Reoperative Aesthetic & Reconstructive Plastic Surgery

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PART V
R EOPERATIVE SURGERY OF THE TRUNK
Inadequate Anterior Excision
In a circumferential lower truncal excision, the operation has not accomplished
one of its main objectives if inadequate anterior tissue is resected to create a at ab-
dominal contour.The procedure has competing anterior and posterior tensions at
closure. It is a very dif cult problem if the combined anterior and posterior tensions
exceed the tension of closure.
The patient on p. 1727 is shown before and after undergoing a belt lipectomy. A
posterior resection was performed rst. An underresection of the anterior excess re-
sulted from the possibility of not being able to complete the anterior closure be-
cause of the tension created by the posterior resection previously performed. In
other words, the anterior resection was adjusted to accommodate the posterior
resection.
A remnant hanging panniculus, no matter how small, should be avoided
because most often it is the patient’s main concern.To avoid this prob-
lem, the anterior resection should always take precedence over the pos-
terior resection.
Thus, if there is a choice of whether to eliminate more excess from the back versus
the front, the front should always be allotted the amount of resection needed to cre-
ate the best possible anterior contour. It is the anterior contour that is most visible
to the patient. One method that promotes the anterior resection primarily is to
perform the anterior resection rst and then adjust the back resection to it, rather
than the other way around. However, as previously mentioned, it matters little what
method is used, as long as the hanging panniculus is eliminated.

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Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient

1728
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Disparity Between a Thick Abdominal Flap and the Line of Closure
After the abdominal ap is tailored in a circumferential lower truncal lipectomy, the
remaining abdominal ap tissue is usually thicker than the tissues of the inferior line
of resection. This mismatch can lead to a less than ideal contour with both lateral
and anterior bulges above the scar.This contour is especially apparent when the ap
is very thick laterally and the nal closure line is at or below the anterior superior
iliac spine (ASIS).
When the ap is draped over the ASIS it is rendered more prominent, because the
ASIS pushes it out further as a result of its protruding nature. Two remedies for
this can be used separately or in combination. If the ap is not overly thick, the scar
should be created at a level where there is a natural depression rather than a promi-
nence. Fortunately, a level just above the ASIS is such an area of depression. Thus
the scar should be placed just above the level of the ASIS. An added bene t of a
scar in this position is its location at a natural junction between the abdomen and
lateral thigh, following a basic principle of placing scars in natural junctions.

1729
Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient
In this patient, despite a fairly thick tailored abdominal ap, the nal scar is located
above the ASIS, leading to a contour that is enhanced by the natural depression
that occurs above the ASIS.
Another method of decreasing the thickness disparity between the abdominal ap
and the inferior line of closure is to avoid signi cant undermining during ap el-
evation so that the ap can be aggressively liposuctioned. This procedure can also
be combined with direct subscarpal fat resection. This combination is especially
important in patients who have very thick aps that, despite good placement of
the scar above the ASIS, would exhibit a signi cant thickness mismatch.

1730
PART V
R EOPERATIVE SURGERY OF THE TRUNK
Too Much Intraabdominal Content
All procedures that are intended to flatten out abdominal contour, such as ab-
dominoplasty and circumferential lower truncal lipectomy, require that the patient’s
presenting intraabdominal content not be so excessive that it prevents the atten-
ing of the abdominal wall by surgical plication.
This patient underwent a belt lipectomy with a persistent amount of excessive in-
traabdominal content. The resulting abdominal contour was very similar to what
can be attained with a simple panniculectomy—a reduction of a hanging pannicu-
lus and a persistent convex contour to the abdomen. It is best not to perform cir-
cumferential procedures on these patients and to encourage further weight loss be-
fore contemplating surgery.

1731
Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient
This 33-year-old woman lost approximately 175 pounds as a result of lifestyle
changes. She was initially managed with an abdominoplasty and liposuction of the
thighs and hips. After these procedures, the patient was dissatis ed with the ap-
pearance of her abdomen, thighs, and buttocks. A body lift was performed to ad-
dress her concerns. She is shown 2 years after the abdominoplasty and liposuction
(top) and 3 months after the body lift (bottom).
Attempts to manage postbariatric patients with abdominoplasty and liposuction
alone are likely to result in an unsatisfactory outcome.3-5 Similarly, extending an
abdominoplasty to be circumferential without thigh and buttock undermining usu-
ally produces less than optimal results. Weight loss produces changes to the ab-
domen similar to the postpartum syndrome;however, in nearly all postbariatric pa-
tients, excess tissue is present along the thighs and buttocks. Attempts to manage
these patients with nonexcisional procedures often worsens their body contours.

1732
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R EOPERATIVE SURGERY OF THE TRUNK
THIGHS
Excess Medial Thigh Skin
This 33-year-old woman lost approximately 150 pounds (68 kg) after gastric bypass
surgery and then underwent a body lift. She presented with a weight of 190 pounds
(86 kg) and BMI of 31.
The patient is shown 3 months after the body lift. She was very pleased with the re-
sults of this initial procedure but had concerns about excess skin along her medial
thighs.The patient was advised to undergo a medial thigh lift with a vertical com-
ponent. However, she was concerned that the vertical scar would be visible and
chose to have an approach limited to the thigh-perineal crease.This procedure was
performed 3 months after the body lift. The patient was carefully advised about
the limitations of this approach.

The patient is shown 3 months after undergoing a bi-
lateral medial thigh lift, with the approach limited to
the thigh-perineal crease.The patient continued to be
concerned about remaining excess skin along her
thighs and was somewhat bothered with the distor-
tion to the labia.
1733
Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient
Four months later, she underwent a revision, at which time a vertical component
was added to the medial thighplasty.The patient is shown 2 years after the body lift
and 18 months after she underwent revision medial thighplasty with the addition
of a vertical or longitudinal component. She remains very happy with the results of
this staged procedure.
Our approach to the medial thighs is to rst perform a body lift for the reasons de-
scribed previously.The need for a medial thighplasty is evaluated 3 months after the
body lift. For individuals with a deformity limited to the proximal third of the
thigh, an approach limited to the thigh-perineal crease may be considered. For pa-
tients with deformities extending beyond the proximal third, a vertical component
is recommended. The vertical component addresses the circumferential excess of
tissue that may be present along the thighs, and the horizontal vector of traction
from this technique at the proximal thigh may help to prevent caudal migration of
the scar at the thigh-perineal crease.6

COMPLICATIONS
ARMS
Complications encountered after brachioplasty are usually minor and relatively in-
frequent. Small skin dehiscences, especially at the axilla, and small seromas along the
arm incision are the two most frequent problems encountered.To prevent skin de-
hiscence at the axilla, the tissue to be removed should be marked at the axilla with
the arm parallel to oor or at a 90-degree angle with the torso. If the arm is at a
more acute angle, excessive tissue may be marked for resection. In addition, pa-
tients are advised to avoid elevating their arms (not forearms) above shoulder level
for several weeks postoperatively. Acute skin dehiscences may be managed with
primary closure using nonabsorbable sutures. Late dehiscences, which are more
commonly encountered, are usually treated using conservative wound care.
Drains are used by most surgeons to minimize the frequency of seromas. If seromas
occur, repetitive needle aspirations are usually successful in eradicating the problem.
Recurrent seromas can be addressed by marsupialization of the cyst cavity.
One of the most dif cult problems encountered with brachioplasty is the intraop-
erative inability to close the wound after resection.Two causes of this problem have
been found: (1) excessive skin excision and (2) development of intraoperative
edema in an otherwise correctly estimated resection. The usual pinch technique
used to estimate the amount to be resected can lead to overestimation in brachio-
plasty because the distance between the pinched ngers is not accounted for.Thus
this distance has to be accounted for in the nal resection.7 Intraoperatively, using
some form of a tailor-tacking technique can help prevent overresection. However,
sometimes even if there is an appropriate amount of tissue resected, the closure
may not be possible because edema develops during the resection, leading to an in-
ability to close around a noncompressible inner musculoskeletal core.Thus to pre-
vent edema, arm resections and wound closures should be performed with relative
ef ciency and speed.
Another problem that occurs to some degree in most brachioplasties is sensory loss
in different parts of the arm. Patients should be warned that there will be areas of
decreased sensation somewhere in the arm, especially proximally. If the nal scar is
planned to be in the bicipital groove, the medial antebrachial cutaneous nerve may
be injured or entrapped, leading to a neuroma. If the resection involves that area, it
is wise to identify the nerve and avoid its injury or entrapment. If a neuroma should
occur it is treated like a neuroma in any other area in the body.
1734
PART V
R EOPERATIVE SURGERY OF THE TRUNK

The upper arm deformity that most massive-weight-loss patients present with has
excess crossing the axilla onto the lateral chest wall. Brachioplasty techniques lim-
ited to the axilla will often result in less-than-optimal results.8
1735
Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient
To treat the axillary and upper arm excess, techniques that cross the axilla are bet-
ter suited for the massive-weight-loss patient with severe deformities.
BREASTS
As mentioned previously, mastopexy can produce very satisfactory and long-lasting
results in appropriately chosen massive-weight-loss patients. Augmentation
mastopexy can be a much more challenging procedure for these individuals in
terms of the performance of the technique and the need for revision or second-
stage procedures. We prefer to perform augmentation at the same time as
mastopexy.This maneuver helps maintain the inframammary scar along the infra-
mammary fold in the case of the inverted-T approach. Placing implants after
mastopexy or breast reduction (it is very common for postbariatric women to have
undergone breast reduction while obese) very commonly leads to elevation of the
inframammary scar to a much more perceptible position above the inframammary
fold. In addition, we always place implants before using the tailor-tack technique to
estimate excess skin. This step helps prevent instances of overresection. In women
with severely de ated breasts and grade III ptosis, the inframammary fold may have

1736
PART V
R EOPERATIVE SURGERY OF THE TRUNK
migrated caudally or be poorly de ned. This may apply to the lateral margin of
the breast as well. In these instances, we use permanent sutures to secure the deep
dermis to the rib periosteum to rede ne these anatomic landmarks. Perhaps the
most important information to impart to the massive-weight-loss patient undergo-
ing augmentation mastopexy is the high likelihood of needing a second-stage pro-
cedure, particularly patients with grade III ptosis.
Postaugmentation mastopexy revisions are usually performed to treat lower verti-
cal excess secondary to skin relaxation. In these situations, the distance from the
nipple-areola complex to the inframammary fold becomes excessive and unaes-
thetic. This problem can usually be addressed using a horizontal wedge excision
based on the inframammary crease. Resecting additional tissue along the vertical
scar will address the horizontal excess. Patients may present postoperatively with
poor de nition of their inframammary fold or lateral breast margin, in which case
permanent sutures may be used.
TRUNK/ BODY
Circumferential lower truncal lipectomies are associated with a relatively high rate
of minor complications and few major complications.3,4 The most frequent com-
plications are skin dehiscence and seroma formation. Cases of deep vein thrombo-
sis and pulmonary embolism have been relatively few. Skin dehiscence can be partly
attributable to the fact that the procedure is circumferential, and a high degree of
tension on the wound closure is needed to produce an ideal outcome. In most in-
stances dehiscence occurs at the buttock cleft, and to a lesser degree at the hips, the
two areas of greatest tension after this procedure. The midline posterior cleft may
also dehisce because of tremendous tension on this minimally mobile part of the
lower back. In addition, the relatively greater amount of time in bed in the early
postoperative period may lead to some degree of ischemia over the sacrum and
coccyx, contributing to poor healing in this area.
The following three measures can be used to prevent dehiscence at the posterior
midline cleft:
1. Preoperative markings of this region should be made with the patient sim-
ulating the sitting position.
2. The intraoperative excision should be performed with the patient again in
a exed or sitting position.
3. Patients should not be moved postoperatively until they are completely
awake and alert because they can then feel tension and help prevent dehis-
cence.
The majority of skin dehiscences are 1 to 2 cm long and occur 1 to 2 weeks after
surgery.They are managed successfully with local wound care.The key elements to
preventing skin dehiscence are an effective and reliable preoperative marking tech-
nique, accurate intraoperative tissue measurement, and a closure technique that
minimizes tension along the skin edges in the postoperative period.

