Plastic Surgery Considerations for Abdominal Wall Reconstruction
The management of skin and soft tissue is an essential component of abdominal wall reconstruction. Patients with complex hernias often have scars, wounds, fistulas, skin graft on bowel, excess adiposity, and excess or deficit of skin. Each of these factor
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Ibrahim Khansa, Terri Zomerlei, and Jeffrey E. Janis
34.1 Introduction Surgical-site infection, seroma, dehiscence, and skin necrosis are complications that may affect the skin and soft tissue of the abdominal wall after complex hernia repair. These complications may actually jeopardize the entire hernia repair, as hernia recurrence has been shown to be significantly more common when infectious complications occur [1]. Several evidence-based strategies can be employed to reduce the risk of wound healing complications. These include the preservation of abdominal wall perforators, the resection of redundant skin and adipose tissue, the resection or reconstruction of the umbilicus, the obliteration of anatomic dead space, the generation of new tissue via tissue expansion, the closure of the skin and soft tissue using optimal techniques, and the judicious use of negative pressure wound therapy.
34.2 Perforator Preservation Perforating vessels to the abdominal wall derive from the inferior and superior deep epigastric vessels. There consist of a medial and a lateral row, with the periumbilical perforators (located within 3 cm of the umbilicus) being the most important [2, 3]. Traditional open components separation requires widely undermined skin flaps, and thus results in high rates of wound healing complications [4]. Attempts to perform components separation without significant undermining started with Lowe’s description in 2000 of endo-
I. Khansa, M.D. • T. Zomerlei, M.D. J.E. Janis, M.D., F.A.C.S. (*) Department of Plastic Surgery, The Ohio State University Wexner Medical Center, 915 Olentangy River Road, Suite 2100, Columbus, OH 43212, USA e-mail: [email protected]; [email protected]; [email protected]
scopic components separation, where the linea semilunaris was accessed through a separate lateral incision located 5 cm medial to the anterior superior iliac spine, and an endoscopic balloon was used to dissect a subcutaneous plane over the mid-axillary line [5]. The external oblique aponeurosis was then incised using laparoscopic instruments inserted into that pocket. This was followed in 2002 by Saulis and Dumanian’s description of a technique for the preservation of the periumbilical perforators, where the linea semilunaris was accessed through subcutaneous dissection superior and inferior to those perforators, without disturbing them [6]. A refinement of this technique was described in 2011 by Butler et al., where the linea semilunaris was accessed via a single 3-cm- wide tunnel located 2 cm inferior to the costal margin [7]. Finally, in 2016, Janis et al. published a further modification using laparoscopically derived techniques of percutaneous transfascial suture fixation of mesh together with a minimally invasive anterior components separation to maximize composite tissue, preserve blood supply, and minimize complications [8]. There is strong evidence that preservation of as many of the abdominal wall perforators as possible improves the blood supply to the skin and subcutaneous ti
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