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Abdominal Wall Reconstruction Treatment & Management

  • Author: Mark A Grevious, MD, FACS; Chief Editor: Jorge I de la Torre, MD, FACS  more...
 
Updated: Mar 04, 2016
 

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 ECG and stress testing.

Once the decision has been made to proceed with operative intervention, it is advantageous for the patient to receive a bowel preparation, both in case of enterotomy during repair as well as for simple decompression of the bowel to facilitate manipulation and closure. For most ventral hernia repairs, preoperative imaging should be obtained to assist in surgical planning. A CT scan (with oral contrast) assists in determining the size and location of fascial defects, as a clinically evident bulge may not always be representative of the size and location of the fascial defect. Moreover, in the patient presenting for reoperation following hernia recurrence, preoperative imaging allows the surgeon to determine the location of any previously placed prosthetic material and associated scarring. Finally, in patients with complicated abdominal histories including ostomies and/or dysmotile bowel, preoperative CT scans may be invaluable in coordinating bowel procedures with abdominal wall reconstruction.

In the perioperative period, patients should receive prophylactic antibiotics and mechanical and pharmacologic prophylaxis for venous thromboembolic (VTE) disease. Consideration should be given to preoperative pharmacologic VTE prophylaxis in patients defined as high risk by the American College of Chest Physicians.[13]

Preoperative considerations

The initial assessment of a patient with a complex abdominal wall defect should focus on which structures are present, absent, or distorted with respect to each anatomical layer of the abdominal wall. Previous scars should be taken into consideration during preoperative planning. Incision design and knowledge of the vascular supply to the skin and soft tissue can be crucial, particularly in patients who have had multiple abdominal procedures. For example, a paucity of well-vascularized skin and subcutaneous tissue may jeopardize the reconstructive outcome. This becomes particularly important if prosthetic material is required to replace or reinforce an area of the musculofascial layer. Patients with actively infected wounds and/or systemic infections are poor candidates for reconstruction with prosthetic materials.

The importance of an accurate assessment of postoperative infection risk is highlighted by pay-for-performance initiatives being proposed at all levels of healthcare reform. These reform measures would withhold or refuse reimbursement for complication-related re-admission in the early postoperative period. Increased 30-day re-admission rates were observed in patients with multiple prior abdominal operations, active infection at the time of repair, and the presence of an enterocutaneous fistula. With regard to wound infections, COPD, steroid use, smoking, low preoperative serum albumin (< 2), and coronary artery disease have all been shown to be independent risk factors for the development of a postoperative wound infection. Wound infections not only increase patient discomfort, healthcare costs, and rates of re-admission, they have also been associated with significantly higher rates of long-term hernia recurrence.[14]

In an attempt to assist the reconstructive surgeon in better defining preoperative risk, the Ventral Hernia Working Group stratified cases into a 4-tier grading system based on risk of developing a surgical site complication (see figure below). Technique and material preferences varied based on case grade, with the Ventral Hernia Working Group expressing a stronger preference for bioprosthetic materials with increasing case grade and ultimately recommending staged or delayed repair in grade 4, actively infected, cases.[14]

Hernia grading system: assessment of risk for surg Hernia grading system: assessment of risk for surgical site occurrences. Wound infection defined as being contained within the skin or subcutaneous tissue (superficial), or involving the muscle and/or fascia (deep).

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 2 key principles for successful reconstruction of the abdominal wall. If a patient has a contaminated wound with necrotic tissue, irrigation and debridement should be the first line of therapy. Once a clean wound has been achieved, wound coverage with occlusive dressings, vacuum-assisted wound closure (VAC) devices, absorbable prosthetic material, or a split-thickness skin graft over fully adhesed and granulated intra-abdominal contents may serve as a temporizing solution.