Seroma formation after circumferential truncal lipectomy is most likely the result
of extensive tissue undermining and the sheering of opposing subcutaneous tissue
surfaces, although the true cause of seromas is not completely understood. It is not
clear why, but there seems to be an increased risk of seroma in high-BMI patients.
Most surgeons use drains in an attempt to reduce their occurrence. A number of
other measures are also used by some surgeons, including pressure garments, quilt-
ing sutures, prophylactic use of sclerosing agents, internal glues, and wound vac-
uum-assisted closure (VAC). Despite all of these measures, seromas still occur. Most
surgeons use serial aspiration to eliminate them. Sometimes drains are reinserted if
the seromas are very large.When seromas lead to a spontaneous opening of a par-
ticular area of the circumferential wound, it is usually best to keep that area open,
either through the use of a wick or a wound VAC, both of which should eventu-
ally lead to resolution of the seroma. Usually seromas will occur if the last remain-
ing drain is producing large amounts of uid when it is removed. Prophylactic use
of a sclerosing agent through that drain will often decrease drainage so that the
drain can be removed safely.
THIGHS
The complications encountered after vertical resection of the thighs are relatively
minor and similar to those that occur with brachioplasty.The most frequent com-
plication has been small skin dehiscences, especially at the T intersection if both
horizontal and vertical excisions are used.The use of skin staples or external stitch-
ing, as well as deep closure, in these areas can be helpful in reducing dehiscence. It
is also bene cial for patients to avoid abducting the thighs more than 30 degrees for
a few weeks postoperatively. Acute skin dehiscences may be managed with pri-
mary closure using a nonabsorbable suture. Dressing changes are advised for late de-
hiscences. Seromas can also occur after thigh reduction. Some surgeons use drains to
reduce their frequency.They are managed similar to the method described for arms.
Horizontally oriented thigh reduction excisions are fraught with more danger and
can lead to devastating complications in a massive-weight-loss patient. Labial
spreading in the female is possible any time a horizontal scar is placed in the thigh-
perineal crease, even if strong permanent sutures are placed through Colles fascia.
In a massive-weight-loss patient, signi cant inferior traction is created by the heavy
thigh tissues that cannot be easily countered. Once the problem occurs it is very
dif cult to eradicate. If the patient has not had a circumferential lower truncal lipec-
tomy before the thigh reduction, then it should be performed to lift the anterior
and lateral aspects of the conically shaped thighs in an effort to reduce the inferior
traction on the medial thighs.Then, either at the same time or at a subsequent pro-
cedure, the medial thigh should be relifted and anchored again to Colles fascia.
Another possible treatment is to use tissue expanders to recruit tissue in the medial
upper thighs, and then hopefully raise the scar to the appropriate level to reduce
tension on the labia. A third method is to skin graft the medial thigh region to re-
lease the labia back to their normal position. It must be stated that all of these so-
1737
Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient

1738
PART V
R EOPERATIVE SURGERY OF THE TRUNK
lutions are less than ideal and require extensive surgical correction. It is best to
avoid this problem by minimizing the tension created on the horizontal scar, and in
most cases it should be avoided altogether.
Another potential problem with thigh reductions is chronic lymphedema. Interfer-
ing with the femoral triangle lymphatic chain is probably the most important cause
of this problem. Some investigators believe injury to the saphenous vein to be the
main culprit. I (A.A.) routinely sacri ce the saphenous vein during thigh reductions
and have not encountered permanent lymphedema; however, I never operate in
the area of the femoral triangle lymphatics, and leave behind as many lymphatics in
the areas of resection as possible.
MONS PUBIS
Virtually all massive-weight-loss patients will present with mons pubis excess and
ptosis. There can be three components to mons pubis deformities: almost all pa-
tients will present with vertical excess, many with differing degrees of horizontal
excess, and others with persistent lipodystrophy of the mons pubis.When contour-
ing the anterior abdominal wall, an attempt should be made to restore the normal
vertical relationship between the vulvar commissure (or base of penis), hair-bearing
mons pubis, and the umbilicus.To accomplish this, marking the mons is performed
with the patient in the supine position. Firm upward traction is applied to the hy-
pogastrium. A transverse line is drawn across the mons pubis, approximately 6 to
7 cm superior to the anterior vulvar commissure or base of the penis, or 1 to 2 cm
superior to pelvic bony rim.To further control the level of the scar intraoperatively,
the superior aspect of the remnant mons pubis can be tacked down to the abdom-
inal wall fascia at the appropriate level. If the mons presents with persistent lipodys-
trophy, either direct excision of the subscarpal fat or liposuction can be performed.
Horizontal excess of the mons pubis is usually present to varying degrees. In most
instances simply lifting the mons as described previously is suf cient to improve the
overall appearance of the region. In some patients the horizontal excess is so signif-
icant that it must be excised.Two things have to be considered when faced with this
problem. First, it is just as deforming to create a small and “framed” mons pubis
(created by scars superiorly and on either side of the mons) as it is to have a redun-
dant and ptotic structure. Second, permanently injuring the lymphatics of the mons
pubis is a very dif cult problem to solve.Thus it is often wise to postpone the lat-
eral resection of the mons pubis until the lymphatics have reconstituted through the
horizontal abdominoplasty incision have recovered suf ciently to allow safe lateral
excisions. The lateral skin excisions should also be performed at a very super cial
level to prevent injury to the femoral triangle lymphatics. Overall it is very impor-
tant to leave enough mons pubis tissue behind because it can always be reduced, but
it cannot be made larger should it be overexcised.

References—With Key Annotated References
1. Aly AS. Approach to the massive-weight-loss patient. In Aly AS, ed. Body Contouring After
Massive Weight Loss. St Louis: Quality Medical Publishing, 2005, pp 50-56.
This book provides useful information to help the plastic surgeon understand the special needs of the
massive-weight-loss patient and to skillfully and safely plan and execute the operations necessary for
contouring each body region.The plastic surgical evaluation of physical and psychological issues in these
patients is discussed in this chapter.The author stresses the importance of (1) educating patients about
options appropriate to their weight loss stage, (2) direct communication about goals, risks and compli-
cations, and (3) what information and tests to elicit and perform.
2. Rohrich R, Kenkel J. Body Contouring Surgery After Massive Weight Loss Supplement. Plast
Reconstr Surg 117:S1-S86, 2006.
3. Aly A, Cram AE, Chao BS, et al. Belt lipectomy for circumferential truncal excess:The Univer-
sity of Iowa Experience. Plast Reconstr Surg 111:398-413, 2003.
When some patients with circumferential truncal excess undergo traditional abdominoplasty, the trunk
is not addressed as a unit. Belt lipectomy, a procedure that combines abdominoplasty with circumfer-
ential excision of skin and fat, is often more appropriate for these patients. In this article, the authors
review the literature on belt lipectomy and evaluate their series of 32 patients who underwent belt
lipectomy.The evolution and current preoperative markings, intraoperative surgical technique, and
postoperative care are described. It was found that belt lipectomy improved abdominal contour, abdom-
inal wall laxity, mons pubis ptosis, back rolls, waist contour, and buttocks contour.The authors con-
cluded that belt lipectomy should be seriously considered for patients who present with circumferen-
tial truncal excess and for a select group of normal-weight patients. It is not recommended for the
obese patient with excessive intraabdominal content. Furthermore, belt lipectomy should be undertaken
only in patients who are well informed about the possible risks and complications.
4. Capella JF, Oliak DA, Nemerofsky RB. Body lift: An account of 200 consecutive cases in the
massive weight loss patient. Plast Reconstr Surg 117:414-430, 2006.
The epidemic of obesity in the United States has led to a rapid increase in the number of bariatric pro-
cedures performed over the past several years.The dramatic changes to the torso after massive weight
loss are only partially addressed by routine procedures such as abdominoplasty and liposuction. Cir-
cumferential body lifts or simultaneous abdominoplasty, thigh, and buttock lifts are becoming the
method of choice for treating the postbariatric condition. In this article, the authors review the senior
author’s experience of 200 body lifts with massive-weight-loss individuals.The preoperative markings,
current surgical technique, and postoperative care are described.The body lift very effectively addresses
the functional and aesthetic concerns of the massive-weight-loss patient. Careful patient selection and
education are essential to a good outcome.
5. Rohrich RJ, Gosman AA, Conrad MH, et al. Simplifying circumferential body contouring:The
central body lift evolution. Plast Reconstr Surg 118:525-535, 2006.
6. Cram AE, Aly AS. Lower extremity body contouring after massive weight loss. In Aly AS, ed.
Body Contouring After Massive Weight Loss. St Louis: Quality Medical Publishing, 2005, pp
214-236.
7. Aly A, Cram AE, Pace D. Brachioplasty in the patient with massive weight loss. Aesthetic Surg
J 26:76-84, 2006.
8. Aly AS, Cram AE. Brachioplasty. In Aly AS, ed. Body Contouring After Massive Weight Loss.
St Louis: Quality Medical Publishing, 2005, pp 304-333.
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Chapter 43
Treatment of Complications After Body Contouring in the Massive-Weight-Loss Patient

1740
PART V
R EOPERATIVE SURGERY OF THE TRUNK
1. The variability of presentation of the massive-weight-loss patient to the plastic
surgeon is dependent on:
a. BMI
b. Fat deposition pattern
c. The quality of the patient’s skin-fat envelope
d. All of the above
2. Which of the following statements is true?
a. The sequence of operations performed on a massive-weight-loss patient
is usually not an issue that requires planning.
b. It is best not to burden the patient with a lot of initial information about
all the different procedures that they may need when they present for an
initial consultation.
c. Patient safety and physician fatigue should be considered when planning
the sequence of procedures that can potentially be performed on a patient.
d. It is always best to combine as many surgical procedures as possible in a
single session to reduce the number of overall operations that a patient
may undergo.
3. When creating a surgical sequence of procedures that a massive-weight-loss pa-
tient will undergo, which of the following is true?
a. The lower truncal region is usually the area of most concern because of
the hanging panniculus.
b. The lower trunk is treated rst because it is the building block on which
other areas are based.
c. The thighs are usually treated after the circumferential lower truncal lipec-
tomy.
d. All of the above
4. Brachioplasty in the massive-weight-loss patient:
a. Is usually performed on less severe deformities than those encountered in
the general population
b. Is not associated with any signi cant complications.
c. Should be performed before patients stabilize their weight loss
d. Should treat the entire deformity at presentation, which most often crosses
the axilla onto the lateral chest wall
5. The mons pubis in massive-weight-loss patients:
a. May present with vertical excess and ptosis
b. May present with horizontal excess of varying degrees
c. May still contain an excessive amount of lipodystrophy on presentation
d. Should be addressed as part of the patient’s overall concerns
e. All of the above
R EVIEW QUESTIONS

Reoperative Surgery of the
Abdominal Wall
Grady B. Core and James C. Grotting
C ha pter 4 4
Reoperative Problems
Ventral hernia
Radiation injury
Inability to close laparotomy
Impaired vascularity or innervation
Acute wound dehiscence
Stoma related hernia
Tissue loss from resection
Scarring and tissue retraction
Stay committed to your decisions,
but stay exible in your approach.
Tom Robbins
It is fortunate that in most plastic and reconstructive procedures the development
of complications rarely results in a serious threat to the patient’s life. However, the
abdominal wall is one area where a major complication can pose such a threat. For
this reason, among others, reoperative surgeons must have a sound knowledge of
the full spectrum of diagnostic and surgical approaches to the abdomen. Optimally
they should be well versed in general surgical principles and be thoroughly con -
dent of their ability to properly assess, approach, and repair any intraabdominal in-
jury that may occur. A plastic surgeon who is fully trained in general surgery ob-
viously has an advantage in this area. Within the context of this chapter, however,
Reprinted from Grotting JC. Reoperative Aesthetic and Reconstructive Plastic Surgery, 2nd Edition. St. Louis:
Quality Medical Publishing, Inc., 2007. Copyright © 2007 Quality Medical Publishing, Inc. All rights reserved.

