eMedicine Specialties > Plastic Surgery > Trunk

Abdominal Wall Reconstruction: Treatment

Author: Mark A Grevious, MD, FACS, Assistant Professor of Surgery, Associate Program Director, Division of Plastic and Reconstructive Surgery, University of Illinois at Chicago
Coauthor(s): Mimis Cohen, MD, FACS, FAAP, Professor and Chief, Division of Plastic, Reconstructive and Cosmetic Surgery, University of Illinois at Chicago; Consulting Staff Craniofacial Center, University of Illinois at Chicago; Aisha D White, MBA, MD, Staff Physician, Department of Plastic Surgery, University of Illinois at Chicago; Bradon J Wilhelmi, MD, Endowed Leonard Weiner, MD, Professor and Chief of Division of Plastic Surgery, Residency Program Director, University of Louisville School of Medicine
Contributor Information and Disclosures

Updated: Jul 18, 2008

Treatment

Preoperative Details

Preoperative preparation

Preoperative preparation for abdominal wall reconstruction, as with any other surgical procedure, involves a thorough patient history and physical examination. Appropriate laboratory studies should be reviewed, as well as chest radiographs and ECG for patients older than 35 years. Furthermore, patients with a history of pulmonary problems such as COPD should undergo pulmonary function tests and a baseline arterial blood gas analysis. Patients with a history of diabetes or chest pain should undergo an appropriate cardiac risk evaluation with echocardiogram and stress test. Once the decision has been made to proceed with operative intervention, the patient should receive a bowel preparation in case of enterotomy. Patients also should receive prophylactic antibiotics and deep venous thrombosis prophylaxis.

Prior to any operative intervention, a thorough evaluation is essential. A proper diagnosis must first be made by evaluating the anatomy and by defining the extent of the defect and understanding which anatomical structures are present or absent. Patient selection is also crucial. Performing a technically sound operation on a patient with multiple comorbidities may result in an outcome that is less than optimal. Comorbidities such as diabetes, poor nutrition, and obesity may also be detrimental to the surgical outcome. If in question, preoperative respiratory function should be assessed as reconstruction of the abdominal wall can compromise vital capacity. Patients with actively infected wounds and/or systemic infections are poor candidates for reconstruction with prosthetic materials. Some of the most important concepts that a surgeon should consider prior to embarking on an abdominal wall reconstructive procedure with prosthetic materials include the following: 

• Establishment of diagnosis
• Perioperative condition of patient
• Definition of defect and relevant anatomy
• Knowledge of and indications for prosthetics/bioprosthetics
• Wound preparation
• Control of infection
• Timing of reconstruction
• Technical competence
• Pathophysiology of foreign body reaction
• Management of complications of procedure or prosthetics  

The timing of reconstruction depends on several factors. Bowel edema, gross contamination, or patient instability may preclude definitive abdominal wall reconstruction. Wound preparation and control of infection are two key principles for successful reconstruction of the abdominal wall. If a patient has a contaminated wound with necrotic tissue present, irrigation and debridement should be the first line of therapy. Once adequate debridement is performed, wound coverage with occlusive dressings, vacuum-assisted wound closure (VAC) devices, absorbable prosthetic material, or a prosthetic patch may be used as a temporizing solution. This method of delayed wound coverage allows for stabilization of the patient until definitive reconstruction can be performed.

Reconstructive options for abdominal wall repair are vast and the complication rates can be high; therefore, preoperative planning is of critical importance. The size and location of skin and fascial defects must be determined by either examination or CT scan. Small skin defects can usually be repaired by direct approximation after extensive undermining of the skin from underlying tissues. If a sizable skin defect is present (eg, after resection of a tumor or skin loss with trauma), staged tissue expansion, fasciocutaneous flap, or myocutaneous flap is required. The location of the skin defect influences flap selection (discussed below).

Moderately sized fascial defects can sometimes be repaired primarily but may require reconstruction with the components separation technique. The components separation technique involves the release of 2 separate components as follows:

1. The longitudinal release of the medial edge of the external oblique aponeurosis with undermining of the external oblique muscle from the internal oblique muscle
2. The release of the medial two thirds of the posterior rectus fascia from the rectus muscle along the midline from the medial to lateral direction

The components separation technique provides midline fascial advancement of 10 cm at the epigastrium, 20 cm at the waistline, and 6 cm in the suprapubic area when separated bilaterally.¹ Thus, the applicability of the components separation technique depends on the size and location of the fascial deficit.

