Reoperative Aesthetic & Reconstructive Plastic Surgery

1776
PART V R EOPERATIVE SURGERY OF THETRUNK
Because of the loss of support of this section of the abdominal wall,
when stress is directed from below with increased IAP, bulging may
occur at the wound site and it may not be possible to close the fascia
without undue tension. Increased IAP in the acute setting usually re-
sults either from the onset of ileus or prolonged operative time, with
bowel and local tissue edema and an increase in intraluminal bowel gas
with secondary distention. However, certain preexisting conditions
may also be present, such as ascites.
– The focus should be on maintaining abdominal wall integrity, either at
the time of primary closure or until the cause of the relative de ciency
resolves. Autogenous techniques are preferable if possible, and if the
defect is closer to the midline, then variations on components separa-
tion techniques can be used. These techniques can be used in con-
junction with permanent mesh in an inlay or onlay fashion to reduce
tension if necessary. However, for more lateral defects, coverage of a
nonabsorbable prosthetic material with a well-vascularized skin ap is
a good choice.
– The VAC may be employed until IAP decreases and allows for pri-
mary closure. The delay in wound closure with secondary contamina-
tion should be weighed against the donor site morbidity from an im-
mediate closure of some type.
Contaminated wound
Example: Preexisting mesh with infection in patient with ascites
– The contaminated wound is treated as described previously. However,
the use of permanent mesh should be avoided if possible to decrease
the risk of late infection of the mesh. If the functional loss is relatively
small, the fascial repair can be temporarily supported with an ab-
sorbable mesh awaiting de nitive repair later, or AlloDerm may be
used. If closure is attempted, the wound should be drained. Again in
certain cases, the VAC may be employed until IAP decreases, if that is
the cause of the relative tissue de ciency.
Dirty wound
Example: Traumatic partial-thickness loss functional abdominal wall from
gunshot, with localized tissue devitalization and contamination; increased
IAP or ileus
– Initially cleanse and debride as indicated, then the skin should left open
and fascial support obtained if absolutely necessary with autologous
bioprosthetics such as AlloDerm. Dressing changes can be performed
directly over the AlloDerm, as can the VAC system. Keep in mind that
frequent sponge changes are necessary in heavily contaminated areas
where the VAC is used. In this setting it is usually best to wait until the
wound is not grossly contaminated or infected before placing the VAC.
Vicryl mesh can also be used for temporary support if needed until
Acute Phase/ Relative Tissue De ciency/ Partial-Thickness Defect/
Deep Functional Loss/ Clean Wound—cont’d

the relative de ciency resolves. Keep in mind the worst case scenario
in a deep functional partial-thickness loss is eventual eventration, which
may or may not be symptomatic. Therefore in these wounds it is usu-
ally best to keep it simple and treat with dressing changes unless there
is some compelling need for fascial support.
• Full-thickness defect
Clean wound
Example: Inability to close the abdominal wall at laparotomy
– This situation would most likely be one of the more common presen-
tations that a general surgeon is faced with in regard to dif cult ab-
dominal wall closures in the acute phase. This, of course, is usually the
result of swelling of intraabdominal contents during extended surgery
as well as distention of the viscera secondary to increased intraluminal
bowel gas. Although it appears that there is a de ciency of tissue, in re-
ality all the tissue is present; therefore the de ciency is relative. Pri-
mary fascial closure should be the optimal goal; however, many times
primary fascial closure in this situation would result in a high inci-
dence of abdominal compartment syndrome not to mention a higher
recurrence of ventral hernia later. Components separation method or
fascial partition methods may be helpful in obtaining primary fascial
closure as long as they are not closed with high tension. If after com-
ponents separation the tension is still high on the fascial closure, the
surgeon should consider an underlay method of nonautologous pros-
thetic material such as Gore-Tex dual mesh or Prolene mesh to help
reduce the tension on the abdominal wall. With Prolene mesh, omen-
tum should be placed over the bowel. In the underlay technique, the
IAP actually compresses the mesh against the underneath surface of
the abdominal wall and actually uses the friction coef cient of the
mesh to stabilize the mesh and to distribute tension evenly. If the pa-
tient’s underlying medical condition militates against a procedure as
extensive as components separation or fascial partition, prosthetic ma-
terials can be used with temporary closure with a staged reconstruction
at a later date. A nonautologous prosthetic material is again the choice
in the clean wound with at least skin closure over this if possible. Re-
cent reports have noted that use of the VAC device in this scenario
has shown it to be effective in maintaining the integrity of the ab-
domen and allowing for early de nitive wound closure, as opposed to
the staged approach. Theoretically, this allows earlier stabilization of
secondary systemic factors that may be a result of the persistent open
abdomen. The VAC pack is applied with an abdominal sponge pack
with a perforated plastic sheet that is placed under the VAC sponge to
cover the bowel. An adherent plastic drape is then placed over the
sponge widely over the abdominal wall, and the negative pressure is
applied. Secondary mechanical forces are thus applied peripherally to
the wound in a symmetrical and concentric fashion. The VAC sponge
placed in a noninfected wound should be changed every 2 days.
1777
Chapter 44 Reoperative Surgery of the Abdominal Wall