1742
PART V R EOPERATIVE SURGERY OF THETRUNK
we review a body of information that allows any plastic surgeon contemplating re-
operative abdominal surgery to proceed safely through this potentially disastrous
and unforgiving area.
Since the rst edition of this book, there have been signi cant advances in the ba-
sic science as well as techniques related to abdominal wall reconstruction. The sur-
gical approach to this challenging problem is now very different in certain situations
from what it was several years ago.
In the rst writing of this chapter, we presented a protocol for decision-making in
abdominal wall reconstruction based on personal experience.1 The protocol or al-
gorithm was based on several key factors that were found to be vital over the years.
These factors are (1) the availability of adjacent tissue, (2) the status of the wound—
was it clean, contaminated, or dirty? and (3) whether the reconstruction was in an
acute or a delayed setting. Earlier algorithms had advocated a systematic approach
to abdominal wall closure based on a classi cation of the abdomen into topographic
subunits.2 Although the location of the defect is important in the decision, it is
only a part of the whole process. In addition, we introduced the concept of relative
or absolute tissue de ciency to distinguish situations in which tissue may appear ab-
sent but in fact it is not, such as in the inability to close at laparotomy acutely, or
when tissues are retracted and scarred but entirely present in late stages.
Since the introduction of that protocol, it has been updated in another algorithm
based on a literature review by others3 to re ect the state of the art at the time,
which was already in signi cant ux as a result of the rapid development of newer
materials and technology. To address the rapid changes that have continued to
evolve, we will provide the second updating of the protocol chart in this chapter.
ANATOMY
Knowledge of anatomy is critical to success in reoperative surgery of the abdomen.
Although the topic of this chapter is reoperative abdominal wall surgery, the inti-
mate relationship of the abdominal wall with the intraabdominal cavity mandates
a thorough review of the anatomy of both regions.
Reoperative surgery of the abdominal wall implies that the anatomy is already dis-
torted. This distortion may be in the form of derangements of the aesthetic appear-
ance of the skin and subcutaneous tissue, integrity or location of the musculofas-
cial structures, impaired vascularity or innervation, or abnormal location of
intraabdominal contents outside the abdominal cavity.

1743
Chapter 44 Reoperative Surgery of the Abdominal Wall
SKIN AND SUBCUTANEOUS TISSUE
The anatomy of the skin envelope is directly related to body habitus. For example,
obese patients have an excess of abdominal skin as a result of a thick subcutaneous
layer. Patients undergoing tissue expansion will also have changes in skin anatomy,
not only with regard to shape but also with increased vascularity to the overlying
skin, which may even aid in ap planning.4 Obviously, previous abdominal incisions
will also change the anatomy of the skin with regard to orientation of blood supply.
Level of cros s s ection A
Level of cros s s ection B
External oblique muscle
Rectus abdominis muscle (cut)
Transversus abdominis muscle
Internal oblique muscle
Transversalis fascia
Arcuate line
Linea alba
Anterior layer
of rectus sheath
External oblique muscle
Transversus abdominis muscle
Internal oblique muscle
Transversalis fascia
Anterior layer of rectus sheath
Cros s
s ection B
Cros s
s ection A
Anterior layer of rectus sheath
Aponeurosis of external oblique muscle
Aponeurosis of internal oblique muscle
Aponeurosis of external oblique muscle
Aponeurosis of internal oblique muscle
Aponeurosis of transversus
abdominis muscle
Aponeurosis of transversus
abdominis muscle

1744
PART V R EOPERATIVE SURGERY OF THETRUNK
The underlying subcutaneous tissue has been studied extensively and is noted to
consist of two layers: super cial and deep. The two layers are separated by Scarpa’s
fascia.5 The deep layer is located in the lower abdomen below an imaginary line ex-
tending from one iliac crest to the other and passing through the umbilicus. Be-
tween the skin and the anterior fascia of the abdominal wall is a subcutaneous fas-
cial system that has been shown to contribute to the aesthetic appearance. Attention
to detail and proper management of this fascial system can prevent later aesthetic
complications.6
MUSCULOFASCIAL LAYERS
The musculofascial layers of the abdominal wall and their respective transition zones
differ in composition based on the level. These differences in composition are clin-
ically important in terms of the structural integrity of the layers available for clo-
sure. Fusion of the fascial layers forms three important vertical lines on the anterior
abdominal wall: midline linea alba and bilateral semilunar lines. The muscles of the
abdominal wall are divided into three regions: anterior, anterolateral, and posterior.
Posteriorly is the quadratus lumborum muscle; anteriorly are the rectus abdominis
and pyramidalis muscles; and anterolaterally are the external oblique, internal
oblique, and transversus abdominis muscles. The anterolateral muscles have exten-
sive fascial aponeuroses, which contribute to the anterior and posterior rectus
sheaths. Below the arcuate line, the transversus abdominis aponeurosis and the in-
ternal oblique aponeurosis pass anteriorly to the rectus abdominis muscle such that
the transversalis fascia is the only layer of structural integrity posterior to the rec-
tus abdominis muscle.7 The transversalis fascia is continuous with the endoabdom-
inal fascia (which lines the entire abdominopelvic cavity) and is particularly impor-
tant in anatomic repair of the lower abdomen. Laterally and superiorly it covers
the internal surface of the transversus abdominis muscle and aponeurosis, separat-
ing them from the underlying fat and peritoneum.8
No area of the abdominal wall has undergone as many variations in surgical tech-
niques as the inguinal region; therefore this area offers the widest variety of
anatomic distortions from prior surgery. The area of transversalis fascia below the
discontinuation of the transversus abdominis muscle and yet above the iliopubic
tract and Cooper’s ligament is known as the weak area.8 Direct hernias occur me-
dially through the posterior oor of the inguinal canal, and indirect hernias occur
laterally through the internal inguinal ring. Femoral hernias, of course, occur
through the femoral canal.

1745
Chapter 44 Reoperative Surgery of the Abdominal Wall
External oblique muscle
Spermatic cord
Aponeurosis of
external oblique muscle
Inguinal ligament
Intercrural fibers
Superficial inguinal ring
External oblique muscle (cut)
Spermatic cord (cut)
Inferior epigastric neurovascular bundle
Inguinal ligament
Internal oblique muscle (cut)
Transversus abdominis muscle
Obturator fascia
Falx inguinalis
Deep inguinal ring
Transversalis fascia
External inguinal ring

1746
PART V R EOPERATIVE SURGERY OF THETRUNK
VASCULAR SUPPLY
Musculophrenic artery
Superficial inferior epigastric artery
Superior epigastric artery
Tenth intercostal artery
Eleventh intercostal artery
Subcostal artery
Periumbilical perforators
Lumbar arteries
Deep circumflex iliac artery
Common iliac artery
Deep inferior epigastric artery
Superficial circumflex iliac artery
Superficial external pudendal artery
Femoral artery
The vascular supply of the abdominal wall consists of a rich network of vessels that
approach from all directions. This network allows the abdominal wall to be resilient
to repeated insults but at the same time dictates a set of surgical parameters that can-
not be violated lest ischemia and necrosis result. The vertical axis of blood supply
to the abdomen is represented by the superior epigastric arteries in the cephalad re-
gion and caudally by a deep and super cial system formed by ve major branches
of the iliac system: deep inferior epigastric, deep circum ex iliac, super cial inferior
epigastric, super cial circum ex iliac, and super cial external pudendal branches.
The horizontal axis is represented by the intercostal arteries (tenth and eleventh),
subcostal arteries, and four paired lumbar arteries.7

1747
Chapter 44 Reoperative Surgery of the Abdominal Wall
Because of this multiaxial in ow, it is dif cult to design an abdominal ap that is not
based on a signi cant artery. Injection studies have demonstrated that the deep in-
ferior epigastric artery is more signi cant than the superior epigastric arteries in
supplying the skin of the anterior abdominal wall.9 Perforating arteries that emerge
through the anterior rectus sheath feed into a subcutaneous vascular network that
has its highest concentration of perforators in the periumbilical region. This partic-
ular collection of perforators has become clinically relevant in relation to the body
of work involving components separation techniques, as will be discussed later.
Within this subcutaneous space there are connections (choke vessels) with adja-
cent vascular territories: inferiorly with the super cial inferior epigastric artery;
inferolaterally with the super cial circum ex iliac artery; superiorly with the super-
cial superior epigastric artery; and superolaterally (and most dominant) with the
lateral cutaneous branches of the intercostal arteries. Thus it should be kept in mind
that there are two levels of an interconnecting vascular supply, one in the deep
muscular plane (where all in ow vessels also have an anastomotic network through
“choke connections”) and the other in the more anterior subcutaneous plane.
The course of venous drainage essentially parallels that of the arterial in ow. How-
ever, venous drainage is controlled by the presence of valves that direct the ow
from the super cial to the deep system. In certain aps it has been shown that ret-
rograde ow can occur despite the presence of valves, although it may require
greater pressure to overcome valvular resistance.10 In addition to understanding the
importance of collateral blood ow to the abdomen as it pertains to reoperative sur-
gery of the abdominal wall, one should especially respect this collateral system in
patients who have atherosclerotic stenosis of the abdominal aorta and thus rely on
this anastomotic network for bypass to the lower extremities since the epigastric ar-
tery arcade can supply an important communication between the left subclavian
and internal iliac arteries.11

