs were palpable but lower limbs were directed posteriorly and genitalia was ambiguous. Baby was in gasping condition and died within 30 minutes after birth. Prenatal accurate diagnosis by providing adequate antenatal care and ultrasonogram would permit an opportunity to counsel the family and to prepare for optimal postnatal care.

Short-term outcomes of the component separation technique for the repair of complex ventral hernia

Backgrounds The component separation technique is a well-known procedure for closure of a large abdominal wall defect. Primary reconstruction either alone or with synthetic mesh reinforcement provides physiological advantages. Our study evaluates this technique in terms of indications, operative outcomes, and postoperative results. Patients and methods Fascial component separation was performed either alone or with mesh reinforcement for patients with large abdominal wall defects between January 2013 and December 2016. Results A total of 40 patients, 15 (37.5%) men and 25 (62.5%) women were included in the study. The mean age of the patients was 53.8 years (range, 27–68 years). The mean body mass index (BMI) was 35.3 kg/m2 (range, 25.5–45.9 kg/m2). The mean defect size was 12.8 cm (range, 10–15 cm). The mean operative time was 152.5 min (range, 81–220.5 min), with the mean duration of hospital stay being 14 days (range, 9–19 days). Forty-five percent of patients needed mesh reinforcement. The mean follow-up period was 24 months. The total recurrence rate was 5% (2/40). No mortality or major intraoperative or postoperative complications were observed. Conclusion The component separation technique provides a reliable, autologous reconstructive modality for treating large abdominal wall defects. Additionally, mesh reinforcement can decrease the recurrence rate without an increase in the rate of major intraoperative or postoperative complications.

Positioning the Umbilicus in African Newborns with Large Anterior Abdominal Wall Defects.

Objective:We tried to determine the normal position of the umbilicus in African newborns with a potential application in aesthetically acceptable umbilical reconstruction.Subjects and Methods:The study involves a cross-sectional study of 896 healthy neonates who underwent clinical abdominal examination and measurement of the distances between the xiphoid process and the umbilicus (XU), xiphoid process and the pubis (XP), umbilicus and the pubis (UP), umbilicus and the anterior superior iliac spine (UASIS), abdominal girth (AG), and inter anterior superior iliac spines (IASIS) distance. The gestational age at delivery, age at measurement, sex, AG measured across the umbilicus, birth weight (BW), body length, and body mass index of the newborns were recorded. The measurements were used to determine the location of the umbilicus and Pearson's correlation analysis performed to determine the relationships of the recorded neonatal parameters with the measurements.Results:The mean XP was 11.97 ± 2.09 cm, XU = 7.94 ± 2.74 cm, UP = 4.26 ± 1.21 cm, UASIS = 5.79 ± 1.04 cm, and IASIS = 10.25 ± 1.54 cm. The BW, length, and AG significantly correlated with the distance between the XU, umbilicus and pubis, umbilicus and anterior superior iliac spine as well as the distance between the two anterior superior iliac spines.Conclusion:The position of the umbilicus is dependent on the selected participants' characteristics. We suggest that a UP: XU ratio of 0.55 should be used to position the umbilicus during umbilical reconstruction in African neonates.

Transversus abdominis muscle release: Technique, indication, and results

Component separation technique (CST) allows the mobilization of large musculofascial flaps of the abdominal wall and was developed for the treatment of very large, primary and incisional abdominal wall hernias. The classic open anterior CST first published by Albanese and later by Ramirez is associated with high complication rates. According to a recent literature review, CST without mesh should no longer be performed because of high recurrence rates. Classic anterior CST is associated with high rates of surgical-site occurrences and infections and should only be performed as endoscopic- and perforator-sparing anterior CST. The unfavorable results of classic CST resulted in the development of numerous new anterior and posterior CST modifications, several of them were minimally invasive. The posterior CST with transversus abdominis muscle (TAM) release (TAR) published by Novitsky et al. is an extension of the original retrorectus Rives operation and Stoppa procedure. The technique avoids vast skin flaps and allows the closure of large abdominal wall defects and insertion of very large retromuscular alloplastic standard sublay meshes without damaging the vessels and intercostal nerves. The TAR procedure is one of the major advances of abdominal wall surgery of the last decades. Several new promising minimally invasive modifications including robotic-assisted TAR have been published recently. The indications and technique of the TAM (TAR) procedure and its minimally invasive modifications are described.

