Abdominal wall defect reconstruction

Dr Subhakanta Mohapatra
Mch plastic surgery, IPGME&R,SSKM Hospital
kolkata

 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

Superficial & deep anatomy of the abdomen
showing muscular layers & fascial layers

The rectus sheath above & below arcuate line

Hernia
repair
Tumor
defect
Congenital
defect
Traumatic
defect

 Not recommended now
 High (25-63%) recurrence, even in <5cm
defect
 May be indicated for <3cm defect

B/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.

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)

 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

Maximal U/L rectus complex mobility with
component separation of EO & IO muscles to
the posterior axillary line

Midline closure at Linea alba after component
separation

 Disadv
 Needs wide undermining
 More chance of seroma
 Skin edge ischaemia
 Recent advance
 Endoscopic & minimally invasive 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.

 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

 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

availability strength
No donor site
morbidity
Host tissue
incorporation

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

 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.

Component separation with onlay mesh

 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

 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 %

 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

 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%

 Adv
 Large underlay allowing better tissue ingrowth
 More secure mesh fascial interface
 Disadv –
 Ring of U sutures may strangulate the fascia
 Neuroma – full thickness suture - injury to nerve

 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 %

 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

 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 expansion
 between EO & IO
 not commonly done

 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)

 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%

 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

A. TFL flap B.ALT flap C. RF flap
(pedicled)

 In conjuction with other transplantation
 Pedicle – inferior epigastric vessel
 Lifelong immunosuppression

 Drain :
 Between mesh & fascia
 Atleast 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 )

 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

 Abdominal binder
 may be given only after 48 – 96 hrs
 Analgesia
 to improve pulmonary toilet, pain control,ileus
 Muscle relaxation
 Use of botulinum toxin at the time or 1wk before
operation
 Activity
 Extremely limited activity for 1st 6 wks

Recurrence
Wound breakdown
Adhesions
Seroma(more in underlay)
Spigelian hernia
Pain
Mesh migration(rare)

 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

 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

 Scar revision
 Contour improvement/
panniculectomy
 Correction of diastases
 Umbilical reconstruction
 Amelioration of pain

 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

Free flap
Regional
flap
Component
separtation
Expander
Fascial grafts
Be closed primarily

Abdominal wall defect reconstruction

Abdominal wall defect reconstruction

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