1748
PART V R EOPERATIVE SURGERY OF THETRUNK
NERVE SUPPLY
The nerve supply to the abdominal wall is derived from the roots of spinal nerves
T7 through L4, which give rise to the intercostal (7-11), subcostal, iliohypogastric,
and ilioinguinal nerves. When possible, it is important to preserve these nerves not
only for sensation but also for motor preservation to the abdominal musculature.
The rectus abdominis muscle is innervated by the lower ve intercostal nerves and
the subcostal nerve. The external oblique muscle is innervated by intercostal nerves
(7 through 11), subcostal, and iliohypogastric nerves. The internal oblique and trans-
versus abdominis muscles are supplied by intercostal nerves (8 through 11) and the
subcostal, iliohypogastric, and ilioinguinal nerves. Interruption of motor nerves re-
sults in defunctionalized muscle units, which causes atrophy and areas of weakness
in the abdominal wall.
LYMPHATICS
The lymphatic drainage of the abdominal wall ows cephalad and caudad in a ver-
tical axis as well as from anterior to posterior, with the horizontal axis thus follow-
ing a similar pattern of the venous drainage. If the vascular architecture in the re-
operative eld is not compromised, lymphatic drainage is rarely a problem.
Eighth intercostal nerve
Ninth intercostal nerve
Tenth intercostal nerve
Eleventh intercostal nerve
Twelfth intercostal nerve
First lumbar nerve
Iliohypogastric nerve
Ilioinguinal nerve
Anterior
cutaneous
nerve
Seventh intercostal nerve

1749
Chapter 44 Reoperative Surgery of the Abdominal Wall
CLASSIFICATION OF ABDOMINAL
WALL DEFECTS
Phase of injury

Acute (immediate)
Subacute (in ammatory)
Chronic (nonin ammatory)
Available tissue

Adequate tissue (no de ciency)
Relative de ciency
Absolute de ciency
Depth of injury
Partial-thickness
Super cial: Skin and subcutaneous tissue
Deep: Involves myofascial layers
– Nonfunctional loss: Supportive components intact
– Functional loss: Eventration resulting from loss of support
Full-thickness
Involves all layers of abdominal wall
Wound status

Clean: No bacterial contamination
Contaminated: Bacterial contamination at less than 105 cm of tissue
Dirty: Grossly soiled or infected wounds (greater than 105 cm)
Location

Upper third, middle third, lower third
Lateral
Central
Wound Classi cations
PHASE OF INJURY
Abdominal wall reconstructive problems generally present in one of three different
settings, acute, subacute, or chronic, and each of these phases has direct implica-
tions on management decisions. Application of these phases in wounds as they
progress from initial injury to in ammation to decreased in ammation has been ap-
plied before elsewhere,12 and these phases can signi cantly affect decision-making
in terms of management of abdominal wounds as well.
In the acute phase the wound is completely nonin amed at the initial setting. Ex-
amples would be an inability to close during a laparotomy because of increased in-
traabdominal pressure (IAP) or bowel swelling, tissue resection from neoplasia, or
acute traumatic loss. This phase could also be termed the immediate phase.

1750
PART V R EOPERATIVE SURGERY OF THETRUNK
In the subacute phase the wound is days to weeks out from an initial event and in
most cases the skin is still not closed. This phase is characterized by an in amma-
tory response in adjacent tissues caused either by the continued effect of the wound
still being open or, in addition, the concomitant presence of mitigating circum-
stances such as bowel injury, infection, or nonviable tissue. This phase could also be
termed the in ammatory phase. Procedures will be limited to some degree during
the peak of this phase. Wounds that cannot be closed in the acute phase, for what-
ever reason, will soon develop into a coalescent mass of in amed and edematous tis-
sue, with possible exposed and friable bowel and visceral surfaces that may degen-
erate in the face of surgical manipulation. At times during the early and late stages
of this phase, certain procedures may still be possible, but the need to obtain closure
will have to be weighed against the risks of not waiting until the tissues become less
reactive. When the skin is still closed in the subacute phase, the level of in amma-
tion will be less.
The third phase, the chronic or delayed phase, is characterized by reduction in local
wound in ammation and edema and the settling of the wound into a more steady
state. This phase generally implies that the skin is closed (though not always), and
the wound environment is relatively quiescent. However, this is not to suggest that
the situation is not capable of being dynamic, since the wound is still susceptible to
further changes that may occur late and over time, such as loss of domain, hernia re-
currence, mesh extrusion, or infected sinus tracts.
The reason for this division into three phases is that the management of the wound
differs based not only on the status of the wound in regard to size, location, and
cleanliness, but also in relation to whether it is in one of these three phases.
AVAILABLE TISSUE
The concepts of absolute or relative tissue de ciency that were introduced in this
chapter in the rst edition are still applicable and have been adopted by others, as
reported in the literature. A relative tissue de ciency exists when it appears that
there is a de ciency of tissue for closure, yet in reality little or no tissue has been lost
at all, and all the tissue necessary for closure is actually present but is compromised
in some way; for example, after a prolonged laparotomy, where there is increased
bowel edema and intraluminal gas preventing primary closure, or, in the chronic
stage, where tissues are scarred and retracted, requiring extensive anatomic dissec-
tion to release and identify tissue available for closure. In some cases tissue has been
lost but there is “extra” tissue adjacent for closure, such as in a panniculectomy.

1751
Chapter 44 Reoperative Surgery of the Abdominal Wall
DEPTH OF INJURY
Further de nitions we need to review before proceeding further have to do with
the anatomic description of the defect. Although this has been done before by oth-
ers by dividing the wound into partial-thickness and full-thickness defects,2,3,13 because
there is a need to be more speci c, the wound can be further subdivided under
partial-thickness wounds to include those that are super cial (skin and subcutaneous
tissue) as differentiated from those that are deep (involving myofascial tissue loss).
The deep wound is further subdivided into those with nonfunctional loss, which in-
cludes myofascial loss but without functional impairment (for example, anterior
rectus sheath above the arcuate line), as differentiated from those with functional loss
and hence eventration (for example, anterior abdominal wall below the arcuate
line). In full-thickness defects one should keep in mind that this is primarily a func-
tional de nition, since the skin may or may not be intact. A ventral hernia with loss
of domain is a full-thickness defect, even though the skin is intact.
W OUND STATUS
Further classi cation of abdominal wounds into clean, contaminated, and dirty was
also done in the rst edition of this chapter and is also necessary for proper deci-
sions regarding management. However, de nitions of these categories have been
different in the literature, especially in regard to the difference between contami-
nated and dirty. As the reader will see, the management of a wound that is techni-
cally contaminated can differ signi cantly from that of a grossly soiled or infected
wound, which may even have necrotic tissue present, so there is clearly a need to
distinguish between the two.
Clean is de ned as without bacterial contamination, such as a sterile laparotomy in-
cision or tumor resection as well as a defect under healed skin (ventral hernia),
which is prepared and draped. Contaminated implies that bacterial contamination has
occurred, although it is minimal or has reached an acceptable level in order to pro-
ceed with a surgical procedure; this is generally stated to be less than 105 bacteria
per square centimeter of tissue on a quantitative culture. A dirty wound is one that
is frankly contaminated with bacterial ora (such as an enterotomy) or has signi -
cant local infection (such as necrotizing fasciitis).
Review of these de nitions in regard to management choices will help guide the
reader through the decision charts presented later in this chapter concerning spe-
ci c situations one may encounter in abdominal wall reconstruction. Therefore it
is important to classify the wound according to (1) phase of injury, (2) available tis-
sue, (3) depth of injury, (4) wound status (clean, contaminated, or dirty), and ulti-
mately, (5) location.

1752
PART V R EOPERATIVE SURGERY OF THETRUNK
LOCATION
The location of the defect is also important in the decision process and has been
described before by Hurwitz and Hollins,2 Mathes et al,13 and later modi ed in
Roh rich’s literature review.3 Defects for abdominal wall reconstruction were clas-
si ed in six anatomic subunits as to whether they were lateral or midline and then
further divided into thirds: upper, middle, or lower.
TOOLS FOR RECONSTRUCTION OF THE
ABDOMINAL WALL
PROSTHETIC MATERIALS
The science of prosthetic materials continues to advance rapidly; in this section we
discuss the current state of affairs in regard to prosthetic materials.
Prosthetic materials can be categorized as autologous or nonautologous. Nonautol-
ogous materials are then further classi ed as to whether they are meshed, non-
meshed, porous or nonporous, absorbable or nonabsorbable, and whether they are
a single material or a composite of several materials. The types of materials com-
monly employed in various techniques are listed in the box. Newer materials and
combinations of materials have expanded our choices for reconstruction.
1
2
3
4
5
6
4
5
6

1753
Chapter 44 Reoperative Surgery of the Abdominal Wall
Nonautologous Prosthetic Materials
Prolene Mesh
Prolene mesh is commonly used in abdominal wall reconstruc-
tion in all phases. Prolene is made of woven polymer of polypropylene with a
porous construction, and while it is exible, it is not amenable to stretch and defor-
mation once implanted. Although Prolene mesh is frequently cited as a possible
culprit in erosion into bowel,14-16 this is not true in regard to modern-day Prolene
mesh. There were reports of cases in association with Marlex mesh, which was an
early polypropylene mesh. Marlex has a larger pore size and is stiffer than poly -
propylene mesh.
The Prolene mesh available today actually has been shown to not contribute to
erosion into bowel in several series,13,15,17 in the acute setting as well as the chronic
or delayed setting. In the author’s own series (G.B.C.), Prolene mesh was used in
more than 65 patients with giant prosthetic reinforcement of the visceral sac
(GPRVS) after the technique of Stoppa18 before changing to Gore-Tex dual mesh
Autologous

Human acellular dermal matrix (AlloDerm; Lifecell Corp.,
Branchburg, NJ)
Porcine intestinal submucosa (SIS; Cook Biotech Corp.,
West Lafayette, IN)
Dura mater
Bovine pericardium (Tutomesh)
Nonautologous
Vicryl mesh (Ethicon, Somerville, NJ)
Polypropylene (Marlex)
Polypropylene (Prolene mesh)
Mersilene (Ethicon, Somerville, NJ)
ePTFE: Expanded polytetra uoroethylene (Gore-Tex soft tissue
patch)
ePTFE (Dualmesh)
Nonautologous
Bard Composix (polypropylene with ePTFE; C.R. Bard, Inc.,
composites
Murray Hill, NJ)
Vypro 1, 2 (polypropylene with ePTFE; Ethicon)
Sepramesh (polypropylene with carboxymethylcellulose–sodium
hyaluronate coating; Genzyme Corp., Cambridge, Massachusetts)
Ultrapro (polypropylene and poliglecaprone; Ethicon)
Proceed (polypropylene with oxidized regenerated cellulose and
polydioxone; Ethicon)
Parietex Composite (polyester with polyethylene glycol–glycerol
coating; Sofradim, France)
Prosthetic Materials Available for Use in Abdominal Wall Repair

1754
PART V R EOPERATIVE SURGERY OF THETRUNK
later in the series. In those 65 patients, there were no cases of internal bowel ero-
sion or stula formation over a 10-year period, with the mesh placed directly on
bowel in more than 50% of the cases. There have been two cases of late small bowel
obstruction, an incidence no different from that of late small bowel obstruction
occurring after routine laparotomy. The main disadvantage to the use of Prolene
mesh is that it decreases the compliance of the abdominal wall over the long term
when used in large sheets. With decreased abdominal wall compliance, some pa-
tients complain of a sensation of discomfort and, in some cases, chronic pain. Pro-
lene mesh can also be extremely dif cult to remove if it becomes infected.
Retroparietal/
preperitoneal
prosthesis
Retroparietal/
preperitoneal
prosthesis
On the other hand, a signi cant advantage to the use of Prolene mesh is its useful-
ness in either an onlay onto the fascial surface with peripheral suture xation or in
an underlay technique. In the underlay technique the mesh is placed retromuscu-
larly or intraperitoneally. Because of its rough surface, there is a friction coef cient
causing it to adhere to the overlying tissue, where it is forced against it by the intra -
abdominal pressure (IAP). It therefore tends to stabilize the wound early on after
Technique of GPRVS underlay (method of Stoppa)