When treating large fascial defects, the components separation technique may not be suitable. Consider other options, such as prosthetic mesh, nonvascularized fascial graft, myocutaneous fascial flap (tensor fascia lata [TFL]), and tissue expansion of fascia.¹⁰ If adequate skin is available to close over the fascial repair, the first choice for repair of a fascial defect is prosthetic mesh. The main advantage of prosthetic mesh for fascial repair is that using a larger piece of mesh avoids the dramatic increase in intra-abdominal pressure often observed with hernia repairs. This pressure can result in decreased functional residual capacity, difficulty in weaning patients from ventilators, and increased risk of hernia recurrence.

The existence of prosthetic mesh infection may require explantation of the mesh and autogenous reconstruction, even the consideration of staged reconstruction, depending on the extent of the infection. Staged reconstruction involves temporarily approximating the fascia with absorbable Vicryl mesh to minimize the fascial defect, which eventually requires permanent reconstruction.

Once the Vicryl mesh has granulated, the wound can be skin grafted. Then, once the graft has matured to allow for ease of separation from underlying viscera, usually at 12 months, the final reconstruction, depending on the size and location of the skin and fascial defect, is approached. Staged reconstructions are commonly required following abdominal wall defects from trauma and infections.

Intraoperative Details

Grafts

Grafts can be used in reconstructing the fascia when ample overlying skin and subcutaneous tissue are present. Autogenous fascial grafts have been used to repair abdominal fascial defects. Hamilton described a recurrence rate of 6.4% in the treatment of 47 ventral hernias with free nonvascularized fascial grafts.¹¹ These free nonvascularized fascial grafts have been demonstrated to maintain their structural integrity.^12,13 Moreover, if adequate soft tissue coverage is present, the free tensor fascia lata (TFL) graft can be used in place of the pedicled TFL for fascial reconstruction because circumferential suturing of the fascia to the defect probably interferes with the delivery of blood to the fascia from the pedicle. The fibers of the TFL graft are directed in one direction. Thus, the fibers may separate and result in graft weakness. Use of TFL grafts is being replaced by bioprosthetic material, such as acellular human dermis (AlloDerm [LifeCell, Branchburg, NJ], Derma-Matrix [Synthes, West Chester, Pa].

Several prosthetic grafts have been successfully used for abdominal fascial repair, including polypropylene (Prolene [Ethicon, Piscataway, NJ], Marlex [ConocoPhillips, Houston, Tex]), polyethylene (Dacron [DuPont, Wilmington, Del]), polytetrafluoroethylene (PTFE [DuPont, Wilmington, Del], Gore-Tex [WL Gore & Associates, Newark, Del]), polyester (Mersilene [Ethicon, Piscataway, NJ]), polyglactin (Vicryl [Ethicon, Somerville, NJ], Dexon [Syneture, Norwalk, Conn]), and autogenous nonvascularized fascial grafts.

Prosthetics

When autologous tissue is not available for the reconstruction because of tissue loss, loss of domain, or other reasons, the use of prosthetics or bioprosthetics is required to assist in the reconstruction of the abdominal wall. Biomaterials are also used in the temporary coverage of these difficult soft tissue defects. Some of the advantages of using prosthetic materials include availability, absence of donor site morbidity, and strength of the prosthetic material. Obvious disadvantages are susceptibility to infection (which may necessitate explantation), fistula formation secondary to bowel erosion, extrusion, and seroma formation. No "one mesh fits all" concept exists in abdominal wall reconstruction; thus, in efforts to address this surgical conundrum, numerous synthetic materials have been designed to facilitate closure of these defects.

Many different types of prosthetic and bioprosthetic materials are currently available, and even more products are being brought to the marketplace. Each new product that is introduced is heralded as the next new and improved biomaterial. Navigating through all of these new products can be difficult, especially without long-term clinical and experimental data to support their use. Therefore, a thorough understanding of each prosthetic material, its cost, its applications, its contraindications, and its incidence of complications, as well as the management of these complications, is of paramount importance.

Polypropylene is probably the most commonly used synthetic prosthetic material for abdominal fascial repair. It has large pores that induce fibrovascular incorporation. Polypropylene is most suitable for clean wounds with adequate soft tissue coverage. Occasionally, polypropylene mesh granulates over and allows for grafting; this occurs less commonly with polytetrafluoroethylene mesh. There are expected disadvantages with polypropylene, as with any prosthetic material. The direct intraperitoneal placement of polypropylene material onto uncovered bowel can cause bowel erosion into the soft tissue, resulting in enterocutaneous fistulas. Furthermore, the material can erode through skin leading to extrusion of the prosthetic material. While more resistant to infection than some other prosthetic material, polypropylene is susceptible to infection.