Abdominal Wall Reconstruction Using an Anterolateral Thigh Free Flap for a Large Abdominal Wall Defect

Objective: To present a complicated case of abdominal wall reconstruction after tumor extirpation using an anterolateral thigh free flap. Methods: This is a report of a case managed at the Philippine General Hospital last September 2016. Results: A 25-year-old male, diagnosed case of recurrent colon adenocarcinoma, underwent wide excision of recurrent abdominal wall tumor with fistula, resulting to 15cm x 30cm full thickness soft tissue abdominal wall defect with exposed bowels. A free anterolateral thigh fasciocutaneous flap was designed and elevated to cover the abdominal wall defect. Recipient vessels (contralateral deep inferior epigastric artery and veins) were anastomosed with donor vessels (descending branch of lateral circumflex femoral artery and veins). The donor site was closed with split thickness skin grafting. Conclusion: The free anterolateral thigh flap allows for coverage of complicated recurrent abdominal wall malignancies, allowing for a single-stage surgery, with little donor site morbidity and shorter hospital stay. Key words: free tissue transfer flap, microsurgical free flap

Transversalis fascia scoring: a new adjunct to anterior component separation technique

Abdominal wall hernia is a significant cause for reoperation following laparotomy. Anterior component separation (ACS) is a widely used technique for closure of large abdominal wall defects. We propose that adding scoring of transversalis fascia to ACS can provide additional midline advancement of the anterior rectus sheath. Open ACS was performed in eight cadavers. The medial advancement of the anterior rectus sheath was recorded at three points bilaterally during application of constant load, and again following scoring of the transversalis fascia. This technique was then used on two patients with recurrent, complex ventral hernias which could not be closed with ACS alone. In the cadaver model, transversalis fascia scoring provides additional 34.01, 27.12, and 25.05% advancement at each point compared to ACS. Results were significant. In both patients, primary fascial closure of defects over 20 cm width at midline was achieved. Adding transversalis fascia scoring in a controlled standard fashion to ACS may help surgeons achieve closure of abdominal wall defects when ACS alone is not sufficient. Level of Evidence: Level V, therapeutic study.

Endoscopic anterior component separation: a novel technical approach.

Open anterior release of the external oblique fascia to enable midline closure of large abdominal wall defects is associated with relevant morbidity due to extensive subcutaneous dissection. Using endoscopic techniques, wound complications can be minimized. However, identification of the correct entry point (e.g. for balloon trocar insertion) can be challenging especially in adipose patients. We therefore present a technical modification facilitating the entire procedure. A novel technique for endoscopic anterior component separation using a trocar system allowing blunt and sharp dissection under direct vision is described. This brief communication also contains our initial experience and learning curve with this novel approach. Endoscopic release of the external oblique fascia was successfully performed 29 times in a total of 15 patients. Body mass index accounted for 30.8kg/m2 (median; range 21.6-42.5). Transverse width of midline defect accounted for 7cm (median; range 4-12). Subsequent hernia repair was successfully done using sublay mesh reinforcement (n=13) or a laparoscopic intraperitoneal onlay mesh procedure (n=2) with midline closure in all cases. One hematoma was seen at site of release managed conservatively. Using a trocar system allowing blunt and sharp dissection under direct vision may be a viable option for the endoscopic anterior component separation.