1755
Chapter 44 Reoperative Surgery of the Abdominal Wall
placement, as demonstrated by Stoppa in his GPRVS technique, although he felt
Prolene was too smooth compared with Mersilene.19 Prolene mesh also is very re-
sistant to infection, allowing egress of uid from the wound, which has signi cant
bene t in grossly contaminated, in amed wounds.20,21 Although there is some risk
of late infection in this setting and permanent prosthetics are generally not recom-
mended in contaminated wounds, Prolene mesh has shown good long-term re-
tention in infected settings when the wound is allowed to granulate through the
mesh and then be covered with well-vascularized tissue. While there are no long-
term comparative studies, it appears that use of prosthetic materials in an underlay
fashion allows much more protection against infection than materials used in an
overlay fashion. It should be noted that problems with Prolene have been related
primarily to mesh extrusion in infected wounds healed by secondary intention and
covered with skin grafts. In several studies, Prolene has been shown not to extrude,
even in infected wounds when covered with full-thickness skin or muscle aps.16
Expanded
Polytetra uoroethylene
Expanded
polytetra uoroethylene
(ePTFE), or Gore-Tex (W.L. Gore & Assoc., Flagstaff, AZ), is a nonporous pros-
thetic material that has a very low reactivity in human tissue22; it is used for a wide
range of applications, including vascular reconstruction, soft tissue augmentation,
and wound repair.23-25 The advantages of Gore-Tex are related to its low reactivity
in the wound environment. In abdominal wound repair Gore-Tex dual mesh has
been the most advantageous. In dual mesh, one surface is smooth, as in the standard
Gore-Tex, and the surface is turned in toward the visceral contents and helps pre-
vent intestinal adhesions. The other surface is textured and is in juxtaposition to
overlying abdominal wall in the underlay technique. The rough surface creates a
friction coef cient to help hold the mesh in place. In this underlay position poste-
rior to the abdominal wall, Gore-Tex has proved useful, with a low infection rate
and a low rate of intestinal adhesions. Gore-Tex is also more exible than some
other materials, such as Prolene mesh. The only signi cant disadvantage to Gore-
Tex is that if infection occurs, the mesh must always be removed and, because of its
microporous nature, when placed subcutaneously it has been associated with seroma
formation. Gore-Tex is easily removed at a later date if necessary because of its low
tissue adherence. Primary indications would be in a clean wound where there is go-
ing to be juxtaposition of the prosthetic with underlying bowel. Contraindications
would be any wound where there is contamination within the wound itself or no
available tissue coverage over the Gore-Tex.

1756
PART V R EOPERATIVE SURGERY OF THETRUNK
These photos show a complete anatomic dissection to separate and de ne all lay-
ers. The underlay technique was used with placement of Gore-Tex dual mesh. The
muscle layers were then closed over the mesh. Note the perforators left intact to the
overlying skin and subcutaneous tissue.
Mersilene
Another woven mesh that has historical interest is Mersilene mesh
which is made out of multi- lament bers as opposed to polypropylene which is
made out of mono lament bers. Mersilene mesh was used extensively in the
GPRVS studies of Stoppa18 and demonstrated signi cant reduction in recurrence
rates over autogenous repair alone. However, Mersilene was used primarily in sta-
ble recurrent hernias that had good skin coverage and it was not being placed in
contaminated wounds. A signi cant disadvantage of Mersilene is that in prosthetic
materials such as this, the interstices are less than 10 microns, which allows bacte-
ria to in ltrate into the material and proliferate. Such materials are contraindicated
in wounds that are contaminated or infected. Because of the signi cant bene ts of
Prolene mesh compared with Mersilene, Mersilene is now rarely used in abdomi-
nal wall reconstruction.
New Materials
Some of the newer prosthetic materials have been developed to
improve on some of the inherent drawbacks of the prosthetic materials. Most of the
newer products are of materials that will provide a smooth surface internally and a
rough surface on the opposite surface, as with dual mesh (Gore-Tex) or Composix,
which is a combination of polypropylene mesh bonded to ePTFE. In addition,

other composite meshes include permanent lightweight polypropylene bonded
with absorbable materials, such as Sepramesh (Genzyme, Cambridge, MA), Pro-
ceed (Ethicon, Somerville, NJ), Ultrapro (Ethicon), and Vypro II (Ethicon). These
materials provide signi cant initial strength in the implant, and after the absorbable
material is gone, the residual permanent polypropylene is left in the wound and
continues to provide long-term support. Long-term studies regarding these meshes
are not yet available.
The bene ts of the use of prosthetic material for reduction in the recurrence rate
of hernia repair are well documented.26 A prosthetic nonautologous material is rec-
ommended for all cases of clean ventral hernia repair. The GPRVS method of
Stoppa for this technique (my preferred method) is discussed elsewhere.
Autologous Prosthetic Materials
Autologous prosthetic materials or bioprosthetics have been used for many years in
abdominal reconstruction. Much of the initial experience was obtained with dura
mater, which did not yield favorable enough results to be widely accepted. Fascial
grafts harvested from tensor fasciae latae (TFL) have been used successfully in the
past.13 However, in recent years processing techniques of bowel materials derived
from animal or human tissue have signi cantly improved.27,28 Interest over the past
few years in the application of bioprosthetics for abdominal wall reconstruction
has been signi cant, and they are now beginning to play more of a role in such re-
construction. The advantage to these materials is the fact that they are autologous
and thus as long as they are able to maintain the integrity of the abdominal repair,
they will eventually become fully integrated. After integration their physical prop-
erties allow them to provide better functional activity of the abdominal wall over
time. At present, long-term studies regarding the outcome of these are lacking but
some studies have shown promise, especially in contaminated or infected wound
environments.29 Currently the two most common bioprosthetic mesh materials in-
dicated for abdominal wall reconstructions are SIS (Surgisis Gold, Cook Surgical
Inc., Bloomington, IN), which is derived from the tunica submucosa portion of the
porcine small intestine, and AlloDerm (LifeCell, Branchburg, NJ).
SIS is an eight-ply product that is available in perforated and nonperforated dehy-
drated sheets. Although SIS has shown promise for use in clean wounds and appears
to provide good support of the abdominal wall, it does not appear to perform well
in contaminated or infected wounds.30
AlloDerm consists of a sheet of decellulized cadaveric human dermis; that is, it has
been treated to remove all cells. Reports have demonstrated the bene t of Allo-
Derm use in abdominal wall reconstruction.29,31,32 Applications have been found
in incisional hernia repair as well as in open abdominal wounds and even in con-
taminated wounds.
1757
Chapter 44 Reoperative Surgery of the Abdominal Wall

1758
PART V R EOPERATIVE SURGERY OF THETRUNK
Once AlloDerm is integrated into the wound, there is little further possibility of
subsequent chronic infection or stula formation at the site. In addition, the mate-
rial can be placed directly on the bowel without concerns of erosion and subse-
quent enterocutaneous stula. Furthermore, if for some reason the AlloDerm be-
comes exposed, it usually can be managed with simple wound dressings and still
will become incorporated into the underlying vascularized tissue. If reoperation is
necessary, incisions and dissection through the soft material that is incorporated is
much easier than having to go through a previous nonautologous prosthetic mesh,
especially when it may be adherent to underlying bowel.
The disadvantage to the use of AlloDerm is that it has not been shown
to provide long-term support of the abdominal wound integrity in
comparison with nonautologous prosthetic materials. In fact, it has
been shown to stretch after placement, requiring that the material be
cut to approximately 70% of the size of the defect.33
The long-term effectiveness will be determined over the coming years with more
recent comparative studies. In addition, because the material has to be sutured into
place peripherally, it puts the repair at risk for the same type of dynamics that causes
high recurrence rates in primarily closed wounds. This is because where the mate-
rial is sutured to fascial edges, there is still some degree of tension and, although it
may be reduced over that of primary closure, is still not as low as when autologous
tissue repairs are supported with mesh. In AlloDerm-to-fascia repairs, the integrity
of the autologous repair must rely entirely on the security of the suture line alone,
until such time as the material becomes integrated into the adjacent tissue. The
overwhelming body of knowledge in the general surgery literature in relationship
to late recurrence of hernia repairs of all types clearly demonstrates that nonautol-
ogous prosthetic materials have lower recurrence rates than autologous repair alone,
even if the autologous repair is a so-called tension-free repair. In actuality, no autol-
ogous repair is technically tension free.21,34
When long-lasting support is necessary in a clean setting for a full-thickness defect,
the use of nonautologous mesh with its low recurrence rates, especially in the
GPRVS underlay method, is preferable at present. AlloDerm is primarily recom-
mended for contaminated wounds at this time.
One other bioprosthetic should be mentioned, an acellular porcine dermis (Perma-
col, Tissue Science Laboratories, Covington, GA). Permacol is treated similarly to
AlloDerm to reduce the cellular components of the graft. However, the feel is dif-
ferent from both AlloDerm and Surgisis in that the chemical process used to de-
velop it makes it more resistant to bowel degradation, and it has less vascularization
over the long term than the other two bowel prosthetics. Outcome studies on Per-
macol at this time are lacking, as are long-term comparative studies.

1759
Chapter 44 Reoperative Surgery of the Abdominal Wall
SUTURES
In general, absorbable sutures have been shown to predispose to late failure of fas-
cial repairs in all forms of abdominal wall repair. Of the permanent sutures, Prolene
has been the most popular, with nylon and Gore-Tex sutures also being used fre-
quently. Nova l is the author’s preferred abdominal wall closure suture in all cases
of fascial repair, because it is the only suture that demonstrates the ability to stretch
and give a little, yet with excellent memory so that it returns to its original length
when the tension decreases. This allows the tissue to swell without the suture
cheese-wiring through, as it would in those which have no ability to give (Prolene)
or in those which can give a small amount but do not have the ability to return to
original length (nylon). In terms of running versus interrupted suture, it has been
demonstrated that a running suture and interrupted suture technique are equivalent
statistically in terms of late failure of the repair.35 The author prefers running suture,
because it distributes the tension of the repair throughout the entire suture line.
Autologous Methods: Relaxing Incision
Various types of relaxing incisions for recruitment of abdominal wall tissue to be
advanced into the wound have been done for many years. Ger and Duboys36 and
others advocated the use of autologous muscle for repair of the abdomen citing
better functional outcome as early as 1983. However, in 1990, Ramirez et al37 pub-
lished an anatomic study with clinical case applications wherein he made detailed
studies in cadavers as to the layers which could be recruited and the extent of
wounds that could be closed in a functional manner. This technique was called the
components separation method, and other similar techniques have since been pub-
lished.38,39 All are variations on a theme, and the reconstructive surgeon needs to be
1 Right external oblique aponeurosis
2 Linea alba
3 Anterior rectus sheath
4 Left external oblique aponeurosis
3
3
3
RA
2
2
2
1
1
1
4
4
Components separation method

1760
PART V R EOPERATIVE SURGERY OF THETRUNK
aware of the various methods available and their limitations and potential compli-
cations.40 The technique is primarily indicated for mostly midline defects, and the
more lateral the defect, then the less there is available innervated pliable tissue to
move into the defect. In addition, the upper and lower abdomen has more limita-
tions in terms of the size of the defect that can be closed. Generally, in the upper
abdomen, a defect of 8 to 10 cm can be closed; in the lower abdomen 6 to 8 cm,
and in the central abdomen 18 to 20 cm.37 The technique has also been performed
endoscopically in an attempt to preserve the midline periumbilical perforators to
the skin and thus prevent ischemia and secondary wound problems.41
Fascial partition release method
In addition lateral skin incisions have been advocated for the same reason to avoid
extensive medial undermining and ischemia to medial skin edges.42 The lateral in-
cisions are placed directly over the cuts to be made in the external oblique fascia.
At present it appears that preservation of these perforators does reduce wound com-
plications to a signi cant degree.
Autologous Tissue Flaps
Clearly, the use of autologous tissue is preferable, depending on the circumstances,
because it does not introduce a foreign body into the tissues, is better integrated,
and is likely more functional in most cases. However, as noted earlier in the case of
hernia repair, long-term recurrence rates may be higher if tension is involved in the
repair, so in some cases autologous is not always best.
We will attempt to provide the proper indications where ap reconstruction is best
under the management section, but here we will provide a description of the var-
ious types of aps that have been shown to be useful over time.

