Complex Tissue Transfer in the Management of Abdominal Wall Defects

Fig. 13.1

The “component separation” technique. After abdominal cavity entry, the bowels are dissected free from the ventral abdominal wall. (a) The skin and subcutaneous fat (1) are dissected free from the anterior sheath of the rectus abdominis muscle (5) and the aponeurosis of the external oblique muscle (2). (b and c) The aponeurosis of the external oblique muscle (2) is transected longitudinally about 2 cm lateral to the rectus sheath, including the muscular part on the thoracic wall, which extends at least 5–7 cm cranially from the costal margin. (d) The external oblique muscle (2) is separated from the internal oblique muscle (3), as far as possible laterally. (e and f) If primary closure is impossible due to tension, a further gain of 2–4 cm can be obtained by separation of the posterior rectal sheath from the rectus abdominis muscle (5). The rectus muscle and the anterior rectal sheath can be advanced to the midline over a distance of about 10 cm at the waistline. Care must be taken not to damage the blood vessels and nerves that run between the internal oblique and transverse (4) muscles and enter the rectus abdominis muscle at the posterior side. (Adapted with permission of Elsevier from de Vries Reilingh et al. [43])

The dissection proceeds in this relatively avascular intermuscular plane and is continued in a lateral direction to at least the level of the midaxillary line. At this point, the mobility of the innervated rectus abdominis-internal oblique-transversus abdominis muscle complex is determined. If additional mobility of these structures on either side of the midline is desired, then the dissection in the intermuscular plane can be continued to the posterior axillary line. Each ipsilateral complex can be expected to advance toward the midline 4 cm in the upper abdomen, 8 cm at the umbilicus, and 3 cm in the lower abdomen. Using specific modification of the components separation technique, up to 20 cm of advancement of native tissues in the umbilical region has been demonstrated [29].

Modifications of Component Separation Method

The original component separation method has several disadvantages, as suggested previously. Mass et al. described three disadvantages [30]. First, the skin and subcutaneous tissue must be mobilized laterally over a large distance to reach the aponeurosis of the external oblique muscle lateral into the flank. This creates a large wound surface that covers the entire abdominal wall, from costal margin to pubic bone. Second, mobilization of the skin endangers its blood supply, which may lead to skin necrosis at the midline if circulation through the intercostal arteries is interrupted. Third, the technique is difficult to use in patients with an enterostomy or when a new enterostomy must be made.

The purposes of modifying the original component separation method are as follows: (1) additional advancement of components; (2) preservation of the blood supply to the skin and subcutaneous tissue; (3) overcoming the problem of stoma reconstruction; and (4) reduction of the subcutaneous tissue mobilization area. The first and second goals are especially important.

For additional advancement of components to the midline, separation of the rectus muscle from the posterior rectal sheath has been used in almost all reported techniques [20, 21, 30–32]. With this modification, the rectus muscle and the anterior rectal sheath can be expected to advance to the midline over a distance of about 10 cm at the level of the umbilicus (Fig. 13.2).

Fig. 13.2

Modified “component separation” technique. (a) I, the external oblique muscle is transected through a separate incision, just lateral to the rectal sheath; II, separation of the rectus abdominis muscle from the posterior rectal sheath. (b) The compound flap can be advanced to the midline. The skin is vascularized through the perforating branches of the epigastric arteries. (1), rectus abdominis muscle; (2), skin and subcutaneous tissue; (3), external oblique muscle; (4), internal oblique muscle; (5), transverse muscle. (Adapted with permission of Elsevier from Maas et al. [30])

Maas and colleagues described a modification of the original technique of component separation, designed to preserve the blood supply to the skin and subcutaneous tissue and to overcome the problem of stoma reconstruction in these patients [30]. Using their technical modification, the aponeurosis of the external oblique muscle is dissected free through a separate, longitudinal skin incision at a distance of about 15 cm from the median skin border (Fig. 13.2). The aponeurosis is transected just lateral to its insertion in the rectal sheath, from the costal margin to 5 cm above the pubic bone. The external oblique muscle is separated from the internal oblique muscle. A well-vascularized compound flap is created and can be advanced to the midline. The rectus muscle is separated from the posterior sheath to further mobilize this flap. Modification of “component separation” technique for preservation of blood supply skin. For the dissection of skin and subcutaneous fat from the anterior sheath of the rectus abdominis muscle and the aponeurosis of the external oblique muscle, perforating arteries from the anterior sheath of the rectus abdominis can be preserved to prevent skin and subcutaneous fat ischemia (Fig. 13.3).

Fig. 13.3

Modification of “component separation” technique for preservation of blood supply skin. For the dissection of skin and subcutaneous fat from the anterior sheath of the rectus abdominis muscle and the aponeurosis of the external oblique muscle, perforating arteries from the anterior sheath of the rectus abdominis can be preserved to prevent skin and subcutaneous fat ischemia

Component separation has become the most commonly used surgical technique for closure of large “planned” ventral hernias covered with a skin graft during the elective reconstruction phase [33–35]. Its use for acute definitive closure in the setting of an open abdomen has not been fully evaluated. Formal component separation is generally considered to be an “elective” reconstruction technique. Although its use in the acute setting aimed for resolving intra-abdominal sepsis, visceral, and abdominal wall edema as a result of systemic inflammatory responses, and ongoing sepsis has not yet been recommended [11], early definitive abdominal wall closure can reduce the need for skin grafting and later abdominal wall reconstruction and may decrease risks associated with open abdomen/abdominal wall defects, especially enteric fistula.

