Use of Vascularized Posterior Rectus Sheath Allograft in Pediatric Multivisceral Transplantation—Report of Two Cases

Abstract

Restoring abdominal wall cover and contour in children undergoing bowel and multivisceral transplantation is often challenging due to discrepancy in size between donor and recipient, poor musculature related to birth defects and loss of abdominal wall integrity from multiple surgeries. A recent innovation is the use of vascularized posterior rectus sheath to enable closure of abdomen. We describe the application of this technique in two pediatric multivisceral transplant recipientsone to buttress a lax abdominal wall in a 22-month-old child with megacystis microcolon intestinal hypoperistalsis syndrome and another to accommodate transplanted viscera in a 10-month child with short bowel secondary to gastoschisis and loss of domain. This is the first successful report of this procedure with longterm survival. The procedure has potential application to facilitate difficult abdominal closure in both adults and pediatric liver and multivisceral transplantation.Key words: Abdominal wall transplantation, composite tissue allotransplantation, multivisceral transplantation, megacystis microcolon intestinal hypoperistalsis syndrome Abbreviations: HFA, hepatic falciform artery; MMIHS, megacystis-microcolon-intestinal hypoperistalsis syndrome; TPN, total parenteral nutrition.

Remote Revascularization of Abdominal Wall Transplants Using the Forearm

“…Closure of 16 visceral transplant patients with nonvascularized rectus fascia resulted in wound infections in half and herniation in one case . Vascularized posterior rectus fascia taken in continuity with the liver graft receiving its blood supply via the hepatic artery has been reported in three cases with short‐term success in the first case and longer‐term success in the other two, although in one of these cases the rectus fascia was not substantial enough to close the abdominal defect without a synthetic mesh, and this patient required re‐operation on two occasions to plicate the rectus fascia and to remove the mesh .…”

“…Closure of the abdomen using biological substrates as well as nonbiological mesh has been widely practiced, but infection and re‐operation rates are high and functional results often poor . The use of nonvascularized or vascularized donor fascia as a component of the visceral transplant has also been described but these measures do not address the problem of skin cover, which may be physiologically important.…”

Reconstruction of Large Abdominal Wall Defects Using Neurotized Vascular Composite Allografts

“…12 Finally, vascularized posterior rectus sheath has been reported in three cases with short-term success, although less is known about the structural integrity of the graft in long-term follow-up. 15,16 Furthermore, there are concerns about the size of the graft when used to reconstruct larger, full-thickness defects. …”

Soft Tissue Coverage in Abdominal Wall Reconstruction

“…Agarwal and colleagues 7 described a novel flap design for pediatric liver transplant patients. 8,9 They design a posterior rectus sheath fascioperitoneal flap based on the terminal branches of the hepatic artery via the falciform ligament, which enables transfer of the vascularized posterior sheath in continuity with the liver by means of the falciform ligament without the requirement for additional vascular anastomoses.…”