The Egyptian Journal of Surgery

ORIGINAL ARTICLE
Year
: 2016  |  Volume : 35  |  Issue : 4  |  Page : 408--413

Value of using the anterior rectus abdominis sheath turnover flap for fascial repair of gapping ventral midline incisional hernia


Ahmed Fawzy, Ahmed S Elgammal, Tamer Fakhry 
 Department of General Surgery, Faculty of Medicine, Menoufia University, Al Minufiyah, Egypt

Correspondence Address:
Ahmed S Elgammal
Department of General Surgery, Menoufia University, Al Minufiyah, 32513
Egypt

Abstract

Background Complex abdominal wall defects are a dangerous situation to the patient and challenging to the surgeon. The defects can occur after trauma, oncologic resection, infection or any other reason. Those patients are frequently left with retracted abdominal musculature. Patients and Methods During a period from June 2012 to November 2015, thirty six patients with complex ventral abdominal wall defect were repaired by autologous fascial reconstruction using bilateral anterior rectus abdominis sheath turn over flaps that were sutured in the medline, then the repair was completed byprolene mesh enforcement. Results All the 36 patients passed without recurrence. The complication rate was 25%, including mild skin infection, seroma, partial superficial skin necrosis, and hematoma. Factors associated with increased rate of overall complications included chronic obstructive pulmonary disease, diabetes mellitus, obesity and factors related to the indication for the primary surgery. Conclusions Ventral incisional hernia and burst abdomen are a frustrating event to the patients. In this study the repair using anterior rectus abdominis sheath turn over flap, was feasible, successful, reliable and effective method for repair of ventral incisional hernia.



How to cite this article:
Fawzy A, Elgammal AS, Fakhry T. Value of using the anterior rectus abdominis sheath turnover flap for fascial repair of gapping ventral midline incisional hernia.Egypt J Surg 2016;35:408-413


How to cite this URL:
Fawzy A, Elgammal AS, Fakhry T. Value of using the anterior rectus abdominis sheath turnover flap for fascial repair of gapping ventral midline incisional hernia. Egypt J Surg [serial online] 2016 [cited 2017 Nov 22 ];35:408-413
Available from: http://www.ejs.eg.net/text.asp?2016/35/4/408/194743


Full Text



 Introduction



Wound dehiscence and incisional hernia are forms of abdominal wound failure, which may be defined as failure of the incision to heal and to maintain normal anatomy of the abdominal wall [1].

Incisional hernia is chronic wound failure and presents some time after surgery, often at follow-up clinics or as a new referral often within 3 years of surgery [2].

Despite advances in surgical techniques, surgical skills, antimicrobial therapy, intensive care support, and better understanding of wound healing, fascial dehiscence after laparotomy remains a potentially fatal complication. The reported incidence of fascial dehiscence after emergency laparotomy ranges from 18 to 38% [3].

Reconstruction of complicated abdominal wall defects can be challenging. Such defects can occur after trauma, oncologic resection, or infection among other reasons. These patients are frequently left with retracted abdominal musculature and loss of domain. A lax abdominal wall can contribute to lumbosacral degeneration and pain, poor respiratory mechanics, and can leave the viscera vulnerable to injury [4]. In addition, the abnormal abdominal contour makes it difficult to wear certain clothing and may contribute to psychosocial impairment [5].

The reconstruction of massive midline abdominal wall defects as a result of intra-abdominal catastrophes has long challenged the reconstructive surgeons. Previously, the lack of autologous tissue often forced the surgeon to resort to synthetic materials, which may be complicated by adhesions, enterocutaneous fistulas, and infection. The introduction of the ‘components of anatomic separation’ technique by Ramirez and colleagues in 1990 allowed for autologous reconstruction using bipedicle rectus flaps. This technique was far superior to any previous option, but it had its limitations [6].

 Patients and methods



During the period from June 2012 to November 2015, 36 patients with complex ventral abdominal wall defect were treated by means of autologous fascial reconstruction using bilateral anterior rectus abdominis sheath turnover flap at Menoufia University Hospitals.

After obtaining the patients’ consent, surgery was performed under general or epidural anesthesia or both after history taking and complete clinical, imaging, and laboratory examinations.

Thirty-six flaps were created. Flaps were created after midline incision in 29 patients (80.55%) and after paramedian incision in seven patients (19.45%). The cause of primary procedure was emergency laparotomy in 15 patients (41.66%) and elective laparotomy in 21 patients (58.34%), of which previous oncological resection was the cause in 12 patients (33.33%) and nononcological resection was the cause in nine patients (25%) who faced postoperative wound infection or chronic obstructive pulmonary disease (COPD).