This method of wound coverage with delayed fascial repair allows for stabilization of the patient until definitive reconstruction can be performed. Similar considerations apply to patients with acute abdominal wall defects secondary to trauma or fascial suture-line dehiscence; efforts are made to render the abdomen “frozen” (eg, with absorbable mesh material followed later by skin grafting) before proceeding with definitive reconstruction.[15]

Decision tree

Attempts to develop a simplified, algorithmic approach to abdominal wall reconstruction have proven difficult. Evidence-based recommendations regarding the optimal approach to abdominal wall reconstruction are lacking due to significant variability in technique, prosthetic material, patient characteristics, and lack of long-term follow-up in the literature. Generally, laparoscopic techniques have demonstrated fewer wound and total complications when compared with open repairs. They have also shown shorter lengths of hospital stay and lower rates of recurrence. However, laparoscopic repair is plagued by a higher rate of unplanned enterotomy and there is a size limitation to what can be repaired laparoscopically.[16, 17]

Emphasizing the role of abdominal wall compliance in hernia management, component separation techniques have gained increased popularity in recent years (see below). Despite differences of opinion in the literature currently, one point of agreement is the finding that rates of recurrence increase substantially with each attempt at reconstruction, with recurrence increasing 10-20% with each successive repair.[14] This underscores the importance of developing a sound surgical plan, with the goal of providing a durable and definitive reconstruction.

Regardless of the specific technique or material used, a surgical approach to abdominal wall reconstruction should consider all of 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
Next

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.[18] These free nonvascularized fascial grafts have been demonstrated to maintain their structural integrity.[19, 20] 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 currently being replaced by bioprosthetic materials (see below).

Prosthetics

Following the first randomized, controlled trial comparing suture repairs to mesh reinforcement of incisional hernia repairs, the standard of care has been to use mesh to produce a supported repair of virtually all abdominal wall defects.[21]

Since that publication in the New England Journal of Medicine in 2000, improvements in synthetic mesh and the development of bioprosthetic meshes have led to a bewildering number of studies comparing one product to its competitor. These investigations were at least partly driven by the development of laparoscopic hernia repair, which inherently requires mesh to be placed directly on the bowel. In general, the advantages of using prosthetic materials include availability, absence of donor site morbidity, and added strength of the prosthetic material. Obvious disadvantages are susceptibility to infection (which may necessitate explantation), fistula formation secondary to bowel erosion, adhesion formation, extrusion, and seroma formation.

Given surgeon preference for one mesh or another, there are very few high-level clinical studies comparing one mesh with another in a scientifically rigorous manner. Thus, the reconstructive surgeon is left to extrapolate the advantages and disadvantages offered by a particular mesh from the large volume of retrospective reviews, preclinical animal studies, and industry-biased information that is available. Fortunately, the clinical performance of the most commonly used prosthetics can largely be inferred from its structure and composition.

Owing to its low cost, favorable handling, and presence on the market since the late 1950s, polypropylene is probably the most commonly used synthetic prosthetic material for abdominal fascial repair. A study by Bender of 538 patients with ventral incisional hernias (292 with primary hernias and 246 with recurrent hernias) who underwent open retrofascial repair with polypropylene mesh found the procedure to have low rates of recurrence and complications. The recurrence rates were 2.7% (primary hernias) and 4.1% (recurrent hernias), with 43 patients (8.0%) developing a wound complication; one death occurred.[22]

The latest variations in polypropylene mesh design feature a lightweight, macroscopic pore structure designed to encourage incorporation while minimizing foreign body reaction. Polypropylene is most suitable for clean wounds with adequate soft tissue coverage, as much of the literature implicating polypropylene in fistula formation or extrusion stems from its use in full-thickness defects with poor soft tissue coverage.[23, 24]

The superior tensile strength provided by polypropylene stems from its ready incorporation into surrounding tissue. However, this same capacity to be incorporated also serves as the basis for adhesion formation. In light of this, direct intraperitoneal placement of polypropylene material onto uncovered bowel has largely been discouraged. While seemingly sound in theory, much of the literature supporting the concern for fistula formation and adhesive bowel disease caused by intraperitoneal polypropylene is anecdotal and has recently been challenged.[25, 26]