Polytetrafluoroethylene (PTFE, Gore-Tex) mesh has unique physical properties; it is not water absorbent and is resistant to adherence. Initial studies in animal models revealed no acute host inflammatory reaction to the material[30]. However, because of the lack of fibrovascular incorporation of this material, it becomes infected easily and has been noted to have a high complication rate. However, Bauer et al, in 1987, reported their experience with PTFE abdominal repairs in 28 patients with only 3 hernia recurrences (10.7%).¹⁴ Another concerning and frequent complication with the use of PTFE for abdominal hernia repair is seroma formation.

Polyglactin 910 (Vicryl) has been found to be inert, nonantigenic, and nonpyrogenic. It has a high tensile strength with material retention of 60% at day 7, 35% at day 14, and only 5% at day 28. Polyglycolic acid is completely hydrolyzed in 90-120 days. Vicryl mesh is a tightly-woven broadcloth that is thick and flexible, though not elastic. In a contaminated operative field, placement of absorbable prosthetic material provides temporary coverage and abdominal wall support until wound contamination resolves. Absorbable material is often utilized in staged-reconstructive procedures. Split-thickness skin graft (STSG) can be placed directly on the granulated base of this prosthetic material for temporary closure. Subsequent hernia formation is expected after the absorption of the prosthetic material.

Composite mesh material

The complications seen with traditional prosthetic materials have led to the development of composite products that combine absorbable with nonabsorbable materials or nonabsorbable materials with tissue-separating barrier materials. Numerous composite products are available today, including Composix (Duval, Inc., Cranston, RI); Sepramesh (Genzyme, Cambridge, Mass); and Proceed, Ultrapro, and Vypro I/II (Ethicon Inc., Somerville, NJ). Additionally, mechanical data on the abdominal wall after mesh implantation evoked an interest in creating a prosthetic material to better duplicate the physiology of the abdominal wall native tissues.

Bioprosthetics

Abdominal wall reconstruction with bioprosthetic material has gained wide popularity over the past several years. The reasons for this paradigm shift are the touted desirable properties of this material, which include the following:

• Bioprosthetics are as strong as synthetics, yet far more pliable.
• Bioprosthetics resist infection.
• Bioprostheticssupport rapid revascularization and remodeling.
• Bioprosthetics are resistant to adhesion formation.
• Bioprosthetics reduce costly complications.
• Bioprosthetics have excellent handling properties.
• Bioprosthetics are safe to use.

Tissue expansion

Tissue expansion has been extensively used to recruit skin and soft tissue to cover fascial repairs with mesh.^15,16 Tissue expansion has been described for expansion of fascia in the treatment of abdominal wall reconstruction;^10,17 however, this application is not commonly performed. Using tissue expansion for abdominal wall reconstruction has several advantages, including color match, contour match, and minimal donor deformity. However, tissue expansion requires at least one extra operation and possibly more, if a complication such as expander extrusion occurs. 

Flaps

Myocutaneous flaps can provide skin, soft tissue, and fascia in the reconstruction of full-thickness abdominal wall defects. Myocutaneous flaps are also the preferred reconstructive option in contaminated wounds for which nonabsorbable prosthetic mesh cannot be safely used. Furthermore, myocutaneous flaps are used to reconstruct clean wounds after tumor resection to provide skin and soft tissue coverage over fascial repairs with mesh.

The rectus abdominis muscle is the workhorse in abdominal wall reconstruction. The rectus abdominis can be used with or without a skin paddle to reconstruct wounds in the upper and lower quadrants of the abdomen as well as the suprapubic and umbilical area.¹⁸ The only area in which this flap is less suitable is the epigastrium. The rectus abdominis muscle can be based cephalically on the deep superior epigastric artery or caudally on the deep inferior epigastric artery. The rectus muscle averages 25 X 6 cm and can provide large transverse or vertical skin components.