1778
PART V R EOPERATIVE SURGERY OF THETRUNK
The VAC sponge is kept in place until the IAP and swelling decreases
to a point at which the wound can undergo an early de nitive pri-
mary fascial closure. In addition the VAC can also be placed on top of
porous, absorbable or nonabsorbable mesh if there is concern about
the possible chance of evisceration.
Contaminated wound
– In wounds with mild to moderate contamination the techniques de-
scribed earlier can still be used; however, nonautologous prosthetic tis-
sue should be avoided. If prosthetic material is necessary, AlloDerm
would be the best choice and has been reported to perform well in
contaminated wounds and maintain fascial integrity. The AlloDerm
should be covered if possible with a skin advancement technique or
other well-vascularized tissue and the wound drained as indicated. A
secondary choice would be Vicryl mesh, which will maintain fascial in-
tegrity initially; however, there is a 100% occurrence rate of late ven-
tral hernia with Vicryl mesh, which would require a secondary sur-
gery. The use of the VAC pack in this phase has also been found to be
very helpful; however, whenever fascial integrity can be accomplished
with the use of a fascia substitute such as AlloDerm, it would be a pri-
mary choice over the use of the VAC.
Dirty wound
– In grossly contaminated and infected wounds the wound should be
debrided as indicated and thoroughly cleansed as much as possible in
an attempt to reduce gross contamination and bacterial count. In the
acute setting, again the fascial integrity is of primary importance and
eviscerations and exposure of intraabdominal contents need to be
avoided as much as possible. In the grossly contaminated or infected
wound, while AlloDerm has been used in wounds such as this in or-
der to stabilize the wound, it is not porous and does not allow egress
of uid through the wound as may be necessary. If indeed this is nec-
essary such as with gross intraabdominal contamination, then a porous
nonautologous material should be used. Either Vicryl or Prolene mesh
are acceptable. With Vicryl there is the risk of late hernia formation al-
though there have been some reports of the VAC pack resulting in
functional closure of the fascia with no late hernia formation. In regard
to Prolene mesh, while it has been shown to have good long-term re-
tention in this setting in the underlay position, the risk of late infection
is still present and should be weighed against the need for maintenance
of the integrity of the abdominal wall and preventing evisceration es-
pecially in larger wounds. Prolene mesh is a second choice in contam-
inated or infected wounds if AlloDerm cannot be used. In addition, as
Acute Phase/ Relative Tissue De ciency/ Full-Thickness Defect/
Clean Wound—cont’d

noted previously, once contamination is reduced to a level where VAC
is applicable, the VAC device can be used to help speed the progress of
the wound.
Absolute Tissue De ciency
• Partial-thickness defect

Super cial loss and deep nonfunctional loss
Clean wound
Examples: Abdominoplasty defect, resection of malignant skin cancer, re-
section of radiation injury.
– Advancement aps or rotation aps as indicated are the mainstay of
therapy. Split-thickness skin grafts are second line due to donor site is-
sues and poor aesthetics. However, for large surface area wounds split-
thickness grafts are indicated for early wound closure, such as after early
debridement of extensive burns of the abdominal region. In radiation
injury, reconstruction of the defect should be done with nonirradiated
tissue brought in from outside the eld using local regional, or free
muscle aps.
Contaminated wound
Examples: Excision of injected and contaminated foreign material in the
subcutaneous tissue resulting in a large defect of skin and subcutaneous
tissue; excision of hidradenitis suppurativa with active infection
– In this type of problem it is possible to close over drains if the contam-
ination is low and the area of resection is far away from contaminated
tissue. However, if the margin of resection is close, it is best to leave the
skin open or apply a split-thickness skin graft.
Dirty wound
– The treatment is the same as for a contaminated wound, except do not
attempt primary closure at all; treat by open methods or apply VAC if
contamination level acceptable.

Deep functional loss
Clean wound
Example: Defect after massive desmoid resection with loss of abdominal
wall support, partial-thickness
– In this setting the use of local myofascial aps or components separa-
tion method as an autogenous method is ideal, but the limitations of
that technique in terms of coverage and location need to be kept in
mind. If good myofascial tissue is not present that could be recruited to
bring fascial support into the wound, such as in radiation injury, non -
autologous prosthetic material covered with well-vascularized muscle
or skin aps can be used. Either a Gore-Tex soft tissue patch or Prolene
mesh is a good choice. Flap choice depends on the location of the de-
fect primarily but also to some degree on the geometry of the wound
and on the quality of tissue surrounding the wound, especially in radi-
ation injury.
1779
Chapter 44 Reoperative Surgery of the Abdominal Wall

1780
PART V R EOPERATIVE SURGERY OF THETRUNK
Contaminated wound
Examples: Excision of infected tumor; gunshot wound with tissue loss
– Management should be the same as in the clean setting, except that
autologous bioprosthetic should be the mainstay of support. This in
turn should be covered with a well-vascularized skin ap or muscle
ap as indicated, and the wound drained as indicated.
Dirty wound
Example: Necrotizing fasciitis requiring partial-thickness resection of the
abdominal wall leaving secondary area weakness
– Cleansing of the wound with debridement as necessary followed by
application of prosthetic material for support if necessary. Vicryl mesh
can temporize while the wound undergoes conversion to a cleaner
wound and then the plan above can be used.
• Full-thickness defect
Clean wound
Example: Dissection of abdominal wall tumor with absolute loss of wide
area of peripheral full-thickness tissue
– Where tissues are missing to a signi cant degree, then regional or on
occasion distant tissues will need to be recruited to help close the
wound. The size and location of the defect will also help determine the
choice of reconstructive options (see p. 1761). Components separation
techniques have been used successfully in this setting. There are now
many reports of variations on this technique and reports of recurrence
rates are quite variable. At the present time, the author (G.B.C.) feels
the gold standard in terms of prevention of occurrence of late ventral
hernia is that of nonautologous mesh with vascularized tissue coverage
in a GPRVS type approach. The vascularized tissue coverage may be
with the components separation method or if the defect is too large
the abdominal wall components can be advanced as far as possible
keeping tension from being signi cant and then skin aps can be ad-
vanced over the repair. In some situations where the defect is quite
large or there has been radiation injury or regional ap failure, it may
be necessary to use free tissue transfer in the absence of suitable re-
gional muscle aps.
Contaminated wound
Example: Loss of full-thickness abdominal wall secondary to tumor with
resection adjacent to the stoma with spillage, followed by irrigation
– In a contaminated wound where possible, nonautologous mesh should
be avoided. Autologous style prosthetic materials such as AlloDerm
can be used with coverage of local or regional aps and the wound
drained as indicated. In extremely large defects the long-term support
of AlloDerm is still in question, and we recommend a large sheet of
Acute Phase/ Absolute Tissue De ciency/ Partial-Thickness Defect/
Deep Functional Loss—cont’d