After excision of previous operation scar, careful herniotomy was performed and good closure of the peritoneum with vicryl 3/0 if possible, followed by elevation of bilateral skin. Subcutaneous flaps were elevated just over muscular plane until about 3–5 cm lateral to the semilunar line, nearly 13–16 cm from midline on each side. It is important to avoid performing this dissection too far laterally, as this may jeopardize the vascularity of the medial skin flap.

Flap elevation technique and its tricks

Just medial to semilunar line by 3–5 mm, the anterior rectus sheath is dissected as a flap from the underlying rectus muscle from lateral to medial until reaching the midline on both sides. The linea alba is kept intact and serves as medial hinge. Here, the fascial flap is then reflected similar to the page of an open book. Both flaps are sutured with continuous 1/0 prolene sutures either in a single layer or in a double-breasting manner according to the width of the defect after insertion of an intra-abdominal drain.

Great care should be taken as regards the following:

To not start from lateral to linea semilunaris as this may cut the innervation and blood supply to rectus muscle, which comes from the lateral side, and may also weaken other points by means of component separation.

When dissecting the flap from points of tendentious intersections, as here the rectus sheath is highly adherent and can easily be torn.

The planes can be difficult to identify in the multiply reoperated abdomen; therefore, the dissection should be started in an area where there is less scarring.

Finally, prolene mesh is put over the repair in one or two layers and fixed to the external oblique muscle on both sides.

Excision of redundant excess skin flaps is usually performed after ensuring perfect hemostasis. Suction drains are inserted over the mesh before closure of skin and subcutaneous flaps.

 Results



Of the 36 patients, there were 20 female (55.5%) and 16 male (44.5%). Their ages ranged from 23 to 65 years, with a mean o 43.3 years.

The operative time ranged from 100 to 150 min, with an average of nearly 120 min. The blood loss due to the flap procedure was about 350–600 cc with an average of 500 cc with no need for blood transfusion.

In most instances, this method provided for unilateral flap advancement nearly 3.5–4.5 cm width in its upper third, up to 7–9 cm width in its middle third, which usually lies in the periumbilical region, which usually is the most affected area, and 2.5–3.5 cm in the lower third.

The hospital stay ranged from 2 to 4 days and the follow-up period ranged from 3 to 41 months.

Most of the patients had no major complications and passed a smooth postoperative period. Only five patients (13.88%) showed mild postoperative seroma after 2 weeks from procedure, which resolved easily with repeated aspiration in four patients, whereas one patient needed reintroduction of a tube drain and left for two more weeks. This patient had very mild partial superficial skin edge necrosis, which responded fairly to repeated dressings with minor debridement.

Mild superficial wound infection occurred in four patients (11.11%), which responded fairly to short-course systemic and local antibiotics with no need for major debridement. One of these patients also had subcutaneous hematoma, which occurred after fall of his subcutaneous drain, and reintroduction of a new sterile drain was carried out in operative theater.

Factors associated with increased rate of overall complications included COPD, diabetes mellitus, and obesity.

No hernia recurrence or entrocutaneous fistula occurred. No affection on flexion power of the trunk or sense of weak abdominal musculature was reported by any patient during the period of follow-up.

No cutaneous flap loss had occurred. No mortalities related to the procedure had occurred during the postoperative period.

As a side effect of the operation, many of our patients reported that they had experienced back pain, which resolved spontaneously during the postoperative period.

 Discussion



Incisional hernias in the abdominal wall are a by-product of multiple previous laparotomies. Unfortunately, the incidence of incisional hernias has risen, as we have progressed with new surgical techniques in the treatment of abdominal pathologies. Although the development of new laparoscopic equipment and techniques has led to a decrease in open laparotomies, this change is offset by an increase in the aggressiveness of surgeons to operate on intra-abdominal pathologies (oncologic, traumatic, and infectious) that were deemed inoperable in the past [7].

Despite advances in many fields of surgery, incisional hernias still remain a significant problem. There is a lack of general consensus among surgeons as regards optimal treatment. A surgeon’s approach is often based on tradition rather than clinical evidence. The surgeon’s treatment plan should be comprehensive, with attention focused not merely on restoration of structural continuity. An understanding of the structural and functional anatomy of the abdominal wall and an appreciation of the importance of restoring dynamic function are necessary for the successful reconstruction of the abdominal wall [8].