Abstract: A Study on the Length of Flap in the Thigh for Abdominal Wall Reconstruction

INTRODUCTION: A pedicled or free tissue thigh flap has been used for large abdominal wall defect reconstruction.1, 2 Anterolateral thigh flaps, tensor fascia lata musculocutaneous flaps, and their combination are reliable and are often used.3, 4 Despite the reported efficacy, it is unclear how large an abdominal defect can be closed with a single thigh flap. The objective of this study was to compare the length of the abdomen and thigh, and to determine whether a thigh flap is suitable for all abdominal wall reconstruction procedures. METHODS: A total of 100 adult Japanese subjects (men: 50, women: 50) with no medical history of musculoskeletal disease or injury were recruited. The length from the xiphoid process to the pubic tubercle was defined as the length of the abdomen (AL). The length of the thigh (TL) was defined as the distance from the anterior superior iliac spine to the upper lateral edge of the ipsilateral patella. The height of each subject and the difference between the TL and AL (TL – AL) were recorded. Statistical analysis was performed. RESULTS: The average age was 42.6 years in men and 41.8 years in women. The average height and standard deviation was 172.65 ± 6.53 cm in men and 158.00 ± 5.14 cm in women. The averages and standard deviations of the TL, AL, and TL – AL were 45.26 ± 3.20 cm, 32.70 ± 2.78 cm, and 12.57 ± 3.73 cm in men, and 40..82 ± 1.68 cm, 32.69 ± 2.93 cm, and 7.91 ± 3.17 cm in women, respectively. The height showed no correlation with AL in female subjects. AL showed no correlation between the male and female subjects. A height of less than 170 cm in males showed a clear correlation with TL – AL. CONCLUSION: Since the TL was larger than the AL in all subjects, a thigh flap is suitable for abdominal wall reconstruction in most cases. AL was consistent according to height in female subjects. In female and male subjects less than 170 cm in height, the thigh flap may be too short for abdominal wall reconstruction. Reference Citations: 1. Kimata Y, Uchiyama K, Sekido M, et al. Anterolateral thigh flap for abdominal wall reconstruction. Plast Reconstr Surg. 1999; 103: 1191–1197. 2. Williams JK, Carlson GW, Howell RL, Wagner JD. The tensor fascia lata free flap in abdominal-wall reconstruction. J Reconstr Microsurg. 1997; 13: 83–90. 3. Lv Y, Cao D, Guo F, Qian Y. Abdominal wall reconstruction using a combination of free tensor fasciae lata and anterolateral thigh myocutaneous flap: a prospective study in 16 patients. Am J Surg. 2015; 210: 365–373. 4. Sasaki K, Nozaki K, Nakazawa H, Kukuchi Y. Reconstruction of a large abdominal wall defect using combined free tensor fasciae lata musculocutaneous flap and anterolateral thigh flap. Plast Reconstr Surg. 1998; 102: 2244–2252.

Injectable in situ cross-linking chitosan-hyaluronic acid based hydrogels for abdominal tissue regeneration

Abdominal wall defect caused by open abdomen (OA) or abdominal trauma is a serious issue since it induces several clinical problems. Although a variety of prosthetic materials are commonly employed, complications occur including host soft tissue response, fistula formation and chronic patient discomfort. Recently, abundant natural polymers have been used for injectable hydrogel synthesis in tissue regeneration. In this study, we produced the chitosan - hyaluronic acid (CS/HA) hydrogel and investigated its effects on abdominal tissue regeneration. The physical and biological properties of the hydrogel were demonstrated to be suitable for application in abdominal wounds. In a rat model simulating open abdomen and large abdominal wall defect, rapid cellular response, sufficient ECM deposition and marked neovascularization were found after the application of the hydrogel, compared to the control group and fibrin gel group. Further, the possible mechanism of these findings was studied. Cytokines involved in angiogenesis and cellular response were increased and the skew toward M2 macrophages credited with the functions of anti-inflammation and tissue repair was showed in CS/HA hydrogel group. These findings suggested that CS/HA hydrogel could prevent the complications and was promising for abdominal tissue regeneration.

Modified components separation technique: experience treating large, complex ventral hernias at a University Hospital.