nonautologous prosthetic material, covered by a well-vascularized ap
with a fascial component if possible. In wounds where skin is not avail-
able the VAC may be used over prosthetic mesh until the wound is sta-
ble and concentrically reduced. Coverage may then be performed in the
subacute setting as noted elsewhere.
Dirty wound
Example: Debridement of large area of abdominal wall secondary to
necrotizing fasciitis
– In such a wound the abdominal integrity needs to be maintained with
a porous, nonautologous mesh or absorbable Vicryl mesh preferably in
an underlay position. The mesh is then covered with local aps if pos-
sible once the wound has bacterial counts reduced to less than 105. If
the absolute de ciency is not large and the intraabdominal environ-
ment is not grossly contaminated then an autologous bioprosthetic may
be used initially if it is not under signi cant tension. The VAC pack
may be used over the prosthetics if frequent changes are performed for
any reason the ap coverage needs to be delayed. Split-thickness skin
grafting over the mesh is also a way to stabilize the wound but results
in frequent mesh extrusion at a later date.
SUBACUTE PHASE
Defects in the subacute setting represent a unique challenge as opposed to wounds
found in the acute setting and the chronic or stable setting. In the subacute setting
with open skin, local tissues are in amed and friable. At times viscera can also be
exposed in the wound and quite adherent covered with granulation tissue. Fre-
quently there have been previous attempts to maintain abdominal wall integrity
with the insertion of either absorbable or nonabsorbable prosthetic meshes. It
should be kept in mind that in subacute settings, for any wounds in which the skin
is still open, the wounds are technically all contaminated or dirty. Thus there is no
clean component noted in the decision chart for a loss in the super cial layer. How-
ever, for defects where the skin remains intact and there is a myofascial defect, there
is a clean component in the decision chart.
Tissue in this setting is not only frequently in amed and edematous
but also relatively stable in terms of abdominal wall integrity with
full-thickness losses. Evisceration is usually not an issue, so stabilization
of the visceral cavity is usually not necessary as in the acute setting.
Adequate Tissue
• Partial-thickness defect

Super cial loss and deep nonfunctional loss
Clean wound
– Not applicable, since these defects by de nition have been open al-
ready and are therefore technically contaminated at a minimum.
1781
Chapter 44 Reoperative Surgery of the Abdominal Wall

1782
PART V R EOPERATIVE SURGERY OF THETRUNK
Decision Chart for Subacute 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
Contaminated
Excision of small defects is usually possible with primary
closure of skin over drains. Delayed primary closure or
closure over drains may be indicated depending on the
situation.
Dirty
Debride as necessary, provide local wound care, healing by
secondary intention.
--------------------------------------------------------------------------------
Clean
No treatment indicated.
Contaminated
Reapproximate fascia when bacteria counts are less than 105.
Otherwise as above for a super cial contaminated wound.
Dirty
Debride and cleanse as well as possible. Perform local wound
care. Proceed as above when counts are reduced to accept-
able levels.
--------------------------------------------------------------------------------
Clean
Postpone de nitive hernia repair until chronic phase.
Contaminated
Protect exposed bowel surfaces. Apply AlloDerm and close
the skin over this with drains. Application of VAC is also
an option.
Dirty
Apply VAC unless contamination is severe. If severe, local
care with dressing changes and cautious serial debridement
is the best approach until the wound is clean enough for
VAC application.
Contaminated
Recruit locally available skin and subcutaneous tissue for
primary closure (or with skin aps) over drains.
Dirty
Debride as necessary with cleansing of wound and local care
to heal by secondary intention. May use VAC when possible.
--------------------------------------------------------------------------------
Clean
Avoid surgery if possible until chronic phase.
Contaminated
VAC to optimize wound. When less than 105 cm bacteria,
close with skin aps over drains with AlloDerm for replace-
ment of fascia.
Dirty
Treat the wound with local care and debride as necessary
until able to VAC. When the wound is at a cleaner state,
proceed as above to prevent late occurrence of eventration.
--------------------------------------------------------------------------------
Clean
Avoid surgery if possible until chronic phase.
Contaminated
Focus primarily on protecting any exposed visceral surfaces
and close in a safe fashion. Apply an autologous bioprosthetic
such as AlloDerm and cover with skin aps over drains. If
increased IAP is a factor, VAC the wound until the relative
de ciency resolves and fascial closure is possible.

