Diese Präsentation wurde erfolgreich gemeldet.
Die SlideShare-Präsentation wird heruntergeladen. ×

Abdominal wall defect reconstruction

Weitere Verwandte Inhalte

Ähnliche Bücher

Kostenlos mit einer 30-tägigen Testversion von Scribd

Alle anzeigen

Ähnliche Hörbücher

Kostenlos mit einer 30-tägigen Testversion von Scribd

Alle anzeigen

Abdominal wall defect reconstruction

  1. 1. Dr Subhakanta Mohapatra Mch plastic surgery, IPGME&R,SSKM Hospital kolkata
  2. 2.  Skin  Subcutaneous fatty layer (Camper’s fascia)  Deep fibrous layer/ Scarpa’s fascia (superficial fascia)  Adipose tissue  Deep fascia(aponeurotic fascia)  Paired flat muscles  Fascia transversalis  peritoneum
  3. 3. Rectus abdominis muscle
  4. 4. External oblique muscle
  5. 5. Internal oblique muscle
  6. 6. Transverse abdominis
  7. 7. Superficial & deep anatomy of the abdomen showing muscular layers & fascial layers
  8. 8. The rectus sheath above & below arcuate line
  9. 9. Hernia repair Tumor defect Congenital defect Traumatic defect
  10. 10.  Not recommended now  High (25-63%) recurrence, even in <5cm defect  May be indicated for <3cm defect
  11. 11. B/L mobilisation of Rectus abdominis muscles as musculo-fascial, bipedicled,neurotized flap Degloving of skin & SC tissue up to anterior / mid axillary line Fasciotomy (1-2 cm lateral to linea semilunaris) with cautery/scissors to separate EO from RA.
  12. 12. Entering in avascular plane in b/w EO & IO (without injuring IO fascia or muscle) Posterior rectus sheath incision( few mm lateral to free edge of fascia) – gives additional 2 cm mobility. Further mobilisation – Sub-periosteally off the costal margin & symphysis pubis Requires reinforcement(underlay/onlay)
  13. 13.  Intraperitoneal adhesions – regarded as a component & must be separated.  Wide adhesiolysis up to paracolic gutter is an important step  If stoma present & to be preserved – wide soft tisssue attachment should be maintained around the stoma  If stoma to be created through rectus component separation Stoma exteriorization after fascia closure
  14. 14. Maximal U/L rectus complex mobility with component separation of EO & IO muscles to the posterior axillary line
  15. 15. Midline closure at Linea alba after component separation
  16. 16.  Disadv  Needs wide undermining  More chance of seroma  Skin edge ischaemia  Recent advance  Endoscopic & minimally invasive component separation
  17. 17.  Peri-umbilical perforator spared  Single , large caliber  Arising from rectus abdominis in each hemiabdomen  Advantage  Minimises ischaemic soft tissue complications  Useful for pts with comorbidities  Disadvantage  More operative time  Limit the degree of release (minor extent)  Underlay mesh used here.
  18. 18.  1. EO perforator 2. DIEA perforator with large musculocutaneous branch 3. intramuscular branching with small musculocutaneous perforator 4. large musculocutaneous branch with no intramuscular branches 5. septocutaneous perforators
  19. 19.  Fascia lata graft  Broad & dense fascia of TFL  28 × 14 cm - max size  5 -10 cm length should be left, to prevent lateral knee instability  Drains in donor site  Can be used in contaminated cases  32 % recurrence rate
  20. 20. availability strength No donor site morbidity Host tissue incorporation
  21. 21. Polypropelene ePTFE  Larger pore size  Strong  More resistant to infection  Less seroma  Can not be placed directly on the bowel  Host tissue incorporation- present  Microporous  More stronger  Less resistant to infection  More seroma  Soft, flexible,conforming quality,minimal tissue ingrowth. So can be placed directly on bowel.  Absent
  22. 22. onlay inlay underlay sandwich
  23. 23. A.Only B.inlay C.underlay
  24. 24.  Mesh placed above the fascia,from one EO to other EO  Quilting sutures between onlay & fascia (to decrease seroma)  Drains above & below onlay  Adv  ease of use  no full thickness U sutures  avoids direct contact with bowel  Disadv  wide tissue undermining  contaminated, if skin breaks down  pressure required to disrupt mesh from abdominal wall is less.
  25. 25. Component separation with onlay mesh
  26. 26.  Excision of hernia sac  Identification of healthy fascial margins  Tensionless repair  Adv - Avoids wide undermining  Disadv - Significant tension to mesh fascia interface (weakest point),so high recurrence
  27. 27.  By Rives & Stopa  Used in increasing frequency  Mesh - between posterior rectus sheath & rectus muscle(within the limits of rectus sheath)  Atleast 4 cm contact between mesh & fascia  Below arcuate line – placed in preperitoneal space  Recurrence rate - < 10 %
  28. 28. Retrorectus underlay
  29. 29.  Adv :  Strength layer placed in proximity to muscle  Not in contact with bowel  Disadv :  No broad resurfacing of abdominal wall  secondary hernia lateral to rectus sheath