An increasing number of patients have large or complex abdominal wall defects. Component separation technique (CST) is a very effective method for reconstructing complex midline abdominal wall defects in a manner that restores innervated muscle function without excessive tension. Our goal is to show our results by a modified CST for treating large ventral hernias. A total of 351 patients with complex ventral hernias have been treated over a 10-year period. Pre- and postoperative CT scans were performed in all patients. All ventral hernias were W3, according to the EHS classification 1. We analyzed demographic variables, co-morbidities, hernia characteristics, operative, and postoperative variables. One hundred and seventy patients (48.4%) were men; the average age of the study population was 51.6±23.2years with an average BMI of 32.3±1.3. The hernia was located in the midline in 321 cases (91.5%) versus the flank in 30 (8.5%). In 45 patients, preoperative botulinum toxin (BT) and progressive pneumoperitoneum (PPP) were needed due to giant hernia defects when the VIH/VAC ratio was>20%. Postoperative complications related to the surgical site were seroma (35.1%), hematoma (9.1%), infection (7.2%), and wound necrosis (8.8%). Complications related to the repair were evisceration in 3 patients (1.1%), small bowel fistula in 4 patients (1.5%), 11 cases of mesh infection (2.9%), and abdominal compartment syndrome (ACS) in 2 patients. There were 29 hernia recurrences (8.2%) with a mean follow-up of 31.6±8.1months. The modified CST is an effective strategy for managing complex ventral hernias that enables primary fascial closure with low rates of morbidity and hernia recurrence.

Giant Ventral Hernia in a Pregnant Patient

Large abdominal wall defects can occur as a result of temporary abdominal closure (TAC). TAC is used in critically ill patients where the abdominal wall cannot be closed due to intraabdominal hypertension, loss of domain (LOD), and other devastating abdominal conditions. Clinically, TAC is similar to giant ventral hernias (GVH) in that both have large facial defects. In the setting of pregnancy GVH is uncommon. In a meta-analysis of pregnant patients only five ventral hernias were described among nearly 33,000 patients [1]. Similarly, pregnancy in the setting of TAC is exceptionally rare. Our review of the literature did not identify other cases of TAC followed by a pregnancy. The literature does contain one case in which a pregnant woman suffered abdominal trauma and was managed with TAC [2]. In this report, we present the case of a woman who sustained penetrating abdominal trauma, received treatment with TAC, failed to return to clinic, then subsequently re-presented with a second trimester gestation.

Role of tissue expansion in abdominal wall reconstruction: A systematic evidence-based review

Tissue expanders (TEs) can be used to assist primary closure of complicated hernias and large abdominal wall defects. However, there is no consensus regarding the optimal technique, use, or associated risk of TE in abdominal wall reconstruction. A systematic search of PubMed and Embase databases was conducted to identify articles reporting abdominal wall reconstruction with TE techniques. English articles published between 1980 and 2016 were included on the basis of the following inclusion criteria: two-stage TE surgical technique, >3 cases, reporting of postoperative complications, hernia recurrence, and patient-based clinical data. Fourteen studies containing 103 patients (85 adults and 18 children) were identified for analysis. Most patients presented with a skin-grafted ventral hernia (n=86). The etiology of the hernia was from trauma or prior abdominal surgery. The remaining patients had TE placed before organ transplantation (n=12) or for congenital abdominal wall defects (n=5). The location for expander placement was subcutaneous (n=74), between the internal and external obliques (n=26), posterior to the rectus sheath (n=2), and intra-peritoneal (n=1). Postoperative infections and implant-related problems were the most commonly reported complications after Stage I. The most common complication after Stage II was recurrent hernia, which was observed in 12 patients (11.7%). Five patients with TE died. Complications and mortality were more prevalent in children, immunosuppressed patients, and those with chronic illnesses. Tissue expansion for abdominal wall reconstruction can be successfully used for a variety of carefully selected patients with an acceptable complication and risk profile.

Repair of Large Abdominal Wall Defect Using Glycerolized Bovine Tunica Vaginalis and Prolene Mesh Implants in Dogs

The repair of large abdominal defects remains a complex surgical problem of insufficient autogenous tissue for adequate reconstruction.