1783
Chapter 44 Reoperative Surgery of the Abdominal Wall
Available
Tissue
Depth of Injury
Relative
Full-thickness
de ciency—
defect—cont’d
cont’d
Absolute
Partial-thickness
de ciency
defect
Super cial loss
and deep non-
functional loss
Deep functional
loss
Full-thickness
defect
Wound Status
Appropriate Action
Dirty
Application of the VAC is the best option if there is no
severe purulence or soilage present. An autologous biopros-
thetic should be applied if necessary and there is no soilage
coming from within the abdominal cavity. If there is gross
soilage or purulence, local wound care with serial debride-
ment is recommended until the wound is cleaner and a
VAC can be applied.
Contaminated
Provide local care with topical agents such as Silvadene if
immediate closure cannot be done. Early closure with skin
grafting is desirable. Local skin aps can be used to close the
wound if the desmoplastic reaction of surrounding tissue
is not extensive. If the wound is in amed, use local wound
care or apply VAC until it improves. Close with local aps
over drains when the wound is stable.
Dirty
As above, except debride as indicated and provide local care
with topical antibiotic agents, followed by split-thickness skin
grafting when the wound is cleaner. In small wounds the
VAC can be used as long as there is no gross contamination
or necrotic tissue present.
--------------------------------------------------------------------------------
Clean
Avoid surgery if possible until chronic phase.
Contaminated
Stabilize the abdominal wall if necessary using AlloDerm.
The AlloDerm should be covered with well-vascularized
tissue when feasible, using local or regional skin aps over
drains. If that is not feasible, the VAC or dressing changes can
be performed over this. Large surface area losses should be
covered with split-thickness skin grafts.
Dirty
Local care and debridement are the mainstays of therapy in
most cases. It is best to put off stabilization of the abdominal
wall until wound conditions allow for application of the
AlloDerm or VAC. Vicryl mesh is also an option.
--------------------------------------------------------------------------------
Clean
Symptomatic: Explore and reclose wound. Added support
with autologous prosthetic material in onlay position recom-
mended, covered with well vascularized tissue (skin and sub-
cutaneous tissue). Asymptomatic: Delay until chronic phase.
Contaminated
Cover with an autologous bioprosthetic; the VAC can be
placed over this. Also, myofascial aps or skin aps can be
rotated into position to obtain wound closure over drains.
Large defects should be closed if possible, even if skin grafts
are necessary. If the patient is stable and the absolute de ciency
is not large, simple protection of the viscera with VAC appli-
cation can be employed until the in ammation is reduced.
Dirty
Skin cannot be closed. Protection of viscera is the main
focus. Split-thickness grafts and AlloDerm are helpful. In the
case of gross soilage from the intraabdominal environment,
perform simple wound care with frequent dressing changes.
Bowel surfaces should be kept moist and dressings changed
frequently.

1784
PART V R EOPERATIVE SURGERY OF THETRUNK
Contaminated wound
Example: Small open wound which was result of dehiscence of prior ex-
cision of redundant skin
– Excision of small defects is usually possible with primary closure. De-
layed primary closure or closure over drains may be indicated depend-
ing on the situation.
Dirty wound
Example: Small open wound with an adjacent stula
– Perform debridement as necessary, administer local wound care; heal-
ing by secondary intention.

Deep functional loss
Clean wound/skin closed
Example: Dehiscence of anterior rectus sheath under intact skin incision
in lower abdomen three weeks after primary repair
– Assumes that the skin is intact. No treatment is indicated in this phase;
wait until later in the chronic phase and repair if the site is sympto-
matic.
Contaminated wound
Example: Small open wound extending through caudal portion of ante-
rior rectus sheath from prior partial dehiscence of rectus fascia repair
– Management is as described above under “Super cial loss and deep
nonfunctional loss/contaminated wound,” except for fascial reapprox-
imation. Wait until the wound is not in amed, then repair as indicated.
Dirty wound
Example: Small open wound in the upper abdomen extending through
the anterior rectus sheath after incision and draining of the wound abscess
– Debride and cleanse as carefully as possible. Administer local wound
care, then proceed as described above.
• Full-thickness defect
Clean wound/skin closed
Example: Dehiscence of myofascial layers of a laparotomy incision during
the third postoperative week under an intact skin incision
– “Clean” assumes that the skin is intact. In this scenario the abdominal
wall myofascial layer is completely separated under intact skin. Assum-
ing this occurs several weeks out in the in ammatory phase, acute evis-
ceration is not an issue, and eventual hernia formation is usually the
worst sequela. If the defect is small and bowel entrapment is a con-
cern, repair may be undertaken using nonautologous mesh, with skin
aps recruited for well-vascularized coverage. However, unless it is ab-
solutely necessary to proceed at this point, the surgery as well as the
eventual repair will be much more successful if one is able to postpone
de nitive repair until the wound is less in amed and the tissues less
friable.
Subacute Phase/ Adequate Tissue/ Partial-Thickness Defect/
Super cial Loss and Deep Nonfunctional Loss—cont’d

Contaminated wound/skin open
Example: Laparotomy reopened for abdominal compartment syndrome
with increased IAP now resolved and Vicryl mesh in place
– By the time the wound is in the subacute stage, issues such as control
of intraabdominal contents are already settled. However, if the defect is
full-thickness it means the wound is open to exposed intraperitoneal
contents which may or may not be covered with granulation tissue.
Therefore extreme care needs to be taken in the management of this
wound. In a wound with adequate tissue available there is no signi -
cant IAP increase, so early closure is not inhibited by this. However,
wound in ammation and friability are an issue as well as the friability
of any exposed viscera. Protection of exposed bowel surfaces is a pri-
ority so coverage of the bowel needs to be done with autologous tis-
sue if possible. Application of AlloDerm and closure of the skin over
this with drains is likely the best option since attempts to dissect the
bowel from the overlying abdominal wall peripherally could easily re-
sult in an enterotomy. If in ammation is not a signi cant issue and the
wound is in the early or very late subacute phase, a fascia-to-fascia clo-
sure may be feasible but should be attempted with caution; a bowel
preparation should be done if possible. Application of the VAC pack is
also an option.
Dirty wound
Example: Open laparotomy wound with enterocutaneous stula
– A dirty wound cannot be closed, so application of the VAC is proba-
bly the best option, unless the contamination is so severe that frequent
dressing changes are needed. If so, local care with dressing changes and
cautious serial debridement is the best approach until the wound is
clean enough for VAC application. There have been some early reports
of VAC application even in wounds with enterocutaneous stulas.
Relative Tissue De ciency
• Partial-thickness defect

