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Abdominal wall reconstruction after extensive abdominal wall necrosis resulting from chevron incision for liver transplant and subsequent Y-shaped incision for re-transplantation – Clinical experience and literature review
Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, e71ee73
CASE REPORT
Abdominal wall reconstruction after extensive abdominal wall necrosis resulting from chevron incision for liver transplant and subsequent Y-shaped incision for re-transplantation e Clinical experience and literature review Ulrich M. Rieger a,*, Fabian Petschke a, Gabriel Djedovic a, Timm O. Engelhardt a, Matthias Biebl b, Gerhard Pierer a a Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Innsbruck (MUI), Anichstrasse 35, 6020 Innsbruck, Austria b Department of Visceral, Transplantation and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
Received 12 July 2011; accepted 8 November 2011
KEYWORDS Abdominal wall reconstruction; Scars; Chevron incision; Interdisciplinary
Summary Extensive Abdominal wall necrosis is a devastating complication. In visceral transplant patients a quick and easy to perform reconstructive technique may be crucial for patient survival. Based on a clinical case a literature review is performed including a thorough analysis of abdominal wall perfusion and surgical options for defect closure are presented and critically appraised. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction We would like to share an illustrating case with an interdisciplinary approach in complication management:
* Corresponding author. Tel.: þ43 512 504 80088. E-mail addresses: [email protected], [email protected]. at (U.M. Rieger).
a 51-year-old female patient had received a liver transplant for primary sclerosing cholangitis 15 years ago via a chevron incision. She now presented with transplant failure due to a relapse of the underlying disease and was short-listed for re-transplantation. In neglect of the primary incision used 15 years ago a Y-shaped incision was used for re-transplantation leading to complete necrosis of the upper abdominal wall (zone between the original chevron incision and the upper part of the Y-shaped
1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.11.021
e72 incision) including both upper rectus muscles. The resulting triangular defect measured 25 cm in each arm. After tissue debridement a gore-tex patch was used for temporary abdominal closure and a VAC-System was applied on top of it (Figure 1a). Plastic surgery was counseled for abdominal wall reconstruction to prevent impeding intra-abdominal infection and transplant loss.
U.M. Rieger et al.
Operative technique Abdominal wall reconstruction was accomplished after further thorough debridement by implantation of a nonabsorbable mesh firmly sutured to the costal arch cephaladly and to the remaining parts of the rectus abdominis muscles caudally as well as to the remnant parts of the
Figure 1 (a) Pre-operative view after re-liver transplantation, abdominal wall necrosis and gore-tex patch implantation; (b) Immediate post-operative view after abdominal wall reconstruction using non-absorbable mesh and extensive reverse abdominoplasty technique with tissue mobilization down to the pubic mons; (c) Four weeks post-operative view after abdominal wall reconstruction; (d) 6 months post-operative view after abdominal wall reconstruction.
Abdominal wall reconstruction e Clinical experience and literature review internal and external oblique muscles in a sub-lay technique. After stabilization skin closure was obtained via an extensive reverse abdominoplasty technique with tissue mobilization down to the groin and pubic mons (Figure 1b). The further course was uneventful and primary healing (Figure 1c,d) could be achieved.
