Abdominal wall defect reconstruction
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ABDOMINAL WALL DEFECT
RECONSTRUCTION
Dr Subhakanta Mohapatra
Mch plastic surgery, IPGME&R,SSKM Hospital
kolkata
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ABDOMINAL WALL ANATOMY
Skin Subcutaneous fatty layer (Camper’s
fascia) Deep fibrous layer/ Scarpa’s fascia
(superficial fascia) Adipose tissue Deep fascia(aponeurotic fascia) Paired flat muscles Fascia transversalis peritoneum
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Rectus abdominis muscle
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External oblique muscle
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Internal oblique muscle
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Transverse abdominis
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Superficial & deep anatomy of the abdomen showing muscular layers & fascial layers
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The rectus sheath above & below arcuate line
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INDICATION OF ABDOMINAL WALL RECONSTRUCTION
Hernia repair Tumor defect
Congenital defect
Traumatic defect
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PRIMARY SUTURE REPAIR
Not recommended now
High (25-63%) recurrence, even in <5cm defect
May be indicated for <3cm defect
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COMPONENT SEPARATIONB/L mobilisation of Rectus abdominis
muscles as musculo-fascial, bipedicled,neurotized flap
Degloving of skin & SC tissue up to anterior / mid axillary line
Fasciotomy (1-2 cm lateral to linea semilunaris) with cautery/scissors to
separate EO from RA.
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CONTD…Entering in avascular plane in b/w EO & IO
(without injuring IO fascia or muscle)
Posterior rectus sheath incision( few mm lateral to free edge of fascia) – gives
additional 2 cm mobility.
Further mobilisation – Sub-periosteally off the costal margin & symphysis pubis
Requires reinforcement(underlay/onlay)
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CONTD….. Intraperitoneal adhesions – regarded as a
component & must be separated.
Wide adhesiolysis up to paracolic gutter is an important step
If stoma present & to be preserved – wide soft tisssue attachment should be maintained around the stoma
If stoma to be created through rectus component separation Stoma exteriorization after fascia closure
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Maximal U/L rectus complex mobility with component separation of EO & IO muscles to the posterior axillary line
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Midline closure at Linea alba after component separation
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CONTD…
Disadv Needs wide underminingMore chance of seromaSkin edge ischaemia
Recent advanceEndoscopic & minimally invasive
component separation
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PERFORATOR SPARING COMPONENT SEPARATION Peri-umbilical perforator spared Single , large caliber Arising from rectus abdominis in each
hemiabdomen Advantage
Minimises ischaemic soft tissue complications Useful for pts with comorbidities
Disadvantage More operative time Limit the degree of release (minor extent)
Underlay mesh used here.
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1. EO perforator 2. DIEA perforator with large musculocutaneous branch 3. intramuscular branching with small musculocutaneous perforator 4. large musculocutaneous branch with no intramuscular branches 5. septocutaneous perforators
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AUTOLOGOUS GRAFT Fascia lata graft
Broad & dense fascia of TFL
28 × 14 cm - max size
5 -10 cm length should be left, to prevent lateral knee instability
Drains in donor site
Can be used in contaminated cases
32 % recurrence rate
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MESH
availability strength
No donor site
morbidity
Host tissue incorporatio
n
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PROSTHETIC MESH MATERIAL
Polypropelene ePTFE
Larger pore size Strong More resistant to
infection Less seroma Can not be placed
directly on the bowel
Host tissue incorporation- present
Microporous More stronger Less resistant to
infection
More seroma Soft, flexible,conforming
quality,minimal tissue ingrowth. So can be placed directly on bowel.
Absent
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MESH PLACEMENT TECHNIQUES
onlay inlay
underlay
sandwich
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A.Only B.inlay C.underlay
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ONLAY Mesh placed above the fascia,from one EO to other
EO
Quilting sutures between onlay & fascia (to decrease seroma)
Drains above & below onlay
Adv ease of use no full thickness U sutures avoids direct contact with bowel
Disadv wide tissue undermining contaminated, if skin breaks down pressure required to disrupt mesh from abdominal
wall is less.
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Component separation with onlay mesh
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INLAY
Excision of hernia sac
Identification of healthy fascial margins
Tensionless repair
Adv - Avoids wide undermining
Disadv - Significant tension to mesh fascia interface (weakest point),so high recurrence
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RETRORECTUS UNDERLAY By Rives & Stopa
Used in increasing frequency
Mesh - between posterior rectus sheath & rectus muscle(within the limits of rectus sheath)
Atleast 4 cm contact between mesh & fascia
Below arcuate line – placed in preperitoneal space
Recurrence rate - < 10 %
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Retrorectus underlay
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RETRO… Adv :
Strength layer placed in proximity to muscle
Not in contact with bowel
Disadv : No broad resurfacing of abdominal wall secondary hernia lateral to rectus sheath
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INTRAPERITONEAL UNDERLAY
Commonly used in open & laparoscopic approach
Span from one EO to other EO
Full thickness U sutures by Reverdin needle (from abdominal wall down in to peritoneum, in to mesh, & back in to abdominal wall)
Mesh should be tensioned (for passive closure of muscles in midline)
Recurrence - < 5%
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U suture by Reverdin needle
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CONTD….