1761
Chapter 44 Reoperative Surgery of the Abdominal Wall
Full-Thicknes s Defect

ß Rectus abdominis flap
ß Omentum flap
ß Free flaps
Partial-Thicknes s Defect
FLAPS FOR ABDOMINAL WALL COVERAGE

ß Superiorly based rectus abdominis flap
ß Latissimus dorsi (extend) flap
ß External oblique flap
ß Free flaps

ß Rectus femoris flap
ß Tensor fascia lata flap
ß Vastus lateralis flap
ß Inferiorly based rectus abdominis flap
ß Free flaps
Lateral
Lateral
Upper
Lower

ß Local random or axial skin flaps
ß Local fascial turnover flaps

ß Local random or axial skin flaps
ß Iliolumbar bipedicled flap

ß Local random or axial skin flaps
ß Fasciocutaneous flaps from thigh
The gure above shows the division of the abdomen into zones and the aps gen-
erally chosen to reconstruct defects in that particular region. The depth of the
wound as well as the location is accounted for.
FLAPS
For repair in the mid to upper abdomen, the extended latissimus dorsi ap has been
shown to be effective.43 This reconstructive technique involves an incision that ex-
tends along the lateral border of the latissimus dorsi muscle and then over the
gluteal region. The pregluteal fascia and the lumbodorsal fascia are exposed, and a
section of this fascia is raised in continuity with the muscle ap. This enlarges the
arc of rotation of the muscle, enabling it to contribute to the fascial closure of the
abdomen. The ap is usually passed through subcutaneous tunnels to the anterior
abdominal wall. A skin island can be transferred with the ap if necessary, or the
muscle or pregluteal fascia can be skin grafted, which allows the defect to contract.
Experience with this ap is limited, but results are encouraging. It should be kept
in mind that the pregluteal fascia is very thin, and dissection over the gluteus max-
imus can be very tedious; however, this fascia has been found to be fairly resilient
and capable of adding strength to the abdominal repair. In addition, it can also be
folded if necessary.44

1762
PART V R EOPERATIVE SURGERY OF THETRUNK
For defects of the upper and lateral abdominal wall, an iliolumbar bipedicle ap
has been described.45 This ap involves a large segment of lower lateral abdominal
wall and is vascularized by the super cial circum ex iliac vessels anteriorly and
perforating cutaneous branches of the lumbar vessels posteriorly. This area is in-
cised down through skin and subcutaneous tissue to the musculofascial layer. This
tissue can then be transposed cephalad over a fascial graft or prosthetic material
and the donor site skin grafted. This ap does not aid in the transposition of fascial
tissues, only in coverage.
Another source of tissue that is useful for reconstruction in the upper abdominal
wall (as well as anywhere else in the abdomen) is the omentum.46 The advantage of
this tissue is that it can reach almost anywhere and conform to almost any defect.
In addition, because it is exceptionally well vascularized, it covers prosthetic mesh
well and supports skin grafts easily. The disadvantage, of course, is that it offers no
intrinsic support and because support is necessary, the need to use a prosthetic ma-
terial is inevitable. Also, omentum tends to weep signi cantly after transposition,
which can be a nuisance postoperatively.
The superiorly based rectus abdominis ap with transfer of anterior rectus sheath
from above the arcuate line can be used for the closure of upper abdominal wall de-
fects.46 This technique provides good fascial support with well-vascularized tissue.
Care should be taken not to extend the fascial donor site below the arcuate line, or
lower abdominal wall weakness will result.
The external oblique musculocutaneous ap has also been used for transposition to
upper abdominal wall defects.47 This muscle ap can provide good support and
coverage; however, the degree of rotation obviously is quite limited, and this ap is
indicated only in selected cases.
In the mid to lower abdomen, the aps of choice are usually taken from the thigh.46
The rectus femoris muscle is a good choice in the lower abdomen because of its re-
liability, arc of rotation, innervation, and minor donor site morbidity.47 However, it
should not be used bilaterally, since it can have an effect on gait. One must always
suture the vastus lateralis and medialis together to preserve knee extension as much
as possible. This ap can be raised as a muscle ap alone or as a musculocutaneous
ap. There is a posterior fascial element on the muscle that aids in reconstructing
the fascial defect of the lower abdomen. The fasciocutaneous territory overlying the
muscle can be used alone for coverage of partial-thickness defects.
The tensor fascia lata has also been used successfully in the closure of defects of
the lower abdomen and midline.13,46 The arc of rotation is similar to that of the
rectus femoris muscle, except that defects in the lower lateral abdomen are more
dif cult to cover with this ap. There is an extensive fascial component associated

with this ap that can aid in fascial repair of the abdomen. Although the muscle can
be transposed as a musculocutaneous ap, care should be taken not to extend the
skin island distally into the lower third of the upper thigh, because this will result
in many cases in necrosis of the distal skin island. The TFL ap has had its arc ex-
tended through tissue expansion with good success, as reported by Mathes et al.13
Inferiorly based rectus abdominis aps can also be a good choice for closure of
lower abdominal wall defects in selected cases. However, one must be careful not to
further compromise the functional integrity of the abdomen in general when
choosing a donor site, since this may create more extensive problems if complica-
tions occur.36
The sartorius ap has been described for closure of lower abdominal wall defects.48
However, since the blood supply is segmental (type IV), the distal portion of this
ap is not as reliable and is not recommended as a rst-line choice.
The gracilis musculocutaneous ap has fallen into disfavor because of the unreli -
ability of the distal skin island. It is primarily of use for reconstruction in the per-
ineal region, as opposed to the lower abdomen. Although the skin island has been
shown to be extendable with turbocharging,49 the muscle component is too small
for most abdominal defects of any signi cance, even if it is transferred as a free ap.
The vastus lateralis ap could be used to repair the lower abdomen; however, there
is no signi cant fascial component with this ap, the arc of rotation is limited, and
because of the success of other muscle aps, experience with this particular ap
for abdominal wall closure is uncommon.47
Free Flaps
At times, free tissue transfer to the abdomen may be the only remaining method
available. Indications for free tissue transfer are for large irregular defects not
amenable to regional muscle ap closure, prior radiation to the area, failed regional
aps, or in contaminated or infected wounds. Advantages to this approach are that
it can allow for a more “customized” placement of the muscle in terms of orienta-
tion, shape, and skin island placement. It provides a more three-dimensional option,
and the donor site can be chosen more selectively, depending on what is needed.
For example in a young female a free latissimus dorsi ap over a mesh in a clean
case would be preferable to the defect left by a free TFL ap providing the outcome
at the defect remains equivalent. Reconstructive surgeons should always keep these
issues in mind when selecting reconstructive measures. Free aps may require mesh
underlay initially with an absorbable mesh to provide a scaffold of support and pro-
tection against early dehiscence. If the ap has little fascial component, a nonab-
sorbable mesh can be used in a clean setting.
1763
Chapter 44 Reoperative Surgery of the Abdominal Wall

1764
PART V R EOPERATIVE SURGERY OF THETRUNK
There are a variety of aps that could be used for reconstruction of the abdominal
wall successfully. The free TFL ap has been reported and brings in a large fascial
element.50,51 Free aps that have been shown to be effective in the abdomen are the
TFL ap, the anterolateral thigh ap, and their combination in a composite ap.52-54
Also, success with latissimus dorsi55 and rectus femoris56 free aps has been reported.
Advances in neural anastomotic techniques have allowed for the functional aspect
of the transferred muscle to be recruited to help with the abdominal wall integrity,
which allows the reconstruction to be not only autologous but also dynamic. Lat-
eral intercostal nerves, when available, can be used for neurorrhaphy.
Recipient vessels for free aps to the abdomen are diverse but the proper choice of
these can sometimes be critical. Choices should initially be focused on vessels
which are not only easily accessible but also less likely to cause problems. For ex-
ample, while the use of the common femoral seems logical because of its proxim-
ity, it should only be chosen as a last resort, since a complication to this vessel could
be devastating to the distal extremity. When local recipient vessels are not available,
the omentum has been described as a vascular supply for a free ap transfer.57
In addition, other intraperitoneal vessels have been shown to work well, but again
the risk of an anastomotic bleed intraperitoneally is far greater than one in the sub-
cutaneous tissue. Also, the use of intraperitoneal vessels automatically creates an ad-
hesion to the abdominal wall as well as a potential source of future small bowel
obstruction. Although all these vessels can work, a ladder of selection based on risk
should be used.
The inferior epigastric vessels are an excellent choice for the lower abdomen, and
if these are not available, a good second choice would be a saphenous vein loop
from the leg using any number of regionally available tributary arteries as in ow.58
In this technique the long saphenous vein is freed up along its entire course and
transected distally at the ankle. Its attachment to the common femoral vein is left in
place, and it is then sewn to the selected arterial in ow source in the region. In this
manner an arteriovenous loop is created, which can be tunneled up into the ab-
dominal area adjacent to the defect. The free ap can then be sewn into position
over the defect and the loop divided, providing arterial in ow and venous out ow.
Neoplasia and radiation injury are common indications for free aps, since large
blocks of tissue have been removed and reconstruction is best accomplished by
bringing in new vascularized tissue.