Super cial loss and deep nonfunctional loss
Clean wound
– Not applicable, as noted on p. 1781.
Contaminated wound
Example: Dehisced panniculectomy site
– Recruitment of locally available skin and subcutaneous tissue for pri-
mary closure (or with skin aps) over drains. In certain cases it may be
in the patient’s best interest to use a split-thickness skin graft to close
the wound early. VAC avoids skin graft donor site.
Dirty wound
Example: Open panniculectomy site after I and D of subcutaneous abscess
– Perform debridement as necessary with cleansing of the wound; ad-
minister local care; healing by secondary intention. VAC may be used
when possible; otherwise, proceed as described previously.
1785
Chapter 44 Reoperative Surgery of the Abdominal Wall

1786
PART V R EOPERATIVE SURGERY OF THETRUNK

Deep functional loss
Clean wound/skin closed
Example: Eventration of lower abdomen 4 weeks after failure of abdom -
inoplasty plication (Relative de ciency is at the myofascial level.)
– “Clean” assumes that the skin is intact. Management is as described for
“adequate tissue.”
– In this setting, the source of the relative de ciency may be prolonged
ileus, ascites, or another source of increased IAP. The relative de ciency
may also be caused by retraction of the fascial edges in the depth of the
wound as a result of early recurrence of prior fascial repair. A subacute
wound with deep functional loss will frequently demonstrate a bulging
defect, but in most cases it is not necessary to apply prosthetic material
to prevent further loss of abdominal wall integrity. Primary fascial clo-
sure should be the goal if the patient is symptomatic; however, if local
tissue is too in amed for primary fascial repair, surgery should be
avoided, since in these types of defects there is no loss of domain and
the wound can further stabilize toward the chronic phase, where closure
may be easier.
Contaminated wound
Example: Patient with increased IAP from ileus, but with open traumatic
defect involving skin and deep functional layers of abdominal wall
– For an open wound in the subacute setting, AlloDerm is ideal, because
it provides for fascial support without requiring local dissection. Dress-
ings may be applied over the AlloDerm; the VAC may be applied as
well. When the tissues are less in amed, coverage of the AlloDerm
with well-vascularized tissue over drains is recommended. Although
aps have been reported frequently in this setting, it is not the optimal
time for local or regional ap mobilization. Unless the need for early
primary wound closure offsets the risk of tissue manipulation in this
phase, it is better to allow the wound to stabilize before performing
more de nitive ap reconstruction. In this setting, the VAC can also
stabilize the nonfunctional area until the relative tissue de ciency re-
solves, which may convert to a situation in which there is no longer a
tissue de ciency and primary fascial closure is possible when the edges
are no longer friable. Some reports of the use of the VAC in such cases
have showed healing of the fascia with no recurrence of hernia or later
eventration. Permanent prosthetic material should be avoided in this
setting. Split-thickness skin grafts will close the wound but will result
in a later cosmetically poor reconstruction and will create a donor site
Subacute Phase/ Relative Tissue De ciency/ Partial-Thickness
Defect—cont’d

issue. This option should be reserved for extensive absolute tissue de-
ciencies.
Dirty wound
Example: Patient with increased IAP from ileus after blunt trauma with
small area of debrided skin, subcutaneous tissue and muscle of lumbar
area after infected hematoma
– With gross contamination or infection, the wound should be treated by
open methods, with local care and debridement as necessary until it is
possible to use VAC. When the wound is at a cleaner state, one should
proceed as described earlier to prevent late occurrence of eventration.
Some authors have reported that AlloDerm works well in dirty
wounds.
• Full-thickness defect
Clean wound/skin closed
Example: Total myofascial dehiscence of a prior laparotomy at 4 weeks
with retraction of the fascial edges under a skin incision which remained
intact.
– A “clean” wound assumes the skin is intact. Again, in this setting evis-
ceration is usually not an issue. With skin remaining intact over a full
myofascial defect at this stage, the in ammation is less than it would be
if the wound were open. As long as the defect is not at risk for stran-
gulation, waiting until later usually is best so that a de nitive repair
can be done.
Contaminated wound
– The main difference between this situation and that of full-thickness
loss with adequate tissue is the fact that there may be factors affecting
the wound that cause the relative de ciency. In the early subacute
phase there may still be increased IAP causing outward pressure on the
abdominal wall and thus making the defect bigger than it actually is. In
the later stage of the subacute phase, the myofascial edges are becom-
ing retracted and encased in early scar tissue formation. The focus again
is primarily on protection of any exposed visceral surfaces and closure
in a fashion that is safe. Again, application of an autologous biopros-
thetic such as AlloDerm and coverage with recruited skin aps over
drains is the best option. However, if increased IAP is a factor, some feel
that it is best to simply VAC the wound until the relative de ciency re-
solves and thus a fascia-to-fascia closure may be possible. Caution is
essential. If the cause of the relative de ciency is wound edge retrac-
tion, one should VAC the wound over AlloDerm until in ammation
decreases to the point where a good anatomic dissection can be carried
out to identify all anatomic components for a fascia-to-fascia closure
with less risk of enterotomy.
1787
Chapter 44 Reoperative Surgery of the Abdominal Wall

1788
PART V R EOPERATIVE SURGERY OF THETRUNK
Dirty wound
Example: Four weeks following low anterior resection for diverticulitis
with abscess with multiple intraabdominal abscesses, open laparotomy
wound, and purulence in the wound
– In this scenario the wound cannot be closed, so application of the VAC
is the best option if there is no severe purulence or soilage. Autolo-
gous bioprosthetic should be applied if necessary and there is no soilage
coming from within the abdominal cavity. If in fact there is gross
soilage or purulence, local wound care with serial debridement is rec-
ommended until the wound is cleaner and then a VAC can be applied.
Absolute Tissue De ciency
• Partial-thickness defect

Super cial loss and deep nonfunctional loss
Contaminated wound
Example: Clean contaminated wound with bacterial counts less than 105
after debridement of noninfected eschar in a burn patient
– In large wounds with absolute de ciencies of the skin and subcuta-
neous tissue, the metabolic status of the patient may be affected if the
surface area of the injury is large, similar to burn patients. Local care
with topical agents such as Silvadene is recommended, if immediate
closure is not done. In this setting early closure with skin grafting is de-
sirable. In smaller wounds with absolute de ciencies local skin aps
can be used to obtain wound closure providing the desmoplastic reac-
tion of the surrounding tissue is not extensive. If the wound is too in-
amed, local wound care or VAC application should be performed un-
til the wound enters the chronic stage, when the wound is more stable
and closure with local aps can be carried out.
Dirty wound
Example: Infected burn wound of the abdominal area
– A dirty wound can be treated as described for a contaminated wound,
except with performance of debridement as indicated and local care
with topical antibiotic agents (Silvadene) in large surface area wounds,
followed by split-thickness skin grafting when the wound is cleaner. In
smaller wounds but still with an absolute de ciency, the VAC can be
used as long as there is no gross contamination or necrotic tissue.