Discussion and review of the literature Thorough knowledge of abdominal wall perfusion is crucial across surgical disciplines. Main perfusion is provided by anastomosing branches of the superior and inferior epigastric arteries, minor vascularization is derived from segmental intercostal vessels laterally. As long as only one single full thickness horizontal scar dividing the rectus muscles crosses the epigastric artery axis perfusion is maintained by either of the transected vessel stumps. If, however, two or more horizontal incisions/scars cross this axis, the interlocked tissue is widely separated from nourishing perfusion since the lateral blood source is not sufficient to ensure viability. Abdominal wall necrosis between the scar lines is highly likely to occur. This is a finding that is well known in obesity surgery or body-contouring procedures.1,2 From cardiothoracic surgery we know that bilateral harvest of internal thoracic arteries in combination with bilateral harvest of inferior epigastric arteries used as conduits for myocardial revascularization may result in abdominal wall necrosis,3 a fact that clearly emphasizes the importance of these vessels for abdominal wall integrity. A variety of techniques for reconstruction of the abdominal wall have been proposed. Staged procedures for abdominal wall closure consisting of implantation of a polygalactin mesh with subsequent growing of granulation tissue followed by split skin grafts have been described for abdominal wound closure following combined liver and intestinal transplantation in pediatric patients.4 This technique has been described for adult patients after intestinal and multi-visceral transplantation as well.5 However, growing of granulation tissue is tedious and takes several weeks, the graft resulting in a very thin and mechanically instable layer which is prone to wound break-down. Abdominal-wall defect reconstruction with a free microneurovascular latissimus dorsi flap in a newborn with a left gastroschisis, exposure of the stomach, jejunum, and left colon has been described,6 but sophisticated microvascular skills are needed. Bilateral tensor fascia lata musculocutaneous flaps for abdominal wall reconstruction have been advocated,7 however for upper-midline defects as described here these flaps are too short and will be unstable in those areas needed to cover the defect and therefore are not an option. In case of a devastating complication such as upper abdominal wall necrosis, a problem solving surgical solution may be crucial for patient survival. Quick decision taking
e73
and an interdisciplinary approach ensure an adequate management of the particular complication. The reconstructive technique described here is a fast and technically easy to do procedure resulting in long-term abdominal wall stability. The patient reported was discharged five days after abdominal wall reconstruction and 4 weeks following re-transplantation. As long as the mesh implanted is sutured tautly to the adjacent structures hernia formation is rare.8
Conclusion We conclude that through a thorough knowledge of abdominal wall perfusion combined with careful re-incision planning tissue loss with abdominal wall necrosis may be preventable. In case of complications surgical cooperation across specialties can yield favorable outcomes through an improved reconstructive management.
Conflict of interest/funding None.
References 1. Rieger UM, Erba P, Kalbermatten DF, Schaefer DJ, Pierer G, Haug M. An individualized approach to abdominoplasty in the presence of bilateral subcostal scars after open gastric bypass. Obes Surg 2008 Jul;18(7):863e9. 2. Rieger UM, Heider I, Bauer T, Hussl H, Schoeller T, Pierer G. Treatment algorithm for abdomino-torso body contouring in massive weight-loss patients in the presence of scars e a comprehensive review. J Plast Reconstr Aesthet Surg 2010 Aug;13 [Epub ahead of print]. 3. Johnson DY, Johnson FE, Barner HB. Abdominal wall necrosis after harvest of both internal thoracic and inferior epigastric arteries. Ann Thorac Surg 2011 Jan;91(1):38e41. 4. Grevious MA, Iqbal R, Raofi V, et al. Staged approach for abdominal wound closure following combined liver and intestinal transplantation from living donors in pediatric patients. Pediatr Transplant 2009 Mar;13(2):177e81. 5. Carlsen BT, Farmer DG, Busuttil RW, Miller TA, Rudkin GH. Incidence and management of abdominal wall defects after intestinal and multivisceral transplantation. Plast Reconstr Surg 2007 Apr 1;119(4):1247e55. discussion 1256e8. 6. Olvera-Caballero C, Victoria-Morales G. Neurovascular latissimus dorsi free-flap transfer for reconstruction of a major abdominal-wall defect in a 13-month-old child: late follow-up. J Reconstr Microsurg 2004 Apr;20(3):237e40. 7. Luce EA, Hyde G, Gottlieb SE, Romm S. Total abdominal wall reconstruction. Arch Surg 1983 Dec;118(12):1446e8. 8. Ammaturo C, Bassi UA, Bassi G. Outcomes of the open mesh repair of large incisional hernias using an intraperitoneal composite mesh: our experience with 100 cases. Updates Surg 2010 Aug;62(1):55e61.