In this study, we report our experience with the value of using the anterior rectus abdominis sheath turnover flap for fascial repair of gapping ventral midline incisional hernia in 36 patients, which is nearly the same number as that in the study by Mericli et al. [5], which included 35 patients, and near to the study by Kushimoto et al. [9], which included 29 patients, and different from the study by Ennis et al. [6], which included 10 patients.

The unilateral flap advancement in our study provided nearly 3.5–4.5 cm width in its upper third, up to 7–9 cm width in its middle third, and 2.5–3.5 cm in the lower third. This is nearly similar to the study by Ramirez [10], who mentioned that the unilateral advancement can provide 5 cm in the epigastric region, 10 cm at the umbilicus, and 3 cm in the suprapubic region. However, it is less than that reported in the study by Fabian et al. [11] and Jernigan et al. [12], who described a modification that involved division of the internal oblique of the anterior rectus sheath, which allowed for unilateral advancement of 8–10 cm in the epigastric area, 10–15 cm in the midabdomen, and 6–8 cm in the suprapubic region. The high values in their study is due to adding the amount of release given by component separation plus the open book rectus sheath flap.

In our study, many of our patients reported that they had experienced back pain, which resolved spontaneously during the postoperative period. This is supported by Ramirez et al. [13], who demonstrated complete relief of back pain after repair of large incisional hernias by restoration of midline myofascial continuity and postulated that this resolution is a result from a restoration of the counterbalancing effect of the abdominal wall muscles with the back musculature. The lateral pull of the internal oblique–transversus abdominus musculature on the lumbodorsal fascia is responsible for a reduction in intervertebral joint stress [13]. In a study by Toranto [14], resolution of back pain was observed in 24 of 25 patients after wide rectus plication.

In our study, the follow-up period ranged from 3 to 41 months, whereas it ranged in the study by Ennis et al. [6] from 5 weeks to 53 months, with an average of 26.5 months; it was 13–19 months with an average of 16 months in the study by Mericli et al. [5].

In our study, the mean age was 43.3 years, whereas in the study by Ennis et al. [6] it was 36.4 years and 47.6 years in the study by Mericli et al. [5].

Anemia (33.3%), malnutrition (36.1%), smoking (30.5%), obesity (50%), malignancy (33.3%), hypertension (36.1%), diabetes (25%), and chest complications (COPD) (40%) were the risk factors in our study, and this is in agreement with the findings of most authors but with different ratios for each. Mericli et al. [5] reported that there was a high rate of comorbidities in this patient population, including hypertension (50%), diabetes (14%), smoking (17%), and COPD (14%). Sixty-three percent of the patients in the study had atleast one recognized comorbidity before surgery. This is in agreement with the results of Breuing et al. [15], who described the Hernia Grading Scale.

[INLINE:1]

The goals of abdominal wall reconstruction depend on the clinical situation. Primary goals are, when possible, to restore the integrity of the abdominal wall, provide dynamic support, protect the abdominal contents, and maximize success while minimizing complications [16].

In our study, the overall complication rate was 11/36 (30.5%): seroma in five patients (13.9%), mild superficial wound infection in four patients (11.11%), hematoma in one patient (2.7%), and mild partial superficial skin edge necrosis in one patient (2.7%). This is nearly similar to that reported by Mericli et al. [5], who described that the overall postoperative complication rate including patients with major and minor complications was 13/35 (40%). There were 11 minor complications in 8 (23%) of 35 patients, including infection in 5 (14%), skin necrosis in 5 (14%), and hematoma in 1 (3%). Five (14%) patients experienced major complications, including 2 (6%) hernia recurrences, 2 (6%) infections, 1 (3%) hematoma, and 2 (6%) patients with skin necrosis. Kushimoto et al. [9] mentioned that 3/29 (10.34%) patients developed wound infection, which is very near to our results. However, Ko et al. [4] documented that of the incidence of complications was 43%. Major complications (n=48, 24.0%) included hematoma, infection that required incision and drainage, repeated operation for any complication, and any other complications that may be deemed significant (i.e. myocardial infarction, pulmonary embolus, and death); minor complications (n=38, 19.0%) included cellulitis, seroma that required aspiration, skin sloughing, and wound breakdown. Slightly different results were obtained by Ennis et al. [6], who reported postoperative complication among studied groups (10 patients) occurred in five patients (50%), which were cellulitis in one patient (10%), skin necrosis in one patient (10%), infected mesh in two patients (20%), and recurrent hernia in one patient (10%).