Developed in response to concerns over the adhesions observed with polypropylene, expanded polytetrafluoroethylene (PTFE, Gore-Tex) mesh was designed with unique physical properties and a microporous structure with the goal of minimizing adherence. Initial studies in animal models revealed no acute host inflammatory reaction to the material. However, the lack of adherence has also been met with poor fibrovascular incorporation of the material, leading to platelike scar formation and high rates of infection and seroma formation. The tendency for expanded PTFE to encapsulate leads to insufficient anchorage of the mesh patch at the interface with the fascia and has resulted in high recurrence rates.[27]

While still used as a component of a composite mesh (discussed below), expanded PTFE has largely fallen out of favor for use in abdominal wall reconstruction. Recently, a condensed variant of PTFE has emerged onto the US market, after seeing increased use in Europe. This macroporous, condensed PTFE (MotifMESH) has been designed to minimize the susceptibility to infection observed in the microporous expanded PTFE and has demonstrated increased incorporation compared with its predecessor, theoretically resulting in decreased rates of shrinkage or seroma formation.[28, 29]

As an absorbable mesh, 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 used in staged-reconstructive procedures.

A split-thickness skin graft 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, thus absorbable materials have a limited role in the definitive reconstruction of large abdominal wall defects. That said, there is currently a considerable industry-led initiative to develop and promote synthetic, bioabsorbable mesh constructs (Bio-A, TigR matrix) that aim to combine the benefits of synthetic and biological prosthetics.

Composite mesh material

Driven by laparoscopic repair and the complications seen with traditional synthetic materials, composite products have been designed to combine nonabsorbable materials with absorbable coatings or nonadhesive barrier materials. Numerous composite products are available in current practice, including Composix (Duval, Inc; Cranston, RI); Sepramesh (Genzyme; Cambridge, Mass); and Proceed, Ultrapro, and Vypro I/II (Ethicon, Inc; Somerville, NJ). Regardless of the material used or design structure, mechanical data on the abdominal wall after mesh implantation have evoked an interest in developing prosthetic materials that better mimic the physiology of the native abdominal wall tissues. As mentioned previously, none of these products has been able to demonstrate a clinically significant and reproducible advantage over the other commonly used prostheses.

Bioprosthetics

While synthetic mesh has dramatically improved the problem of hernia recurrence, when used in contaminated or in emergent cases, it has been plagued by high rates of infection. Based on the success of autologous grafts such as the TFL, the search for a strong, infection-resistant material contributed to the introduction of bioprosthetics. These biological meshes are derived from human or animal sources and are all composed of a preserved extracellular matrix that has been decellularized to mitigate an immune response. Cross-linking and other processing of these bioprostheses must balance durability with tissue ingrowth, in order to facilitate repopulation of the matrix with autologous cells. The ultimate aim of bioprosthetic design is to foster regeneration and remodeling over inflammation and a foreign body response.

Abdominal wall reconstruction with bioprosthetic material has gained wide popularity over the past several years, largely attributable to its application for use in contaminated surgical fields or in conjunction with concomitant bowel surgery. Three major types of bioprosthetics are being used in current practice: acellular human dermis, porcine small intestinal submucosa (SIS), and acellular porcine dermis. While an effective alternative to synthetic mesh in the face of contamination, routine use of a bioprosthetic in an elective setting should be balanced by a consideration of the high cost of the material. Available literature also suggests a higher rate of recurrence compared with synthetics when used in a supportive fashion, as well as reports of eventration when used as fascial replacement (ie, bridged technique).[30]

The great interest in bioprosthetics has fueled a large volume of active research into the underlying biology and clinical performance of these materials, which should help to more clearly define the optimal role of bioprosthetics in the management of abdominal wall defects.