The TFL flap is the next option for reconstruction of the umbilical, suprapubic, and lower quadrant abdominal areas.¹⁸ The TFL flap is a myocutaneous flap based on the lateral femoral circumflex artery. The TFL muscle is 13 cm long, 3 cm wide, and 2 cm thick. The TFL muscle originates from the anterior superior iliac spine (ASIS) and the iliac crest and inserts into the iliotibial tract. The skin paddle is harvested 10 cm in width and designed over the muscle along an axis from the ASIS to the lateral tibial condyle. The inferior limit of the cutaneous territory can be extended to 6 cm above the knee and 25-35 cm in length. The lateral femoral circumflex artery can be found approximately 6-8 cm inferior to the ASIS. The flap can be made to be sensate by designing it to include the T12 dermatome; this is done by fashioning the flap to include the area 6 cm posterior to the ASIS.¹⁹ The rotation arc of the pedicled flap reaches the costal margin if the tensor muscle is completely detached from its origin and raised as an island flap. However, the TFL flap is not useful to reconstruct defects of the upper abdomen because the distal third of the skin paddle is less reliable.

The rectus femoris can provide muscle and fascial coverage to the lower quadrant, umbilical, suprapubic, and epigastric areas. Dibbell described the mutton chop modification with medial fascial extension to reach this difficult area.²⁰ The rectus femoris muscle originates from the anteroinferior iliac spine and inserts on the patellar tendon. The rectus femoris is supplied by the lateral femoral circumflex vessels entering the muscle 6-8 cm below the anterior superior iliac spine or at the level of the pubic tubercle. A cutaneous paddle of 11 X 30 cm can be reliably harvested with this muscle and still allow primary closure of the donor. The primary function of this muscle is the terminal 20° of knee extension. This flap is easier to dissect than the TFL flap but has been accused of resulting in weak knee extension, which can be avoided by suturing the vastus medialis and lateralis muscles to the cut rectus femoris tendon.

Several other muscle flaps have been reported to reconstruct abdominal defects, including the anterolateral thigh; external oblique; and the distally based internal oblique, gracilis, vastus lateralis, and latissimus muscles. Other flaps that have been used to reconstruct abdominal defects include the omentum, thigh, and groin flaps.

Vacuum-assisted closure (VAC) therapy

The vacuum-assisted closure (VAC) device has really revolutionized the management of wounds over the past decade or so. The VAC has been shown to decrease infection, decrease wound edema, and stimulate neovascularization of the wound bed. Depending on the depth of the wound and the extent of the defect, the wound VAC has been used to accelerate healing by secondary intention and wound preparation prior to reconstruction with flaps and/or grafts. It is frequently used as a bridge between initial wound care and final stage definitive wound closure. The VAC has also been used to treat enterocutaneous fistulas. Enterocutaneous fistulas cause the adjacent wound to be exposed to succus entericus, which contains acids and enteric enzymes that hinder wound healing. The VAC can be used to remove these secretions and promote ingrowth of granulation tissue that, ultimately, contracts and epithelializes but may still need skin grafting. A general surgeon should assist in treating an abdominal wound that communicates with the intestine or colon.

Decision tree

In determining the appropriate management of abdominal wall hernias and wounds, it seems more deliberate to address elective ventral hernia repairs separate from contaminated/infected/traumatic abdominal wounds and abdominal wounds after tumor resection.

Reconstruction of small abdominal wall defects, particularly in an elective setting, can be achieved by using direct primary closure of the fascial edges or by using the components separation technique to achieve a tension "reduced" repair. The overlying skin, if healthy, can be undermined safely to the anterior axillary line to provide adequate soft tissue coverage following myofascial reconstruction. In the case of adequate skin but a large deficit of fascia, the abdominal fascia can be repaired with polypropylene mesh and the skin closed by direct approximation. If a large deficiency of skin and fascia is present, the reconstruction can be performed by regional flap reconstruction, by free tissue flap reconstruction, or by a staged reconstruction with placement of a tissue expander insertion as the first stage and fascial repair with polypropylene mesh and skin repair by direct approximation as the second stage.

Complications

The list of possible complications to abdominal wall reconstruction is extensive and includes hernia recurrence, infections, dehiscence, donor site complications, ileus, enterotomy, loss of umbilicus, abdominal compartment syndrome, renal failure, respiratory failure, pneumonia, and failure of implanted prosthetic and bioprosthetic materials.

• Search for CME/CE on This Topic »

• Prune Belly Syndrome (Urology)

• The Emergence of Minimally Invasive Functional Abdominal Wall Reconstruction
• Endoscopic Component Separation Technique - A Minimally Invasive Functional Abdominal Wall Reconstruction
• The Acute Pain Service Nurse Practitioner: A Case Study in the Postoperative Care of the Child With Bladder Exstrophy