During the period of follow-up (3–41 months), there was no hernia recurrence, which was similar with the study reported by Kushimoto et al. [9] and differed from the study by Ennis et al. [6] and Mericli et al. [5], who reported rates of recurrence of 10 and 6%, respectively. The same condition with enterocutaneous fistula or abdominal abscess where Mericli et al. [5] had 6% intra-abdominal suppuration.

No affection on flexion power of the trunk or sense of weak abdominal musculature was reported by any patient. No cutaneous flap loss had occurred. No mortalities related to the procedure had occurred in the postoperative period. No mesh extrusion occurred in our study, which is in agreement with the results of Kushimoto et al. [9] ([Figure 1],[Figure 2],[Figure 3],[Figure 4],[Figure 5],[Figure 6]).{Figure 1}{Figure 2}{Figure 3}{Figure 4}{Figure 5}{Figure 6}

 Conclusion



Ventral incisional hernia is a frustrating event to the patients and the surgeons. Autologous fascial reconstruction is the optimum choice to return to more anatomical, structural, and physiological functions. Our study documents that the repair using anterior rectus abdominis sheath turnover flap was feasible and successful with fairly good results. It provides everything that surgeons need as it is autologous, anatomical, physiological, strong, reliable, easy to harvest, and can be performed easily by general surgeon, performed in relatively short time, and has a relatively low rate of complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Waqar SH, Malik ZI, Razzaq A, Abdullah MT, Shaima A, Zahid MA. Frequency and risk factors for wound dehiscence/burst abdomen in midline laparotomies. J Ayub Med Coll Abbottabad 2005; 17:70–73.
2Mudge M, Hughes LE. Incisional hernia: a 10 year prospective study of incidence and attitudes. Br J Surg 1985; 72:70–71.
3Marwah S, Marwah N, Singh M, Kapoor A, Karwasra RK. Addition of rectus sheath relaxation incisions to emergency midline laparotomy for peritonitis to prevent fascial dehiscence. World J Surg 2005; 29:235–239.
4Ko JH, Wang EC, Salvay DM, Paul BC, Dumanian GA. Abdominal wall reconstruction: lessons learned from 200 ‘components separation’ procedures. Arch Surg 2009; 144:1047–1055.
5Mericli AF, Bell D, DeGeorge BR Jr, Drake DB. The single fascial incision modification of the ‘open-book’ component separation repair: a 15-year experience. Ann Plast Surg 2013; 71:203–208.
6Ennis LS, Young JS, Gampper TJ, Drake DB. The ‘open-book’ variation of component separation for repair of massive midline abdominal wall hernia. Am Surg 2003; 69:733-742; (discussion 742-743).
7Heller L, Chike-Obi C, Shengnan Xue A. Abdominal wall reconstruction with mesh and components separation. Semin Plast Surg 2012; 26:29–35.
8ShellIV DH, de la Torre J, Andrades P, Vasconez LO. Open repair of ventral incisional hernias. Surg Clin N Am 2008; 88:61–83.
9Kushimoto S, Yamamoto Y, Aiboshi J, Ogawa F, Koido Y, Yoshida R, Kawai M. Usefulness of the bilateral anterior rectus abdominis sheath turnover flap method for early fascial closure in patients requiring open abdominal management. World J Surg 2007; 31:2–8.
10Ramirez OM. Inception and evolution of the components separation technique: personal recollections. Clin Plast Surg 2006; 33:241–246.
11Fabian TC, Croce MA, Pritchard FE, Minard G, Hickerson WL, Howell RL et al. Planned ventral hernia. Staged management for acute abdominal wall defects. Ann Surg 1994; 219:643–650.
12Jernigan TW, Fabian TC, Croce MA, Moore N, Pritchard FE, Minard G, Bee TK. Staged management of giant abdominal wall defects: acute and long-term results. Ann Surg 2003; 238:349–355.
13Ramirez OM, Ruas E, Dellon AL. ‘Components separation’ method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg 1990; 86:519–526.
14Toranto IR. Resolution of back pain with wide abdominal rectus plication abdominoplasty. Plast Reconstr Surg 1990; 85:545–555.
15Breuing K, Butler CE, Ferzoco S, Franz M, Hultman CS, Kilbridge JF et al. Ventral Hernia Working Group. Incisional ventral hernias: review of the literature and recommendations regarding the grading and technique of repair. Surgery 2010; 148:544–558.
16Lowe JB 3rd. Updated algorithm for abdominal wall reconstruction. Clin Plast Surg 2006; 33:225–240.