Deep functional loss
Clean wound/skin closed
Example: Dehiscence of TRAM ap donor site repair 2 weeks postoper-
atively with skin closure remaining intact
Subacute Phase/ Relative Tissue De ciency/ Full-Thickness
Defect—cont’d

– A clean wound assumes the skin is intact. No treatment is done until
later, when the wound is quiescent.
Contaminated wound/skin open
Example: Dehiscence of TRAM ap donor site including fascial repair
and skin ap
– For stabilization of the abdominal wall, if necessary, an autologous bio-
prosthetic material (AlloDerm) can be applied. Vicryl mesh can be used
but will result in an eventration of the area at a later date. Although this
is not as serious as a hernia, and many surgeons may have a somewhat
cavalier attitude toward leaving eventrations, they are frequently symp-
tomatic and many patients present for late repair of them. The Allo-
Derm should be covered with well-vascularized tissue when feasible
using local or regional skin aps. If this is not possible, VAC therapy or
dressing changes can be performed over this. Reconstruction of the
area can also be carried out with aps if early wound closure is para-
mount over other issues. The VAC again is also helpful in this setting
by stabilizing the abdominal wall and decreasing wound edema until
reconstruction is carried out. Some reports state that VAC is the treat-
ment of choice in this setting until de nitive repair and closure is eas-
ier. Large surface area losses should be covered with split-thickness skin
grafts.
Dirty wound
Example: Open wound lower abdomen with residual cellulites, four days
after complete debridement of necrotizing fasciitis of anterior abdominal
wall requiring debridement of skin, subcutaneous tissue and anterior rec-
tus sheath.
– In grossly contaminated or infected wounds with a functional loss of
abdominal tissue the surgeon will need to balance the need for ab-
dominal wall stabilization against the use of the VAC. When possible,
the VAC can be applied and provide stabilization. Some authors have
reported that AlloDerm works well in this situation, but it should not
be used in association with necrotizing tissue or severe contamination.
Local care and debridement are the mainstay of therapy, and in most
cases it would be best to put off stabilization of the abdominal wall if
possible until wound conditions allow application of AlloDerm or the
VAC. Vicryl mesh is also an option as a temporizing measure, since it
is porous and allows good drainage from the wound.
• Full-thickness defect
Clean wound/skin closed
Example: Separation of all layers of laparotomy repair except for skin clo-
sure at 3 weeks postoperatively.
– A “clean” wound assumes the skin is intact. Complete separation of all
myofascial layers with skin closure remaining intact leads to eventual
ventral hernia.
1789
Chapter 44 Reoperative Surgery of the Abdominal Wall

1790
PART V R EOPERATIVE SURGERY OF THETRUNK
This particular scenario is different than those where the skin has been
open for days to weeks since not only is the wound clean (unless there
is underlying infection) but the viscera, if retained intraabdominally
until the time of myofascial separation, will not be as in amed as when
they have been exposed with open skin. For that reason repair in this
setting may be indicated depending on the situation. For a stable pa-
tient with a large symptomatic myofascial dehiscence in this phase re-
pair can be undertaken; however, if the dehiscence is not symptomatic
or if the patient is fairly ill, then repair may wait until the chronic phase
is entered. Also in wounds wherein there has been a complete myofas-
cial dehiscence with the skin repair remaining intact, a high index of
suspicion needs to be maintained that there may be infection present
since this is one of the more common causes of dehiscence. Reclosure,
if attempted, should be supported with autologous prosthetic material
such as AlloDerm in an onlay fashion to prevent dissection of friable
intraabdominal contents. If fascial edges are friable, reapproximation
should be avoided, the AlloDerm sutured peripherally, and covered
with well-vascularized skin aps.
Contaminated wound
Example: Two weeks status post full-thickness resection of sarcoma of ab-
dominal wall with early infection of Gore-Tex prosthetic requiring re-
moval and subsequent open wound with exposed viscera encased in
granulation tissue.
– With absolute de ciencies the issue of closure in this phase becomes
more complex. Abdominal viscera while possibly exposed have likely
already been managed in some manner and are now stable so eviscer-
ation is not an issue as much as protection. Coverage with split-thick-
ness skin grafts, although done frequently in the past and still an option,
are usually not the best option. Coverage with an autologous biopros-
thetic allows for good protection and dressing changes or the VAC can
be placed over this. Also myofascial aps or even skin aps can be ro-
tated into position to obtain wound closure without disturbing the in-
terface between the abdominal wall and the underlying viscera which
is usually quite adherent and in amed in this stage. Large defects can
adversely affect the overall metabolic status of the patient and should be
closed if possible, even if with skin grafts. However, if the patient is sta-
ble, and metabolic issues are not a factor, and the absolute de ciency is
not quite large, then simple protection of the viscera with VAC appli-
cation until in ammation is reduced is a good option since closure in
the chronic stage with less in ammation and edema will result in a less
morbid procedure.
Subacute Phase/ Absolute Tissue De ciency/ Full-Thickness
Defect/ Clean Wound—cont’d