CASE REPORT
Abdominal wall reconstruction after extensive abdominal wall necrosis resulting from chevron incision for liver transplant and subsequent Y-shaped incision for re-transplantation e Clinical experience and literature review Ulrich M. Rieger a,*, Fabian Petschke a, Gabriel Djedovic a, Timm O. Engelhardt a, Matthias Biebl b, Gerhard Pierer a a Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Innsbruck (MUI), Anichstrasse 35, 6020 Innsbruck, Austria b Department of Visceral, Transplantation and Thoracic Surgery, Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
Received 12 July 2011; accepted 8 November 2011
KEYWORDS Abdominal wall reconstruction; Scars; Chevron incision; Interdisciplinary
Summary Extensive Abdominal wall necrosis is a devastating complication. In visceral transplant patients a quick and easy to perform reconstructive technique may be crucial for patient survival. Based on a clinical case a literature review is performed including a thorough analysis of abdominal wall perfusion and surgical options for defect closure are presented and critically appraised. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction We would like to share an illustrating case with an interdisciplinary approach in complication management:
* Corresponding author. Tel.: þ43 512 504 80088. E-mail addresses: [email protected], [email protected]. at (U.M. Rieger).
a 51-year-old female patient had received a liver transplant for primary sclerosing cholangitis 15 years ago via a chevron incision. She now presented with transplant failure due to a relapse of the underlying disease and was short-listed for re-transplantation. In neglect of the primary incision used 15 years ago a Y-shaped incision was used for re-transplantation leading to complete necrosis of the upper abdominal wall (zone between the original chevron incision and the upper part of the Y-shaped
1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.11.021
e72 incision) including both upper rectus muscles. The resulting triangular defect measured 25 cm in each arm. After tissue debridement a gore-tex patch was used for temporary abdominal closure and a VAC-System was applied on top of it (Figure 1a). Plastic surgery was counseled for abdominal wall reconstruction to prevent impeding intra-abdominal infection and transplant loss.
U.M. Rieger et al.
Operative technique Abdominal wall reconstruction was accomplished after further thorough debridement by implantation of a nonabsorbable mesh firmly sutured to the costal arch cephaladly and to the remaining parts of the rectus abdominis muscles caudally as well as to the remnant parts of the
Figure 1 (a) Pre-operative view after re-liver transplantation, abdominal wall necrosis and gore-tex patch implantation; (b) Immediate post-operative view after abdominal wall reconstruction using non-absorbable mesh and extensive reverse abdominoplasty technique with tissue mobilization down to the pubic mons; (c) Four weeks post-operative view after abdominal wall reconstruction; (d) 6 months post-operative view after abdominal wall reconstruction.
Abdominal wall reconstruction e Clinical experience and literature review internal and external oblique muscles in a sub-lay technique. After stabilization skin closure was obtained via an extensive reverse abdominoplasty technique with tissue mobilization down to the groin and pubic mons (Figure 1b). The further course was uneventful and primary healing (Figure 1c,d) could be achieved.
