Reconstruction of Large Full-Thickness Abdominal Wall Defects Using a Free Functional Latissimus Dorsi Muscle

Abstract

IntroductionThe large full-thickness abdominal wall defect has to be treated by considering anatomical and functional requirements. The abdominal wall must regain total physiological function, which means that the full thickness abdominal wall defect must be reconstructed anatomically, not only according to the anatomical requirements but also maintaining the functional dynamic voluntary movement. Defects in the abdominal wall alter respiratory mechanics and can impair the diaphragm function. Additionally, muscles of the anterolateral abdominal wall increase the stability of the lumbar region of the vertebral column by tensing the thoracolumbar fascia and by increasing intraabdominal pressure.Materials and MethodsThe timing and method of reconstruction must be chosen depending upon the etiology of the defect. Severe traumatic injuries, abdominal wall infections, necrotizing soft tissue loss, or sepsis needs to undergo staged reconstruction following adequate debridement to control the infectious process, establish the zone of injury, and for proper treatment of intraabdominal pathology, thereby achieving temporary primary closure using split-thickness skin grafting to the viscera. At the time of definitive reconstruction, deep skin graft dermabrasion give us a facial-like layer with adequate strength to stabilize the static abdominal wall. This dermal layer is supported by free functional (innervated) latissimus dorsi muscle (fLDM), giving full anatomical coverage and functional stability. After oncologic resections full-thickness abdominal wall reconstruction was performed immediately with a combination of fLDM flaps and meshes.ResultsA total of 14 patients underwent abdominal wall reconstruction using the fLDM flap. Staged reconstruction was applied in 8 cases. In the remaining six cases, two had no mesh support, three had synthetic mesh, and one had a fascial graft, which were covered with fLDM flap. There were no free flaps failure. One flap revision due to venous anastomosis thrombosis was performed. Donor site seromas occurred in 5 cases and were treated with punction and direct doxycycline injection. Electromyographic testing postoperatively confirmed reinnervation of transplanted LDM.ConclusionUsing fLDM as a definitive solution, we are not only able to repair soft tissue defects, but also reconstruct voluntary contractility and dynamic natural functional abdominal wall. Transplanted LDM offers enough contractile capacity and strength to replace the function of the missing abdominal wall muscles.

Traumatic abdominal wall hernia as a component of the seatbelt syndrome: Complete abdominal wall muscles transection treated with two-stage surgery and retrospective review in a first-level hospital.

“…In some cases, myocutaneous aps can be used with a revascularization technique, such as the rectus abdominis ap with an epigastric pedicle, to improve ap irrigation or a latissimus dorsi muscle ap. [22][23][24] In the case of our patient, the fact that he is an athlete and the evidence from preoperative vascular CT showing complete section of the epigastric vessels was one of the factors that led us to opt for reconstructive surgery without aps, considering the risk of being unable to guarantee proper vascularization to a limb ap.…”

Contemporary Abdominal Wall Reconstruction: Emerging Techniques and Trends

“…Re-innervation by an intercostal nerve, previously supplying the rectus abdominis muscle, is a key benefit of free functional muscle transfer as compared to pedicled flap reconstruction. This allows for the restoration of voluntary synergistic control of the reconstructed abdominal wall, obviating the need for neuromuscular retraining [80,81]. Ninkovic et al described this technique utilizing the latissimus dorsi muscle for free functional muscle flap reconstruction of the abdominal wall.…”

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