  30. 30.  Commonly used in open & laparoscopic approach  Span from one EO to other EO  Full thickness U sutures by Reverdin needle (from abdominal wall down in to peritoneum, in to mesh, & back in to abdominal wall)  Mesh should be tensioned (for passive closure of muscles in midline)  Recurrence - < 5%
  31. 31. U suture by Reverdin needle
  32. 32.  Adv  Large underlay allowing better tissue ingrowth  More secure mesh fascial interface  Disadv –  Ring of U sutures may strangulate the fascia  Neuroma – full thickness suture - injury to nerve
  33. 33. Intraperitoneal underlay
  34. 34.  Intraperitoneal mesh underlay  Mesh secured by tacking device /transabdominal suture/both  Adv : ↓ hospital stay, ↓wound complication  Disadv :  No restoration of dynamic abdominal wall  No cosmetic improvement by excising excess tissue & scar  Recurrence : 2-4 %
  35. 35.  Derived from human & animal tissues  Human acellular dermis(Alloderm)  Less adhesions – intraperitoneal use possible  Size limitations (small size patch)  Porcine submucosa  Come in larger sheet  Adv  Resistance to infection  Tolerance of cutaneous exposure  Mechanical stability  Disadv  High cost  Lack of long term follow up study
  36. 36.  Provides well vascularised, autologous, innervated tissue  Indicated for pts having both fascial & soft tissue deficiency  In congenital defect & large hernias  Site – in S.C space (over fascia) – commonly done  Intermuscular  both fascia & soft tissue expansion  between EO & IO  not commonly done
  37. 37.  Upper third defect – Thoraco epigastric flap - EO flap(rotational flap)  Middle third defect – ilio-lumbar bipedicled flap (based on superficial circumflex iliac & lumbar perforators)  Lower third defect – SIEA ,DIEA flap,groin flap  Lateral wall defect – Rectus abdominis flap  Paramedian defect - EO flap(advancement flap)
  38. 38.  pedicled/free  muscle/fascial/fascio cutaneous  Adv  Dispensable  good arc of rotation  Disadv  no dynamic reconstruction  distal third – unreliable  donor site morbidity  Complications  seroma/hematoma/lateral knee instability/STSG loss  recurrence – 9- 42%
  39. 39.  Rectus femoris musculofascial / musculofasciocutaneous flap - Free/ ( pedicled flap for lower 2/3rd defect)  ALT flap with mesh – free/(pedicled – lower abdominal defect)  LD flap free/(pedicled – upper abdominal defect)  Gracilis muscle/musculofasciocutaneous flap - lower third small defect
  40. 40. A. TFL flap B.ALT flap C. RF flap (pedicled)
  41. 41.  In conjuction with other transplantation  Pedicle – inferior epigastric vessel  Lifelong immunosuppression
  42. 42.  Drain :  Between mesh & fascia  Atleast 2 additional subcutaneous drains (in component separation)  In paracolic gutters  Fibrin based tissue glues in S.C space (to prevent seroma)  Quilting sutures (from skin flap down to fascia )
  43. 43.  DVT prophylaxis  Prophylactic antibiotic 30 mins before surgery  Consideration of extubation on 1st post op day  Intra abdominal pressure monitoring  Drain  Larger drain for potential hematoma area  Smaller drain for seroma risk area  Kept at least 1wk  Early enteral feeding/ TPN
  44. 44.  Abdominal binder  may be given only after 48 – 96 hrs  Analgesia  to improve pulmonary toilet, pain control,ileus  Muscle relaxation  Use of botulinum toxin at the time or 1wk before operation  Activity  Extremely limited activity for 1st 6 wks
  45. 45. Recurrence Wound breakdown Adhesions Seroma(more in underlay) Spigelian hernia Pain Mesh migration(rare)
  46. 46.  Wound breakdown :  Local wound care & hyperbaric oxygen for biological/light weight mesh  Synthetic mesh - More likely to be removed (if periprosthetic infection develops)  Adhesions :  Prevention – by interposing omentum in between bowel & abdominal wall  Biologic mesh & fascial grafts – lower adhesions  Seroma :  Serial aspiration  Sclerosant  Excision of pseudobursa
  47. 47.  Chronic pain :  Prevention - using long term absorbable sutures  T/t –  Neuronal stabilising medications  Massage,desensitisation,US pulses, acupuncture  Surgery -  removal of offending suture,staple,mesh  neurolysis/neurectomy of involved nerve
  48. 48.  Scar revision  Contour improvement/ panniculectomy  Correction of diastases  Umbilical reconstruction  Amelioration of pain
  49. 49.  Multiple small fascial defects  When one defect repaired, the other unrepaired defect enlarge  Recurrence due to failure of diagnosis of multiple defects  Pre op CT scan confirms location & number of defects  Wider dissection to identify occult hernia  Laparoscopic view - broader view
  50. 50. Free flap Regional flap Component separtation Expander Fascial grafts Be closed primarily

×