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Title:

Complex Abdominal Wall Defects

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Limited to small defect ( 5 cm in diameter) Highest recurrence rate (up to 27 ... Causes: removal infected mesh, removal of STSG, trauma; abd wall desmoid rsxn ... – PowerPoint PPT presentation

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Title: Complex Abdominal Wall Defects


1
Complex Abdominal Wall Defects
2
Muscle and investing fascia
3
Risk Factors
  • Wound Infection
  • Abdominal Compartment Syndrome
  • Trauma
  • Infected Mesh
  • Incisional Hernia
  • Multiple Re-operations through same wound
  • Tumor resection
  • Obesity, Malnutrition, Sepsis

4
Treatment Options
  • Primary Repair
  • Mesh Rives-Stoppa
  • 3 Stage delayed repair
  • Components Separation
  • Local flaps v. Free tissue transfer
  • Human Acellular Dermis (Alloderm)

5
Primary repair
  • Limited to small defect (lt5 cm in diameter)
  • Highest recurrence rate (up to 27)
  • Patient selection is most important
  • Excessive tension leads to ischemia and
    failureavoided with mesh and flap

6
Retention sutures
7
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

8
  • Retro-rectus mesh repair ant to posterior
    fascia or pre-peritoneal 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)

9
Mesh closure
10
Rives-Stoppa
11
Three Staged Closure
  • Mostly in pts w/ abdominal compartment syndrome
  • Stages
  • Absorable mesh / VAC
  • STSG
  • Ventral hernia repair

12
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

13
Component separation
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  • 22 pts / 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

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Goals of abdominal wall reconstruction
  • Restoration of function and integrity of the
    abdominal wall
  • Prevention of evisceration
  • Dynamic muscle support

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23
Flap closure
  • Flap selection based on location and arc of
    rotation
  • High success rate when combine with mesh

24
Common flaps used
25
Free tissue transfer?
  • Requires adequate recipient vessels
  • Allows to transfer innervated muscle
  • Technically more demanding

26
Acellular Cadaveric Dermis (Alloderm)
27
  • Goal 3 stage ? single operation
  • Bilateral bipedicle advancement flaps
  • Incisions _at_ anterior axillary lines-undermine _at_
    junction of SQ fat anterior fascia
  • Donor site w/ STSG
  • 9 Pts followed for mean 20 months
  • Conclusion

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Transplantation of the abdominal wall
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