The Anterior Rectus Abdominis Sheath Turnover Flap Method

We recently demonstrated the usefulness of this method for early fascial closure in patients requiring open abdomen management [19]. This technique may reduce the need for skin grafting and later abdominal wall reconstruction. It can also be used for later reconstruction, as previously reported [24, 36].

During open abdomen management, care must be taken to prevent damage to the fascia, including the linea alba, to allow a definitive turnover flap of the anterior rectus sheath. If the abdominal fascia could be fully approximated without tension, standard fascial closure was performed. At 10–14 days after the initial laparotomy, a turnover flap of the anterior rectus abdominis sheath was considered instead if the distance to be closed with fascia was less than 15 cm in patients who were not candidates for standard fascial closure because of prolonged visceral edema. Formation of a planned ventral hernia using a skin graft over granulated abdominal contents was employed in patients without edema resolution 3 weeks or more after the initial laparotomy who were not candidates for either method of fascial closure.

Surgical Procedures

The procedure starts with separation of the skin and underlying adipose tissue from the anterior rectus sheath as a flap, with a base several centimeters beyond the lateral border of the rectus sheath. Next, turnover flap creation from the anterior sheath is initiated by incising the anterior sheath along the entire length of its lateral border. When making this longitudinal incision, the specific incision site must be chosen carefully to avoid entry at the conjoined point of the internal and external oblique aponeuroses, which could weaken the anterior sheath and predispose the patient to subsequent hernia formation. Because the largest fascial gap is in the midabdomen, where a wide flap is needed to approximate the fascia in most patients, longitudinal incision of the anterior rectus sheath should be started at the upper or lower abdominal surface of the anterior sheath to avoid entry at the conjoined point. The anterior sheath is then dissected laterally to medially, freeing it from the rectus muscle. Kept intact, the linea alba serves as a medial hinge to mobilize the flap (Fig. 13.4). If the linea alba is no longer intact, suture repair must be performed. The fascial flap is then reflected medially, with careful attention not to damage the anterior sheath.

Fig. 13.4

Cross-sectional schematic diagram of the technique for turnover flap creation from the anterior rectus abdominis sheath. The procedure is started by separating the skin and underlying adipose tissue from the anterior rectus sheath as a flap, with a base several centimeters beyond the lateral border of the rectus sheath (a). The turnover flap is then fashioned from the anterior sheath by longitudinally incising the sheath along the entire length of its lateral border. The site of this incision must be chosen carefully to avoid entry at the conjoined point of the internal oblique aponeurosis and the external oblique aponeurosis (b). The anterior sheath is then dissected from lateral to medial, freeing it from the rectus muscle. The linea alba is kept intact to serve as a medial hinge. The turnover flap of the anterior rectus sheath is approximated by interrupted sutures (c), and the skin is closed primarily (d). (Adapted with kind permission of Springer from Kushimoto et al. [19])

After creating bilateral turnover flaps, we approximate the flaps to cover the abdominal contents using interrupted sutures (3–0 polyglactin 910). We never use prosthetic materials to reinforce the turnover flaps or to repair exceptionally large fascial defects. Thereafter, the skin and underlying adipose tissue are approximated with drainage to the base of the adipose tissue dissection (Figs. 13.5, 13.6, and 13.7).

Fig. 13.5

Intraoperative view of the anterior rectus abdominis sheath turnover flap method (initial steps). (a) View just after vacuum-packing removal (11 days of open abdomen). (b) Kin and underlying adipose tissue are first separated from the anterior rectus sheath as a flap. (c) Skin and adipose tissue have been completely dissected from the anterior sheath bilaterally beyond the lateral border of the rectus sheath. (d) The anterior rectus sheath flap is reflected medially by dissecting from lateral to medial, freeing it from the rectus muscle. The linea alba is kept intact as a medial hinge. (Adapted with kind permission of Springer from Kushimoto et al. [19])

Fig. 13.6

Intraoperative view of the anterior rectus abdominis sheath turnover flap method (later steps). (a) Approximating the bilateral turnover flaps. (b and c) Turnover flaps from the anterior rectus sheaths are approximated by interrupted sutures. (d) Skin and subcutaneous tissue are sutured primarily. (Adapted with kind permission of Springer from Kushimoto et al. [19])

Fig. 13.7

Intraoperative view of the turnover flap method using the anterior rectus abdominis sheath carried out 30 days after initial laparotomy. (a) View just after vacuum-packing removal (30 days of open abdomen) showing granulated abdominal contents and retracted musculofascial structures of the anterior abdomen. (b) The anterior rectus sheath flap is reflected medially, dissecting from lateral to medial to free it from the rectus muscle. (c) Bilateral turnover flaps from the anterior rectus sheaths are approximated using interrupted sutures. (d) Skin and subcutaneous tissue are sutured primarily. (Adapted with kind permission of Springer from Kushimoto et al. [19])

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