Closure of Chronic Abdominal Wall Defects: The Components Separation Technique
Incisional hernias and abdominal wall defects are frequently iatrogenic problems that have complicated up to 11% of abdominal operations. The ideal reconstruction of the abdominal wall would fulfill four requirements as outlined by DiBello and Moore: (1)
- PDF / 2,233,313 Bytes
- 10 Pages / 612.283 x 790.866 pts Page_size
- 60 Downloads / 209 Views
Closure of Chronic Abdominal Wall Defects: The Components Separation Technique Oscar M. Ramirez and John A. Girotto
Introduction Incisional hernias and abdominal wall defects are frequently iatrogenic problems that have complicated up to 11 % of abdominal operations. l The ideal reconstruction of the abdominal wall would fulfill four requirements as outlined by DiBello and Moore 2: (1) prevent visceral eventration, (2) incorporate the abdominal wall, (3) provide dynamic muscle support, and (4) provide a tensionless repair. Current techniques for closure of large, chronic abdominal wall defects all have limitations. Primary repair can have a recurrence rate as high as 45%,3 whereas the use of prosthetic materials carries the risk of infection, skin erosion, and enteric fistula formation. 4 Both fail to fulfill all the requirements. Closure of abdominal wall defects can require the transposition of remote myocutaneous flaps or free tissue transfers. Transferred tissues are usually denervated and consequently atrophy over time. The use of local musculofascial flaps is preferable to fascial patches, such as tensor fasciae latae, or synthetic material for the repair of chronic abdominal wall defects. The superiority of innervated muscle flaps that provide dynamic abdominal support has been demonstrated. The use of tissue-expanded external oblique muscle flaps has also been described. 5,6 However, this requires an additional surgical procedure and a prolonged expansion phase and can be complicated by local infection, erosion, or expander failure. This discussion focuses on patients with chronic abdominal wall defects in whom previous techniques have failed. In 1990, Ramirez et al. 5 presented a landmark paper describing the technique for separation of the abdominal wall components to close abdominal wall defects. This technique is first described in anatomical dissections, and then an algorithmic approach to planned clinical reconstruction is presented, utilizing the "components separation" technique as its basis (Table 72.1). An additional 48 patients who have undergone abdominal reconstruction following this algorithm are reviewed, and their clinical course is outlined.
History As early as 1979, the senior author (O.M.R.) broached the feasibility of transferring muscle units to cover defects in a "sliding" fashion. The first of these units was the gluteus maximus flap.7
The basic premise of this technique was to mobilize the muscle, keeping its origin or insertion intact, and to "slide" it toward the location of the defect requiring coverage, taking advantage of the muscle's intrinsic elasticity. The motor innervation and the vascular pedicles were kept intact. This maximized preservation of muscle function, particularly in ambulatory patients. Success with this muscle stimulated anatomy laboratory investigations, looking for other muscle units amenable to this sliding technique. s Clinically, the principle has been logically extended to the muscles of the abdominal wall. The first patient to be treated with the "co
Data Loading...
