Staged Reconstructions of Abdominal Wall Defects

Abstract

A staged reconstruction of an abdominal wall defect is required when primary fascial closure is not possible or appropriate. Regardless of the initial cause of the open abdomen, the first stage requires some form of temporary abdominal closure technique while the patient’s physiological derangement is corrected. If delayed primary fascial closure cannot be achieved, a more sustainable cover of the abdominal viscera is needed for the maturation period. If the patient’s original skin does not allow “skin-only” closure, a split-thickness skin graft provides a readily available, cheap, foreign-body-free, and infection-resistant coverage that closes the “catabolic drain” of the open abdomen and protects the viscera from erosion. After a maturation period of 9–12 months, the skin graft is removed, and definitive reconstruction of the abdominal wall is performed. To achieve the best functional result, the rectus muscles should be brought together in the midline using a component separation or other local tissue transfer technique if possible. In patients with intact original skin, the hernia can be repaired with a mesh. However, in patients with large midline or epigastric hernias or in the presence of contamination or infected mesh, a more complex reconstruction technique is needed. The most promising of these is the free tensor fascia latae (TFL) flap utilizing a saphenous vein arteriovenous loop. The advantages of the TFL flap include constant anatomy of the pedicle, strong fascial layer, large caliber vessels matching the size of the AV loop, and the ability to use large flaps. It can also be combined with other repair techniques to provide an optimal anatomic, functional, and cosmetic result.