Dirty wound
– Management of this defect will be similar to that just described, except
that the skin cannot be closed. Therefore protection of viscera is the
main focus. Measures as mentioned previously, such as split-thickness
grafts and AlloDerm, are helpful; however, if gross soilage is emanating
from the intraabdominal environment, simple wound care with fre-
quent dressing changes is recommended until the wound improves.
Bowel surfaces should be kept moist and dressings changed frequently.
VAC therapy may have some role in this situation.
CHRONIC PHASE
In this phase the wound is at a steady state in terms of in ammation, and one usu-
ally assumes the skin is closed in this setting, either with full-thickness normal skin
or skin grafts. A persistent open wound indicates the wound is still in the subacute
phase with secondary in ammation. The wound may have signi cant scarring and
retraction of tissues. Secondary problems such as loss of domain and respiratory
compromise may be present in late stages. Sources of contamination are usually
from chronic issues as well such as enterocutaneous stula, sinus tracts, stomas or re-
tained infected mesh.
Adequate Tissue
• Partial-thickness defect

Super cial loss and deep nonfunctional loss
Any prior loss of redundant or excess skin or subcutaneous tissue leaving a
defect wherein the super cial layer is de cient. Deep fascia loss which does
not affect the functional integrity.
Clean wound
Example: Old healed gunshot wound through subcutaneous tissue with
tissue loss and scarring
– Excise the defect and close primarily. If excision creates a tissue de -
ciency, use local aps as indicated.
Contaminated wound
Example: An old scarred defect caused by fat necrosis resulting from cel-
lulites in a localized area
– A contaminated wound is treated as described for a clean wound, ex-
cept the wound should be drained.
Dirty wound
Example: Infected mesh in a localized area of anterior rectus sheath up-
per abdomen with overlying abscess
– Excise the wound, debride as necessary, remove any foreign material,
and leave the skin open.
1791
Chapter 44 Reoperative Surgery of the Abdominal Wall

1792
PART V R EOPERATIVE SURGERY OF THETRUNK
Decision Chart for Chronic 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
Wound Status
Appropriate Action
Clean
Excise defect and close primarily. If there is a tissue de -
ciency then use local aps as indicated.
Contaminated
As above.
Dirty
Excise wound, debride as necessary, remove foreign material,
and leave skin open.
--------------------------------------------------------------------------------
Clean
Excise scarring of skin subcutaneous tissue and fascia if
necessary and close fascia and skin primarily. Plication of
redundant fascia.
Contaminated
Proceed as above, but close the skin with delayed primary
closure.
Dirty
Source of infection or contamination should be removed and
the wound treated by an open method or with VAC therapy.
Proceed as above. Primary fascial closure should be obtained.
--------------------------------------------------------------------------------
Clean
Obtain primary fascial closure in small defects. If recurrent,
consider use of a permanent prosthetic mesh to reinforce the
closure and reduce the risk of late recurrence. Use the under-
lay method of Gore-Tex dual mesh. For giant ventral hernias
use GRPVS.
Contaminated
Address the source of contamination. Avoid the use of a
permanent prosthetic material. Obtain primary fascial repair.
If the wound is a recurrent defect with controlled contami-
nation, use Prolene mesh (not Gore-Tex). Otherwise, use an
autologous prosthetic material in an underlay fashion.
Dirty
Address the source of increase infection/contamination.
Convert to clean before proceeding with closure as above.
Clean
Excise scarred and retracted tissues with good anatomic
dissection to recruit available tissue and close primarily.
Contaminated
As above, except all sources of possible contamination
should be removed. It this is not feasible, cover with well-
vascularized tissue.
Dirty
Treat the wound by open methods until able to proceed
with closure.
--------------------------------------------------------------------------------
Clean
De ne the extent of the defect with anatomic dissection,
then repair primarily as indicated. If the defect is recurrent,
consider adding a nonautologous prosthetic material.
Contaminated
As above, with nonautologous material. Use autologous if
necessary to reinforce repair.
Dirty
Leave the wound open and treat with local wound care until
it is cleaner, then proceed as above. Remove all sources of
contamination as much as possible.

1793
Chapter 44 Reoperative Surgery of the Abdominal Wall
Available
Tissue
Depth of Injury
Relative
Full-thickness
de ciency—
defect
cont’d
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
If scarring is present, it should be excised as necessary.
Identify all remaining usable tissue. Perform primary fascial
repair. Components separation or local fascial ap methods
may be helpful. Placing nonautologous prosthetic mesh in an
underlay or overlay fashion over the fascial repair is helpful.
The mesh should be covered with well-vascularized tissue.
Previous skin grafts should be removed. In large recurrent
ventral hernias with retracted fascia, our preferred technique
is the GPRVS method of Stoppa.
Contaminated
Remove the source of contamination and convert the wound
to clean. Avoid the use of permanent mesh if possible and use
an autologous bioprosthetic for fascial support. Close the skin
over the prosthetic with drains.
Dirty
As above. May need to leave the skin open.
Clean
For a wound of a reasonable size to be amenable to recon-
struction, local tissue needs to be recruited to obtain closure.
In smaller defects local aps or regional aps can be used.
Larger defects would be the ideal indication for tissue expan-
sion techniques.
Contaminated
As above. Tissue expanders are contraindicated if an adjacent
site is contaminated.
Dirty
The source of persistent soilage should be resolved, then
proceed as above.
--------------------------------------------------------------------------------
Clean
Identify all anatomic components of the defects with exci-
sion of scarred tissue and obtain primary fascial closure if
possible, if tension is not excessive. Variations on components
separation can be used here, but extensive dissection can
create a more extensive defect if failure occurs, so this is
recommended only if closure can be very low tension.
Otherwise, nonautologous prosthetic material can be used
and covered with well-vascularized tissue.
Contaminated
As above, except avoid use of nonautologous prosthetic ma-
terial. If an overlay repair is needed then use an autologous
prosthetic such as AlloDerm.
Dirty
Remove the source of infection or soilage and proceed as
above. May need to treat the wound by open methods.
--------------------------------------------------------------------------------
Clean
Excise scarring and perform a thorough anatomic dissection
of all peripheral wound elements. Regional muscle or fascial
aps may be helpful. In most cases application of a nonautol-
ogous mesh covered with vascularized tissue is best.
Contaminated
The source of contamination should be addressed as much as
possible. For fascial support, avoid the use of permanent mesh;
instead, use AlloDerm covered with well-vascularized tissue.
Dirty
As above.

