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Abdominal wall reconstruction - TAddona

Abdominal wall reconstruction - TAddona - Complex Abdominal...

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Unformatted text preview: Complex Abdominal Wall Complex Abdominal Wall Defects Muscle and investing fascia Muscle and investing fascia Risk Factors Risk Factors Wound Infection Abdominal Compartment Syndrome Trauma Infected Mesh Incisional Hernia Multiple Re­operations through same wound Tumor resection Obesity, Malnutrition, Sepsis Treatment Options Treatment Options Primary Repair Mesh: Rives­Stoppa 3 Stage delayed repair “Components Separation” Local flaps v. Free tissue transfer Human Acellular Dermis (Alloderm) Primary repair Primary repair Limited to small defect (<5 cm in diameter) Highest recurrence rate (up to 27%) Patient selection is most important Excessive tension leads to ischemia and failure…avoided with mesh and flap Retention sutures Retention sutures Mesh closure Mesh closure Nonabsorbable is advocated Polypropylene allows for ingrowth of tissue (as opposed to PTFE) Important to anchor mesh to well vascularized tissue Complications: Infection, fistula formation, erosion, & continued drainage “Retro­rectus” mesh repair – ant to posterior fascia or pre­peritoneal space 57pts – 6 years 26.4% prev incisional hernia repair ePTFE: 8x8 to 20x28cm Mean f/u 35 months 12.3% Seromas Two (3.5%) infected mesh – removed One hernia recurrence(removed prosthesis) Mesh closure Mesh closure Rives­Stoppa Rives­Stoppa Three Staged Closure Three Staged Closure Mostly in pt’s w/ abdominal compartment syndrome Stages: Absorable mesh / VAC STSG Ventral hernia repair Components separation Components separation Oscar Ramirez (1990) describes technique Cadaveric dissection Incision 1cm lateral to linea semilunaris Ext oblique (EO) easily separated from internal oblique (IO) in AVASCULAR plane EO has limited advancement Rectus w/ IO flap can be advanced Unilateral ­ 5cm epigastrum/10cm middle/3cm suprapubic Component separation Component separation 22 pt’s / 4yr period Defects from 6x10 to 14x24cm Causes: removal infected mesh, removal of STSG, trauma; abd wall desmoid rsxn Complications: 2 wound infections, 1 seroma, 1 recurrent hernia Goals of abdominal wall reconstruction Goals of abdominal wall reconstruction Restoration of function and integrity of the abdominal wall Prevention of evisceration Dynamic muscle support Flap closure Flap closure Flap selection based on location and arc of rotation High success rate when combine with mesh Common flaps used Common flaps used Free tissue transfer? Free tissue transfer? Requires adequate recipient vessels Allows to transfer innervated muscle Technically more demanding Acellular Cadaveric Dermis Acellular Cadaveric Dermis (Alloderm) Goal: 3 stage single operation Bilateral bipedicle advancement flaps Incisions @ anterior axillary lines­undermine @ junction of SQ fat & anterior fascia Donor site w/ STSG 9 Pt’s followed for mean 20 months Conclusion Transplantation of the abdominal wall Transplantation of the abdominal wall ...
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