Discussion and review of the literature Thorough knowledge of abdominal wall perfusion is crucial across surgical disciplines. Main perfusion is provided by anastomosing branches of the superior and inferior epigastric arteries, minor vascularization is derived from segmental intercostal vessels laterally. As long as only one single full thickness horizontal scar dividing the rectus muscles crosses the epigastric artery axis perfusion is maintained by either of the transected vessel stumps. If, however, two or more horizontal incisions/scars cross this axis, the interlocked tissue is widely separated from nourishing perfusion since the lateral blood source is not sufficient to ensure viability. Abdominal wall necrosis between the scar lines is highly likely to occur. This is a finding that is well known in obesity surgery or body-contouring procedures.1,2 From cardiothoracic surgery we know that bilateral harvest of internal thoracic arteries in combination with bilateral harvest of inferior epigastric arteries used as conduits for myocardial revascularization may result in abdominal wall necrosis,3 a fact that clearly emphasizes the importance of these vessels for abdominal wall integrity. A variety of techniques for reconstruction of the abdominal wall have been proposed. Staged procedures for abdominal wall closure consisting of implantation of a polygalactin mesh with subsequent growing of granulation tissue followed by split skin grafts have been described for abdominal wound closure following combined liver and intestinal transplantation in pediatric patients.4 This technique has been described for adult patients after intestinal and multi-visceral transplantation as well.5 However, growing of granulation tissue is tedious and takes several weeks, the graft resulting in a very thin and mechanically instable layer which is prone to wound break-down. Abdominal-wall defect reconstruction with a free microneurovascular latissimus dorsi flap in a newborn with a left gastroschisis, exposure of the stomach, jejunum, and left colon has been described,6 but sophisticated microvascular skills are needed. Bilateral tensor fascia lata musculocutaneous flaps for abdominal wall reconstruction have been advocated,7 however for upper-midline defects as described here these flaps are too short and will be unstable in those areas needed to cover the defect and therefore are not an option. In case of a devastating complication such as upper abdominal wall necrosis, a problem solving surgical solution may be crucial for patient survival. Quick decision taking
e73
and an interdisciplinary approach ensure an adequate management of the particular complication. The reconstructive technique described here is a fast and technically easy to do procedure resulting in long-term abdominal wall stability. The patient reported was discharged five days after abdominal wall reconstruction and 4 weeks following re-transplantation. As long as the mesh implanted is sutured tautly to the adjacent structures hernia formation is rare.8
Conclusion We conclude that through a thorough knowledge of abdominal wall perfusion combined with careful re-incision planning tissue loss with abdominal wall necrosis may be preventable. In case of complications surgical cooperation across specialties can yield favorable outcomes through an improved reconstructive management.
Conflict of interest/funding None.
References 1. Rieger UM, Erba P, Kalbermatten DF, Schaefer DJ, Pierer G, Haug M. An individualized approach to abdominoplasty in the presence of bilateral subcostal scars after open gastric bypass. Obes Surg 2008 Jul;18(7):863e9. 2. Rieger UM, Heider I, Bauer T, Hussl H, Schoeller T, Pierer G. Treatment algorithm for abdomino-torso body contouring in massive weight-loss patients in the presence of scars e a comprehensive review. J Plast Reconstr Aesthet Surg 2010 Aug;13 [Epub ahead of print]. 3. Johnson DY, Johnson FE, Barner HB. Abdominal wall necrosis after harvest of both internal thoracic and inferior epigastric arteries. Ann Thorac Surg 2011 Jan;91(1):38e41. 4. Grevious MA, Iqbal R, Raofi V, et al. Staged approach for abdominal wound closure following combined liver and intestinal transplantation from living donors in pediatric patients. Pediatr Transplant 2009 Mar;13(2):177e81. 5. Carlsen BT, Farmer DG, Busuttil RW, Miller TA, Rudkin GH. Incidence and management of abdominal wall defects after intestinal and multivisceral transplantation. Plast Reconstr Surg 2007 Apr 1;119(4):1247e55. discussion 1256e8. 6. Olvera-Caballero C, Victoria-Morales G. Neurovascular latissimus dorsi free-flap transfer for reconstruction of a major abdominal-wall defect in a 13-month-old child: late follow-up. J Reconstr Microsurg 2004 Apr;20(3):237e40. 7. Luce EA, Hyde G, Gottlieb SE, Romm S. Total abdominal wall reconstruction. Arch Surg 1983 Dec;118(12):1446e8. 8. Ammaturo C, Bassi UA, Bassi G. Outcomes of the open mesh repair of large incisional hernias using an intraperitoneal composite mesh: our experience with 100 cases. Updates Surg 2010 Aug;62(1):55e61.