USE OF NEGATIVE PRESSURE WOUND
THERAPY (VAC SYSTEM) IN ABDOMINAL WALL
RECONSTRUCTION
The vacuum-assisted closure device (VAC; KCI, San Antonio, TX) for closure of
abdominal wound defects is perhaps the most signi cant change in abdominal wall
closure since the rst writing of this book.59 VAC-assisted therapy has signi cant ef-
fects on the wound environment in the acute, subacute, and nonacute setting. VAC-
assisted therapy helps reduce peripheral wound edema and increase blood ow,
which in turn theoretically proceeds to the ability of the host to have improved
bacterial clearance from the wound environment.60 However, in cases of grossly
contaminated or necrotizing wounds, VAC-assisted closure can be contraindicated,
because it can prevent adequate drainage from the wound.61 However, when com-
bined with local wound care, associated debridement and sponge changes as usu-
ally recommended, every 1 to 2 days, the VAC has been shown to improve wounds
even in this setting. The actual level of wound contamination wherein a VAC can-
not be used has not been determined at this time, but reports in the literature in-
dicate it has been helpful in infected wounds so long as the sponge is changed more
often.62 Based on uniformly poor experience with VAC usage in infected wounds
of all types, at the present time, we would not use a VAC in the presence of gross
contamination and/or infection.
Perhaps the most signi cant bene t of the VAC-assisted therapy for abdominal wall
closure has been to allow early de nitive reconstruction of the abdominal wall.59
Early de nitive closure is a signi cant goal in the acute setting, because an open ab-
domen results in signi cant loss of uid and protein, which can lead to systemic
problems. If this situation is allowed to continue for a long time, the patient’s over-
all nutritional and wound healing status will be further compromised. Thus the
primary impact of VAC therapy has been seen in the subacute phase when the
wound is still open. However, VAC therapy has also found some application in the
acute phase in patients who are insuf ciently stable to undergo immediate wound
closure or who have a relative de ciency from an inability to close the abdomen
from increased IAP and swelling.63 The VAC abdominal wound pack has been ap-
plied to these patients, which helps maintain abdominal wall integrity and reduces
in ammation and edema while abdominal compartment syndrome resolves. After
the patient and the wound stabilize and the relative tissue de ciency resolves, the
patient can proceed to early de nitive wound closure.
Long-term studies on VAC therapy are not available at this time; however, the ap-
plication of negative-pressure wound therapy in all phases of abdominal wound
closure seems to have signi cant promise. Some studies have shown a low recur-
rence of abdominal wall hernia (although these studies are not long term) in pa-
tients whose entire course from initial injury to full closure was with VAC therapy.
1765
Chapter 44 Reoperative Surgery of the Abdominal Wall

1766
PART V R EOPERATIVE SURGERY OF THETRUNK
At present my protocol (G.B.C.) re ects the current state of the literature in rela-
tion to VAC therapy in that it is recommended primarily in patients who for one
reason or another have not been able to undergo immediate wound closure and are
in the acute or subacute phase awaiting de nitive wound closure until either IAP
decreases or constitutional factors or local wound factors are stable enough to pro-
ceed. Time will tell if the VAC wound pack will replace other temporizing mea -
sures for management of acute phase wound closure, such as prosthetic materials.
TISSUE EXPANSION
Tissue expansion has been used successfully in abdominal wall reconstruction and
should be kept in mind as a primary or adjuvant procedure. Although experience
is limited with tissue expansion in the abdominal wall, it has been shown to have
promise in defects that are not grossly contaminated or infected, and closure can be
delayed until expansion is complete.64 Advantages are that reconstruction can be
performed with well-vascularized, innervated autogenous tissue that is a good color
match and similar tissue.
If tissue expansion is chosen as the reconstructive option, it is prefer-
able to place the expanders into planes where they will not interfere
with the neurovascular supply of the abdominal wall. One option is
anterior to the musculofascial wall so that only skin and subcutaneous
tissue are expanded. Alternatively, a safe place within the abdominal
wall is in the plane between the internal oblique and the transversus
abdominis muscles.64,65
Tissue expanders have been placed endoscopically for successful expansion and
closure in the abdomen; however, the delay for expansion to occur as well as risk
of infection of the expanders must be weighed against the bene t of a more imme-
diate approach. It should be noted that during expansion the internal organs pro-
vide such a soft cushion to the expander that although most of the expansion is an-
terior, there is also some expansion of the posterior layers of the abdominal wall and
peritoneum. In congenital defects, defects in excess of 50% of the abdominal sur-
face can be repaired.64
MANAGEMENT
GOALS
A clear understanding of the obtainable goals is essential. At a minimum, these
should include (1) coverage of the abdominal contents, (2) restoration of the func-
tion and integrity of the musculofascial abdominal wall, (3) eradication of preexist-
ing factors that contributed to the patient requiring the reoperation (such as poor
technique with excessive tension on repair, wrong technique, inadequate debride-
ment, inadequate tumor resection, and infection), (4) reconstruction with like tis-
sue (providing goal number 3 can still be met), and (5) attention to aesthetic detail.

ASSESSMENT
This section applies to patients whose wound is subacute or chronic phase and there
is time to undertake planning. It is important to evaluate the patient and the wound
thoroughly before undertaking surgical intervention. First and foremost, the med-
ical condition of the patient is taken into account, because the extent of what is un-
dertaken is going to be based on what the patient can tolerate. Patients who are too
ill to undergo surgery will need to be managed without anesthesia, which means ei-
ther nonoperatively with dressing changes alone, or with VAC therapy or another
temporizing measure.
For patients able to undergo surgery, a thorough assessment of both the patient and
the wound are necessary. Pertinent diagnostic tests other than physical examina-
tion and a laboratory workup include CT scan of the abdomen to help delineate
anatomy. It should include abdomen and pelvis with a contrast medium. In ventral
hernia patients with loss of domain, it is important to include pulmonary function
tests as well, and if the patient already has paradoxical breathing, he or she should
be seen by a pulmonologist preoperatively. Patients should be advised of possible
ventilator therapy that may be necessary postoperatively.
The wound itself is examined and categorized for the characteristics mentioned ear-
lier and noted in the decision charts on pp. 1772-1773, 1782-1783, and 1792-1793.
If there is going to be possible encroachment on internal structures, it is advisable
to have general surgical consultation before surgery. It is unfortunate when the
plastic surgeon calls the general surgeon at the time an enterotomy is encountered.
PREOPERATIVE PREPARATION
Patients’ overall nutritional condition should be optimized, and all constitutional
factors that may play a role in failure should be addressed, such as cessation of smok-
ing. For those with loss of domain and secondary respiratory compromise, preop-
erative pulmonary function tests and pulmonology consultation is important. In
recent years it has become necessary to inquire closely about the use of nutritional
supplements, since many of these have been shown to have a lathyrogenic effect on
wound healing. In elective cases bowel preparation should be performed if any en-
croachment on adjacent bowel is a possibility. One should always remember that in
an obese ventral hernia patient, weight reduction will vastly lower the chances of
recurrence of the hernia. Attention to the preoperative correction of other under-
lying problems, such as nutritional de cits, pulmonary disorders, and uid and elec-
trolyte disorders, is important.
1767
Chapter 44 Reoperative Surgery of the Abdominal Wall

1768
PART V R EOPERATIVE SURGERY OF THETRUNK
PERIOPERATIVE CARE
In the preoperative period there are several adjuvant therapies that can be bene -
cial, such as placement of a nasogastric tube for preoperative bowel decompres-
sion. Appropriate skin preparation and preoperative antibiotic therapy are essential.
A broad-spectrum antibiotic regimen is desirable; usually one agent is adequate.
However, certain special circumstances, such as intraluminal stasis of bowel con-
tents, or perhaps an emergent infectious problem, such as fasciitis or gangrenous
bowel, may require expanded coverage. In such cases broad-spectrum gram-nega-
tive and gram-positive coverage is indicated as well as strong anaerobic coverage. In-
termittent pneumatic compression stockings are standard, as is the placement of a
Foley catheter. A close watch on the peak inspiratory pressure will also be helpful
to avoid development of abdominal compartment syndrome.
POSTOPERATIVE MANAGEMENT
Abdominal wall defects in the acute stage are associated with a high incidence of
critical illness requiring ICU care and ventilatory support. Management of those
patients is beyond the scope of this chapter although we will cover operative ap-
proaches for those situations. Patients in the subacute stage will vary in terms of the
level of illness, and again, we do not intend to cover those issues of critical illness
management.
Although most patients in the chronic or nonin ammatory stage are operated on
electively and will not require ventilatory support, patients with giant ventral her-
nias and loss of domain could very well require ventilatory support. In addition,
antiembolic measures (Lovenox and early ambulation) as well as antacid therapy
and incentive spirometry need to be kept in mind postoperatively. Postoperative
ileus is common in these patients, and the use of a nasogastric tube is continued un-
til peristalsis returns. I use nasal oxygen at 2 L for 24 to 48 hours if the patient is not
on the ventilator so that peripheral tissues are fully oxygenated. In addition, supple-
mental oxygen has been shown to be helpful with reduction of postoperative in-
fections. Antibiotics are not continued past the second dose, unless infections are al-
ready present and must be treated. Otherwise, continuing antibiotic therapy can
have a negative effect, especially in a patient who has received bowel preparation
preoperatively, because Clostridium dif cile can develop with secondary colitis. Any
postoperative patient who has diarrhea, especially in the presence of fever, should
be tested for C. dif cile. Diet is advanced on resumption of peristalsis, and nutrition
is maintained with early use of total parenteral nutrition. Average postoperative re-
covery for patients with a recurrent ventral hernia of signi cant size has been
5 days in the hospital. Recovery from giant ventral hernias has ranged from 5 to
14 days, depending on whether ventilatory support was necessary. Abdominal
binders are not used, since they add little to the support of the repair and in fact in
some cases can be harmful by compressing in ow to aps, as in the case of abdom -
inoplasty or rotation aps. When the patient sits up, the binder forms a tourniquet-
like effect on the central abdomen.

1769
Chapter 44 Reoperative Surgery of the Abdominal Wall
OPERATIVE PLANNING
INCISIONS
It is important to begin the reoperative procedure with incisions that are designed
for relaxed skin tension lines as well as underlying neurovascular and muscular
structures. A midline incision is the least damaging from a functional standpoint, al-
though it does place the wound under tension because the lines of tension extend
horizontally. No signi cant difference in dehiscence rates has been found between
vertical, horizontal, or oblique incisions.35 However, the dehiscence rate is not the
only factor that should be considered in selecting an incision.
Paramedian incisions are to be avoided if possible, since they interrupt neurovascu-
lar structures entering from the lateral abdomen and create a defunctionalized seg-
ment of abdominal wall between the incision and the midline. The surgeon must
also consider vascular in ow, and, to prevent ischemia, acute angles of incision
should be avoided.
This patient demonstrates the need for careful planning of incisions. A recurrent
ventral hernia in the midline with multiple prior incisions and redundant tissue were
present. After resection of redundant tissue, the ventral hernia was repaired with
GPRVS technique with Gore-Tex dual mesh and minimal undermining because of
a cholecystectomy scar.
Extreme care should be taken to avoid causing bowel injury when making the inci -
sion. However, if bowel perforation occurs, it can usually be managed with simple
oversewing of the enterotomy in a patient who has had an adequate bowel prepa-
ration. In an unprepared bowel, enterotomies in the small bowel and colon enter -
otomies with minimal contamination can still be oversewn. However, with more
extensive contamination from a colon enterotomy, the creation of a colostomy or
an exteriorization of the injured bowel may be indicated.66 Copious localized irri-
gation of the areas involved with spillage of enteric contents should be performed.