Components separation

Since its original description by Ramirez et al in 1990,[31] the technique of components separation, or “separation-of-parts,” has been increasingly used as a means of restoring the dynamic properties of the abdominal wall. The technique relies on lateral release of the external oblique muscles and the creation of sliding myofascial flaps to allow reapproximation of the rectus abdominis muscles at the midline. In contrast to bridging mesh repair or other autogenous techniques that achieve closure through the use of the hernia sac itself, the components separation repair creates a more compliant abdominal wall and eliminates unhealthy, scarred tissue at the midline. Massive ventral hernias as large as 35-40 cm in transverse dimension have been successfully repaired using this method.[32] Hernia recurrence rates have been favorable, in the range of 10-20% over the long term.[33]

While high rates of postoperative wound infection and dehiscence have been reported in some studies, these complications can be significantly reduced by preservation of the periumbilical rectus abdominis perforating vessels. The use of lateral subcostal incisions to access the external obliques can obviate the need for wide undermining of skin flaps, thereby preserving the periumbilical perforators.[34]

The classic components separation technique involves the following:

  1. The longitudinal release of the medial edge of the external oblique aponeurosis (approximately 1.5-2 cm lateral to the linea semilunaris), followed by blunt separation of the external oblique muscle from the internal oblique muscle in an avascular plane out to the anterior axillary line
  2. Separation of the rectus abdominis muscles from the underlying posterior rectus sheath

Release of the external oblique at the linea semilunaris and the consequent advancement of the rectus abdominis muscle toward the midline is schematized in the figure below. Note that the second step, release of the rectus muscles from the posterior sheath, may not be necessary in many cases to achieve closure.

This drawing illustrates the component separation This drawing illustrates the component separation technique. A longitudinal incision is made at the semilunar line, and the relative vascular plane is dissected between the external and internal oblique muscles. Incising the anterior rectus sheath allows for advancement of musculofascial components medially.

Important to note is that the current literature on components separation features a number of variations in technique without significant, high-level, evidence-based support for any one technique in particular. Long-term follow up greater than 1 year is lacking among the majority of published studies. As mentioned, consensus now appears to exist with regard to the importance of sparing the periumbilical perforators to preserve the integrity of the skin and soft tissue overlying the fascial repair. How to approach the fascial repair itself, however, is the subject of much disagreement.

Some investigators prefer the use of mesh underlay to provide support for the midline fascial repair, whereas others prefer the sole use of autogenous tissue without any prosthetic or bioprosthetic material. The choice of underlay mesh has also been debated. The largest reported series of component separation repairs (200) from Northwestern University has shown that soft polypropylene mesh underlays, in combination with components separation, yields the lowest rate of long-term hernia recurrence (0% in this series). A higher rate of recurrence was seen for bioprosthetic-reinforced repairs (33%) relative to component separation repairs with no reinforcement (23%), leading to the conclusion that bioprosthetic materials be reserved only for contaminated cases in which mesh use would best be avoided.[35]

Nonetheless, new bioprosthetic materials (eg, Strattice; LifeCell, Branchburg, NJ) are now available in large sheets with different biomechanical properties from first-generation acellular dermal matrices (eg, AlloDerm; LifeCell, Branchburg, NJ), and these agents have yet to be reported upon in large-scale ventral hernia studies.

A study by Criss et al indicated that in ventral hernia repair, moving the rectus muscles back to the midline in order to retain the linea alba restores native abdominal wall function and improves patient quality of life. In the study, dynamometric analysis was performed on 13 patients before they underwent open ventral hernia repair with midline restoration and again at 6 months postsurgery. Dynamometric evaluation showed improved isometric and isokinetic measurements during abdominal flexion. Associated improvement was found in patient quality of life at 6 months, as measured using the HerQLes survey.[36]

Tissue expansion

Tissue expansion has been extensively used to recruit skin and soft tissue to cover fascial repairs when available skin is sparse or unhealthy and scarred.[37, 38] Tissue expansion has been described for expansion of fascia in the treatment of abdominal wall reconstruction[39, 40, 41] ; however, this application is not commonly performed. Using tissue expansion for the skin 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.[42] 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.[42] 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.[43] 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.[44] 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 ASIS 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 site. 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 suggested to cause 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 as useful in the reconstruction of 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 therapy

The vacuum-assisted closure (VAC) device has revolutionized the management of wounds over approximately the past decade. The wound VAC has been shown to decrease infection, decrease wound edema, and stimulate neovascularization of the wound bed.[45] Depending on the depth of the wound and the extent of the defect, 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.