AdvLarge underlay allowing better tissue
ingrowthMore secure mesh fascial interface
Disadv – Ring of U sutures may strangulate the
fasciaNeuroma – full thickness suture - injury to
nerve
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Intraperitoneal underlay
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LAPAROSCOPIC REPAIR Intraperitoneal mesh underlay
Mesh secured by tacking device /transabdominal suture/both
Adv : ↓ hospital stay, ↓wound complication Disadv :
No restoration of dynamic abdominal wall
No cosmetic improvement by excising excess tissue & scar
Recurrence : 2-4 %
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BIOPROSTHETICS Derived from human & animal tissues Human acellular dermis(Alloderm)
Less adhesions – intraperitoneal use possible Size limitations (small size patch)
Porcine submucosa Come in larger sheet
Adv Resistance to infection Tolerance of cutaneous exposure Mechanical stability
Disadv High cost Lack of long term follow up study
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EXPANDER Provides well vascularised, autologous,
innervated tissue Indicated for pts having both fascial & soft
tissue deficiency In congenital defect & large hernias
Site – in S.C space (over fascia) – commonly done
Intermuscular
both fascia & soft tissue expansionbetween EO & IO not commonly done
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LOCAL FLAPS
Upper third defect – Thoraco epigastric flap
- EO flap(rotational flap) Middle third defect – ilio-lumbar bipedicled
flap (based on superficial circumflex iliac & lumbar perforators)
Lower third defect – SIEA ,DIEA flap,groin flap
Lateral wall defect – Rectus abdominis flap
Paramedian defect - EO flap(advancement flap)
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TFL FLAP pedicled/free muscle/fascial/fascio cutaneous Adv
Dispensable good arc of rotation
Disadv no dynamic reconstruction distal third – unreliable donor site morbidity
Complications seroma/hematoma/lateral knee
instability/STSG loss recurrence – 9- 42%
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OTHER FLAPS Rectus femoris musculofascial /
musculofasciocutaneous flap - Free/ ( pedicled flap for lower 2/3rd defect)
ALT flap with mesh – free/(pedicled – lower abdominal defect)
LD flap free/(pedicled – upper abdominal defect)
Gracilis muscle/musculofasciocutaneous flap - lower third small defect
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A. TFL flap B.ALT flap C. RF flap (pedicled)
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ABDOMINAL WALL TRANSPLANTATION
In conjuction with other transplantation
Pedicle – inferior epigastric vessel
Lifelong immunosuppression
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ADJUNCTS TO REPAIR
Drain :Between mesh & fasciaAtleast 2 additional subcutaneous drains (in component separation) In paracolic gutters
Fibrin based tissue glues in S.C space (to prevent seroma)
Quilting sutures (from skin flap down to fascia )
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PERI-OPERATIVE M/N DVT prophylaxis
Prophylactic antibiotic 30 mins before surgery Consideration of extubation on 1st post op day
Intra abdominal pressure monitoring Drain
Larger drain for potential hematoma area Smaller drain for seroma risk area Kept at least 1wk
Early enteral feeding/ TPN
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CONTD…
Abdominal bindermay be given only after 48 – 96 hrs
Analgesia to improve pulmonary toilet, pain
control,ileus
Muscle relaxationUse of botulinum toxin at the time or 1wk
before operation
Activity Extremely limited activity for 1st 6 wks
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COMPLICATIONS
Recurrence
Wound breakdown
Adhesions
Seroma(more in underlay)
Spigelian hernia
Pain
Mesh migration(rare)
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M/N OF COMPLICATIONS Wound breakdown :
Local wound care & hyperbaric oxygen for biological/light weight mesh
Synthetic mesh - More likely to be removed (if periprosthetic infection develops)
Adhesions :
Prevention – by interposing omentum in between bowel & abdominal wall
Biologic mesh & fascial grafts – lower adhesions
Seroma : Serial aspiration Sclerosant Excision of pseudobursa
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CONTD… Chronic pain :
Prevention - using long term absorbable sutures
T/t – Neuronal stabilising medications Massage,desensitisation,US pulses,
acupuncture Surgery - removal of offending
suture,staple,mesh neurolysis/neurectomy of involved
nerve
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SECONDARY PROCEDURES
Scar revision Contour improvement/
panniculectomy Correction of diastases Umbilical reconstruction Amelioration of pain
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SWISS CHEESE DEFECTS
Multiple small fascial defects
When one defect repaired, the other unrepaired defect enlarge
Recurrence due to failure of diagnosis of multiple defects
Pre op CT scan confirms location & number of defects
Wider dissection to identify occult hernia
Laparoscopic view - broader view
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CONCLUSIONRegional flap
Component separtation
Fascial grafts
Be closed primarily
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