1770
PART V R EOPERATIVE SURGERY OF THETRUNK
INTRAABDOMINAL PRESSURE
Intraabdominal pressure (IAP) is an important consideration in the management of
abdominal reconstruction. Recent advancement in the understanding of this has
better de ned the role of increased IAP in relation to management of acute, sub -
acute, and delayed reconstructive techniques. When IAP starts to increase above 5
to 7 mm Hg, it is called intraabdominal hypertension (IAH). IAH is subdivided into
four grades with the highest being greater than 25 mm Hg. When the IAP is
greater than 25 mm Hg and is associated with organ dysfunction or failure, it is
called abdominal compartment syndrome (ACS). ACS is a well described entity that
reconstructive abdominal surgeons must appreciate and understand.67 Predisposing
conditions include acidosis, multiple transfusions, coagulopathy, sepsis, hypother-
mia, bacteremia, liver dysfunction, ventilatory support (especially with positive end
expiratory pressure [PEEP]), and pneumonia. Etiologic factors include abdominal
surgery (especially wherein restriction of the abdominal wall is created), massive
uid resuscitation, ileus, abdominal infection, pneumoperitoneum, and hemoperi-
toneum.
ACS results in compromised blood ow to internal organs with secondary sys-
temic problems, such as low urine output, decreased excursion of the hemidia -
phragms, pulmonary compromise, and acidosis. Multisystem organ failure and death
is the endpoint if treatment is not effective. Treatment is obviously aimed at the
reduction of IAP and correction of underlying causes. Treatment with continuous
negative pressure devices such as the VAC may be helpful. An abdomen closed in
the face of increased IAP of this magnitude should be decompressed by opening the
wound and obtaining control of the wound environment as noted under the man-
agement protocols detailed elsewhere in this chapter, speci cally under acute
phase/relative tissue de ciency/ full-thickness defect/clean wound. It should be kept
in mind that even an open wound that is packed or in which the wound is secured
with some type of restrictive dressing can still develop ACS. Measurement of IAP
is best done through a Foley catheter with no more than 15 ml of sterile saline so-
lution displacement using either a bedside manometer or a pressure transducer.
The patient should be supine and measurement is taken at end expiration.
MANAGEMENT PROTOCOLS FOR ABDOMINAL
WALL DEFECTS
We will base our discussion of the operative management of abdominal wall defects
on the three phases noted earlier, along with the depth of injury and the availabil-
ity of adjacent tissue; also to be considered is whether the wound is clean, contam-
inated, or dirty based on the de nitions we introduced earlier. Wounds will be fur-
ther divided into the depth of functional injury. Although the decision charts have
a summary of the management plan, the reader can refer to the outline that follows
for a full exposition of each approach. After the wound is classi ed according to the
protocols discussed here, the location will still need to be considered for execution

1771
Chapter 44 Reoperative Surgery of the Abdominal Wall
of the chosen procedure. For example, if an absolute de ciency in the chronic phase
has a full-thickness defect that is clean and the surgeon chooses a myofascial ap, the
location of the defect must be considered in choosing the best ap for that option
(see Flaps, p. 1761).
ACUTE PHASE
Adequate Tissue
• Partial-thickness defect

Super cial loss and deep nonfunctional loss (NOTE: Always classi ed to-
gether in the decision chart, since treatments are essentially the same)
Clean wound
Examples: Excision of small localized tumor, traumatic skin loss, excision
of panniculus
– For partial-thickness super cial wounds in a clean setting with ade-
quate tissue available, primary closure in layers is indicated. For exam-
ple, closure of Scarpa’s fascia in the lower abdomen will help prevent
the skin from adhering to the abdominal fascia and causing an un-
sightly depression.
Contaminated wound
Examples: Excision of infected sebaceous cyst, excision of foreign body,
traumatic skin loss in contaminated setting
– Wash and close over drains or delayed primary closure.
Dirty wound
Examples: Grossly contaminated traumatic defect, excision of injected
material with high bacterial count
– Debride if necessary, wash out the wound, leave the skin open.
– For a deep partial-thickness defect with nonfunctional loss in all cate-
gories: adequate tissue, relative de ciency, or absolute de ciency; clean,
contaminated, or dirty, treatment would be the same as that for super-
cial partial-thickness wounds in each category.

Deep functional loss
Clean wound
Example: Sharp intraoperative traumatic injury to the anterior rectus
sheath below the arcuate line
– Close all layers of involved fascia with permanent suture. Running su-
ture is as effective as interrupted suture, since it distributes tension
along the entire suture line. Close all skin and subcutaneous tissue in
layers as indicated.
Contaminated wound
Example: Same injury as above from external contaminated source, such
as a knife wound
– Treat as for a clean wound, except for wash-out and delayed skin clo-
sure or closure over drains. If delay in skin closure is anticipated to be
more than a few days, the VAC may be applied.

1772
PART V R EOPERATIVE SURGERY OF THETRUNK
Decision Chart for Acute Phase
Available
Tissue
Depth of Injury
Adequate
Partial-thickness
tissue
defect
Super cial loss
and deep non-
functional loss
Deep functional
loss
Full-thickness
defect
Relative
Partial-thickness
de ciency
defect
Super cial loss
and deep non-
functional loss
Deep functional
loss
Full-thickness
defect
Wound Status
Appropriate Action
Clean
Primary closure in layers as indicated.
Contaminated
Cleanse wound, cover drains, or delayed primary closure.
Dirty
Cleanse wound, debride as indicated. Leave skin open.
--------------------------------------------------------------------------------
Clean
Close fascia primarily with closure of skin and subcutaneous
tissue in layers.
Contaminated
As above, cleanse delayed primary closure of skin over drains
or VAC over fascial closure.
Dirty
Close fascia if possible. Debride and wash out. Otherwise
local care and leave open.
--------------------------------------------------------------------------------
Clean
Primary closure of skin and fascia.
Contaminated
Repair fascial defect. May need relaxing incisions. Early
application of wound care or VAC.
Dirty
Cleanse wound, debride as indicated. Repair fascial defect
with Vicryl mesh underlay or AlloDerm; use VAC with
frequent sponge changes.
Clean
Primary closure in layers if wound is small, otherwise local
skin aps.
Contaminated
Cleanse wound, close over drains and delayed primary
closure.
Dirty
Cleanse wound, debride as necessary. Leave skin open.
--------------------------------------------------------------------------------
Clean
Close fascia primarily versus components separation in
central defect. If lateral, permanent mesh with skin ap
coverage.
Contaminated
As above, except avoid permanent mesh and use drains if
closed. Can use VAC until relative de ciency resolves.
Dirty
Cleanse wound. AlloDerm for fascial support if necessary.
Dressing changes with or without use of VAC.
--------------------------------------------------------------------------------
Clean
Repair fascia if possible. Relaxing incision. Components
separation if central. If lateral, prosthetic mesh (permanent)
and cover with skin aps. VAC pack if unable to approximate
fascia without tension.
Contaminated
As above. Close fascia if possible. Skin closure delayed or over
drains. Repair with AlloDerm if prosthetic is needed. Use
VAC if fascia cannot be closed.
Dirty
As above. For gross intraperitoneal contamination use
porous mesh with VAC over mesh (Vicryl or Prolene). Use
AlloDerm if there is no need for peritoneal cavity drainage.
Leave skin open. Use VAC if the fascia cannot be closed.

Acute Phase/ Adequate Tissue/ Partial-Thickness Defect/
Deep Functional Loss—cont’d
Dirty wound
Example: Sharp trauma to the abdominal wall below the arcuate line with
secondary necrosis or infection
– Treat as described previously. However, fascial closure may need to be
delayed if tissue is adequate but is infected or in amed. Debridement
should be carried out as necessary to remove all nonviable or grossly
infected tissue. If debridement converts the wound to one with a tis-
sue de ciency, see the guidelines for that category. If the fascia is still
adequate but not closed because of wound conditions, a temporary
supporting prosthetic material can be applied such as Vicryl or Allo-
Derm if eventration is signi cant. The VAC may be applied if contam-
ination is not gross; it tends to provide support itself. However, if the
condition of the fascia will allow, it should be closed as described ear-
lier. The skin should be left open and local wound care measures un-
dertaken with delayed closure, or the VAC applied when possible, or
healing by secondary intention.
1773
Chapter 44 Reoperative Surgery of the Abdominal Wall
Available
Tissue
Depth of Injury
Absolute
Partial-thickness
de ciency
defect
Super cial loss
and deep non-
functional loss
Deep functional
loss
Full-thickness
defect
Wound Status
Appropriate Action
Clean
Skin aps. For large surface area use split-thickness skin graft.
Contaminated
As above, with delayed primary closure of skin using local/
regional aps. Drain as indicated.
Dirty
As above; skin to be left open and to heal by secondary
intention.
--------------------------------------------------------------------------------
Clean
Autogenous repair with local myofascial aps, components
separation. Nonautologous prosthetic secondary choice.
Contaminated
As above; use AlloDerm if fascial support is needed. Drain
as indicated.
Dirty
As above; use a porous prosthetic material if needed.
--------------------------------------------------------------------------------
Clean
Closure possible over nonautologous prosthetic. Components
separation. Local regional or free aps in large defects.
Contaminated
As above, with delayed skin closure. Use AlloDerm if fascial
support is needed. For large defects, a nonautologous pros-
thetic material can be covered with vascularized tissue. Drain
as indicated.
Dirty
Maintain abdominal integrity with mesh in underlay position
(Prolene or Vicryl). Manage wound with dressing changes
or VAC.

1774
PART V R EOPERATIVE SURGERY OF THETRUNK
• Full-thickness defect
Clean wound
Example: Closure of laparotomy incision
– Closure in this situation is straightforward and should include primary
fascial closure including the skin.
Contaminated wound
Example: Acute wound dehiscence.
– The incidence of acute abdominal wound dehiscence is approximately
1.8%68,69 and is similar regardless of the technique of abdominal wall
closure (whether running or interrupted). Risk factors include age over
50 years, poor nutrition, pulmonary disease, ischemia, male sex, emer-
gency surgery, and bacterial contamination with wound infection.70 At
initial presentation the wound may appear normal if the skin is still in-
tact. The patient may complain of a sudden sensation of “tearing” or
“popping,” usually precipitated by vomiting, coughing, or sneezing. A
high level of suspicion must be maintained. Serosanguineous drainage
may be the only hailing sign, although the initial presentation may also
be complete evisceration. Dehiscence most commonly occurs approx-
imately 1 week after initial surgery.
– The very nature of dehiscence implies that the abdominal wall has lost
its integrity completely by rupture of the musculofascial layers.
– Wound dehiscence is characterized by partial or complete opening of
the abdomen incision, with partial or complete longitudinal disrup-
tion of the fascial repair. The underlying viscera will either be exposed
or will extrude through the wound. This condition may be present for
a while before discovery and technically should be considered a con-
taminated wound. Immediate attention is necessary to prevent further
loss of abdominal integrity with extrusion of intestines and subsequent
damage to the viscera. Increased mortality has been reported when it
is not managed aggressively. Initial management should begin with im-
mediate application of sterile wet-to-dry dressings or application of
the VAC device. If the wound is still fairly clean and increased IAP is
not a factor, a primary fascial closure can be performed if there is no
signi cant tension on the fascial repair. Later, delayed primary closure
of the skin can be performed. However, a high incidence of incisional
hernia has been reported with primary fascial closure.
Dirty wound
Example: Acute dehiscence with enterocutaneous stula
– If the wound is grossly contaminated or infected, primary fascial clo-
sure should still be obtained if possible after cleansing and debride-
ment. Added support to the abdominal wall may be helpful in the
form of a Vicryl mesh underlay or AlloDerm. The skin should be left
Acute Phase/ Adequate Tissue—cont’d