Necrotizing soft tissue infection in pregnancy

Introduction. Necrotizing soft tissue infection (NSTI) is a life-threatening condition, characterized by widely spread necrosis of skin, subcutaneous fat, fascia and muscles. Treatment involves surgical debridement and broad-spectrum antimicrobial therapy. Mortality is still high due to diagnostic delays. NSTI is rare in general population, there are even less literature data of this condition in pregnancy. Timely diagnosis and therapy is crucial for outcome of these patients. Clinicians should have in mind NSTI in patients with perianal infections, especially in cases where immunosuppressive role of pregnancy is present. Case outline. We present a case of a 21-year-old pregnant woman with NSTI spreading from perianal region. The patient was admitted to hospital in the 31st week of otherwise healthy twin pregnancy one day after incision of perianal abscess. At admission she was examined by a gynecologist; vital signs were stable, laboratory results showed the presence of infection. She was referred for another surgical procedure and broad-spectrum antibiotics were prescribed. The next morning the patient complained of intense abdominal pain. Clinical exam revealed only discrete redness of the skin tender on palpation, crepitating. She was immediately referred to surgery. Intraoperative findings revealed massive soft tissue infection spreading up to the chest wall. Wide skin incisions and debridement were performed. The patient developed septic shock and after initial resuscitation gynecologist confirmed intrauterine death of twins and indicated labor induction. Over the next few days the patient?s general condition improved. On several occasions the wounds were aggressively debrided under general anesthesia, which left the patient with large abdominal wall defect. Twenty-three days after the initial operation, the defect was reconstructed with partial-thickness skin grafts, providing satisfactory results. Conclusion. Diagnosis and outcome of NSTI are challenging for many reasons. Course of the disease is rapid and hidden. Chances of survival depend on early recognition and prompt treatment.

Differentiated approach to the treatment of large hernial defects of the anterior abdominal wall in children (clinical observations)

To present an experience of treatment of children with large hernial defects of the anterior abdominal wall. This article describes management of 43 children with large (n=31) and giant (n=12) ventral hernia who were at N.F. Filatov Children´s City Hospital #13 for the period 2005-2015. All patients underwent surgical correction using local tissues in 'edge to edge' fashion (n=23), aponeurosis dublication of 'coat floors' type (n=14) and biological implant 'Permacol' (n=6). Etiological causes of ventral hernias in children were comprehensively analyzed. Optimal time for surgical treatment and features of viscero-abdominal disproportion were discussed. Early restoration of anatomical and functional structures of the anterior abdominal wall is necessary for good cosmetic result and prevention of recurrent ventral hernia. We presented three clinical examples of commonly used surgical procedures in children including anterior abdominal wall repair using biological material 'Permacol'.

Unusually Large Dermatofibrosarcoma Protuberans Involving Entire Abdominal Wall Reconstructed with Bilateral Large TFL and Groin flaps: A Case Report.

Background: Dermatofibrosarcoma Protuberans (DFSP) is a rare low grade soft tissue tumor with high recurrence rates. DFSP represents 1% of all soft tissue tumors. Recurrent DFSP requiring an entire abdominal wall reconstruction poses a challenge to the reconstructive surgeon. Case Report: Here we report a large recurrent anterior abdominal wall DFSP in a teenage girl involving the anterior rectus sheath and the deep fascia of the abdominal wall (20 x 17 x 9 cm) posing difficult reconstructive challenge. The reconstruction was done by B/l tensor fascia lata flap and extended right groin flap. Discussion: A large composite anterior abdominal wall defects are usually reconstructed by free flaps, but the more common local flaps can also be equally effective. Conclusion: Complete surgical excision for DFSP of the abdominal wall, which result in defects of entire abdominal wall can be reconstructed with simpler local pedicled flaps.

Recurrent spindle cell sarcoma in pregnancy: a case report

Malignant Fibrous Histiocytoma (MFH) is a soft tissue sarcoma usually involving limbs and retroperitoneum. MFH of the anterior abdominal wall is rare with a high recurrence rate. Though wide surgical excision is the mainstay of treatment, it creates large abdominal wall defects that need reconstruction. The addition of chemotherapy and radiotherapy optimize the chances of survival and cure. We report a case of twice recurrent pleomorphic spindle cell sarcoma of the anterior abdominal wall in pregnancy, with adverse maternal and fetal outcome.