In a commonly used reconstructive algorithm for acute abdominal wall defects, absorbable mesh may be used to render the abdominal contents “frozen.” Following this, a VAC device may be placed to allow a bed of granulation to accumulate over the absorbable mesh, after which time split-thickness skin grafting can be performed. After several months with a stably covered wound, definitive abdominal wall reconstruction can be performed via components separation.[15]

The VAC device has also been used to control 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 device can be used to remove these secretions and promote ingrowth of granulation tissue that ultimately contracts and epithelializes but may still require skin grafting. A general surgeon should assist in treating an abdominal wound that communicates with the intestine or colon.

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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, renal failure, respiratory failure, pneumonia, and failure of implanted prosthetic and bioprosthetic materials.

One important complication of definitive abdominal wall repair is the potential for a sudden, sharp increase in intra-abdominal pressure with the return of visceral contents to the peritoneal cavity. Intra-abdominal pressure greater than 20 mm Hg constitutes intra-abdominal hypertension (IAH). IAH can have far-reaching systemic consequences, including a decrease in cardiac output secondary to caval compression, elevated intrathoracic pressure with associated ventilatory difficulties, reduced hepatorenal perfusion with organ dysfunction, and a rise in intracranial pressure with a risk of cerebral ischemia. In its most severe form, IAH gives way to abdominal compartment syndrome (ACS), a condition requiring emergent abdominal decompression. This generally occurs when intra-abdominal pressure exceeds 25 mm Hg and can quickly progress to multiorgan failure and death if not promptly recognized and addressed.[46, 47]

The risk of ACS following definitive abdominal wall repair remains especially significant for those patients with a history of recurrent small bowel obstructions. Ventral hernias may cause frequent episodes of mechanical obstruction, each of which may take days, if not weeks, to resolve with conservative measures. Over time, chronic dysmotility of the bowel may develop. This contributes to elevated intraluminal pressure with resultant smooth muscle dilation, impaired microcirculation with resultant bowel wall edema, and bacterial overgrowth with a risk for translocation and sepsis.[47] An overall rise in intra-abdominal pressure accompanies these effects. It follows that any surgical attempt to reduce the size of the abdominal cavity might further raise the intra-abdominal pressure and incite a vicious cycle that leads to ACS. Resection of adynamic small bowel in combination with components separation may be a viable strategy to both prevent ACS and restore bowel function.[48]

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Future and Controversies

The management of complex abdominal wall defects continues to evolve. Successful abdominal wall reconstruction relies on careful perioperative planning, thorough technical execution, close follow-up, and appropriate selection of synthetic or bioprosthetic material, when indicated.

Smaller defects can be reconstructed with local or regional tissue rearrangement procedures. Larger defects of the abdominal wall, which may have resulted from trauma or tumor extirpation, may require the use of myocutaneous flaps, synthetic or bioprosthetic material, or both. These reconstructions can be performed in either 1 or 2 stages. Posttraumatic abdominal wall reconstruction may require a 2-stage reconstruction.

The reconstructive surgeon must be well informed about the indications, properties, and complications associated with the use of these important biomedical tools in order to improve the quality of the lives of the patients being treated for these complex defects.

Defect size, location, depth of involvement, contamination, and comorbidity all are considerations that influence the management of abdominal wall defects. Because the potential for complications with abdominal wall reconstruction is significant, patients with comorbid conditions must be appropriately evaluated and screened. However, with meticulous planning, application of operative techniques that incorporate the principle of reconstruction with appropriate tension, and diligent postoperative care, abdominal wall reconstruction can be achieved with reasonable functional and cosmetic outcomes, patient satisfaction, and acceptable complication rates.

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Contributor Information and Disclosures
Author

Mark A Grevious, MD, FACS Chairman, Division of Plastic and Reconstructive Surgery, John H Stroger, Jr Hospital of Cook County

Mark A Grevious, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Bradon J Wilhelmi, MD Leonard J Weiner Professor and Chief of Plastic Surgery, Plastic Surgery Residency Program Director, Hiram C Polk Jr Department of Surgery, University of Louisville School of Medicine

Bradon J Wilhelmi, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Hand Surgery, American Society for Reconstructive Microsurgery, Association for Surgical Education, Plastic Surgery Research Council, American Association of Clinical Anatomists, Wound Healing Society, American Society for Aesthetic Plastic Surgery, American Burn Association, American College of Surgeons, American Society for Surgery of the Hand, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Gregory Ara Dumanian, MD, FACS Professor of Surgery, Neurosurgery, and Orthopedics, Northwestern University, The Feinberg School of Medicine

Gregory Ara Dumanian, MD, FACS is a member of the following medical societies: American Society of Plastic Surgeons

Disclosure: Nothing to disclose.

Jason M Souza, MD Resident Physician, Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine

Disclosure: Nothing to disclose.

Jordan P Steinberg, MD, PhD Pediatric/Craniofacial Plastic Surgeon, Advocate Children's Hospital

Jordan P Steinberg, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association of Pediatric Plastic Surgeons, American Cleft Palate-Craniofacial Association, American Society for Aesthetic Plastic Surgery, American Society of Craniofacial Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, AO Foundation, Johns Hopkins Medical and Surgical Association

Disclosure: Nothing to disclose.

Jafar S Hasan, MD, MBA Plastic and Reconstructive Surgeon, J S Hasan Plastic Surgery; Attending Surgeon, Division of Plastic Surgery, John H Stroger, Jr Hospital ofCook County, Chicago, IL

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jorge I de la Torre, MD, FACS Professor of Surgery and Physical Medicine and Rehabilitation, Chief, Division of Plastic Surgery, Residency Program Director, University of Alabama at Birmingham School of Medicine; Director, Center for Advanced Surgical Aesthetics

Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, American Society for Reconstructive Microsurgery, Association for Academic Surgery, Medical Association of the State of Alabama

Disclosure: Nothing to disclose.

Additional Contributors

Dennis P Orgill, MD, PhD Professor of Surgery, Harvard Medical School; Associate Chief of Plastic Surgery, Brigham and Women's Hospital

Dennis P Orgill, MD, PhD is a member of the following medical societies: American Society for Reconstructive Microsurgery, Plastic Surgery Research Council, American Medical Association, Massachusetts Medical Society

Disclosure: Received consulting fee from Integra LifeSciences, Inc for consulting; Received consulting fee from Integra LifeSciences, Inc. for program and training services agreement; Received grant/research funds from Integra LifeSciences, Inc. for clinical research; Received grant/research funds from KCI for basic science research; Received grant/research funds from KCI for clinical research; Received consulting fee from DSM for consulting; Received consulting fee from Musculoskeletal Transplant Foundatio.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Michael Neumeister, MD, FRCSC, FACS; Arian Mowlavi, MD; Elvin G Zook, MD; Mimis Cohen, MD, FACS, FAAP; and Aisha D White, MD, to the development and writing of this article.

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This drawing illustrates the component separation technique. A longitudinal incision is made at the semilunar line, and the relative vascular plane is dissected between the external and internal oblique muscles. Incising the anterior rectus sheath allows for advancement of musculofascial components medially.
Forty-six-year-old patient with chest wall recurrence of primary visceral carcinoma requiring composite resection.
Resultant complex abdominal wall defect following resection. Note repair of the diaphragm to the revised costal margin and exposure of the liver.
Coverage of the open abdominal defect with a Parietex composite mesh (Covidien; Norwalk, CT).
Soft tissue closure of defect with right-sided pectoralis muscle flap, left myocutaneous latissimus flap, and "4-quadrant" fasciocutaneous advancement flaps.
Hernia grading system: assessment of risk for surgical site occurrences. Wound infection defined as being contained within the skin or subcutaneous tissue (superficial), or involving the muscle and/or fascia (deep).
 
 
 
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