1794
PART V R EOPERATIVE SURGERY OF THETRUNK

Deep functional loss
Deep functional loss usually implies the presence of abdominal wall even-
trations in which there has been no tissue loss covered with skin, and the
defect is symptomatic enough to warrant repair. These eventrations can be
a result of denervations or weakness in fascial support.
Clean wound
Example: Eventration of the abdominal wall as a result of diastasis recti or
a denervated segment after
– Perform anatomic dissection to excise scarring of the skin, subcuta-
neous tissue, and fascia if necessary and close the fascia and skin
primar ily. Plication of redundant fascia may suf ce, as in abdomino-
plasty.
– In cases of denervation, either plication or the addition of support with
nonautologous prosthetic material in overlay fashion may be helpful.
Contaminated wound
Example: Eventration of lower abdomen 2 years after placement of a
TRAM ap with poor closure of abdominal wall layers, indwelling mesh,
and multiple chronic sinus tracts
– Proceed as for a clean wound, but close the skin with delayed primary
closure or with skin aps over drains.
Dirty wound
Example: Parastomal eventration with adjacent cellulitis
– The source of infection or contamination should be removed and then
the wound is treated by an open method or with VAC therapy until
the wound is cleaner, then proceeding as for a contaminated wound. A
primary fascial closure should be done.
• Full-thickness defect
All primary and secondary hernias fall in this category, since the defect is full-
thickness but there has been no actual loss of tissue—just failure of support.
These defects may remain small or become signi cantly enlarged over time.
An in-depth discussion of abdominal wall hernias is beyond the scope of this
chapter.34
The defect commonly seen by the reconstructive surgeon in this setting is
a recurrent hernia after primary fascial repair has failed. (For giant ventral her-
nias with associated issues, see p. 1767.)
Clean wound
Example: Any hernia of the abdominal wall with a complete fascial defect
– Obtain primary fascial closure in small defects. In recurrent defects,
even when there is adequate tissue one should consider using a perma-
nent prosthetic mesh to reinforce the closure and reduce risk of late re-
currence. The underlay method with Gore-Tex dual mesh is our pre-
ferred technique. For giant ventral hernias the technique of giant
Chronic Phase/ Adequate Tissue/ Partial-Thickness Defect—cont’d

prosthetic reinforcement of the peritoneal sac (GPRVS) after Stoppa is
preferred.18 (See Complications, p. 1815, for a report of the author’s
[G.B.C.] series.)
Contaminated wound
Example: Failed mesh repair of abdominal wall hernia with chronic low
grade infection and sinus tract.
– Address source of contamination. Avoid use of permanent prosthetic
material in cases where contamination cannot be contained. Obtain
primary fascial repair. If defect is recurrent, and contamination issue
can be controlled, then underlay with Prolene mesh (not Gore-Tex)
will still likely be successful with low risk of infected mesh in this po-
sition. Otherwise, use an autologous prosthetic.
Dirty wound
Example: Infected mesh repair of abdominal wall hernia with secondary
overlying cellulitis.
– Address source of increased infection/contamination. Convert to clean
wound as much as possible before proceeding with closure as above.
Relative Tissue De ciency
In the chronic setting a relative tissue de ciency would most often be relegated
to the deep myofascial layers that have retracted and scarred into place, thus mak-
ing it appear that tissue is de cient when in fact it is not. However, it is also pos-
sible to have a relative de ciency in the super cial layer as well if previously non-
de cient tissues have for whatever reason become retracted and scarred. Other
causes of relative tissue de ciencies more common in earlier stages (such as in-
creased IAP) are rare in this setting.
• Partial-thickness defect

Super cial loss and deep nonfunctional loss
Clean wound
Example: Prior panniculectomy with dehiscence treated with wet-to-dry
dressings and now with complete skin coverage but residual defect
– Excise scarred and retracted tissues with good anatomic dissection to
recruit available tissue and close primarily.
Contaminated wound
Example: Same defect as the clean wound just described, but the wound
was closed secondarily over previously exposed mesh
– Management is as described for the clean wound, except all sources of
possible contamination should be removed, or if this is not feasible (for
example, an extensive overlay mesh is present on the fascia), cover this
with well-vascularized tissue.
Dirty wound
– Treat the wound until it is possible to proceed with closure.

Deep functional loss
This type of defect results from situations in which there has been partial-
thickness loss of myofascial support with retraction of adjacent layers of sup-
1795
Chapter 44 Reoperative Surgery of the Abdominal Wall

1796
PART V R EOPERATIVE SURGERY OF THETRUNK
porting tissue but no absolute tissue loss has occurred.
Clean wound
Example: Suture line failure of previous external oblique advancement
in abdominoplasty
– De ne the extent of the defect with good anatomic dissection, then re-
pair primarily as indicated. If the defect is recurrent, consider adding
nonautologous prosthetic material.
Contaminated wound
Example: Prior mesh overlay to reinforce diastasis recti repair, now failed
with chronic sinus tract
– Manage as described previously, but without nonautologous material.
Use autologous material if it is necessary to reinforce the repair.
Dirty wound
Example: Active cellulitis with infected mesh in a failed repair of a de -
nervated segment
– Leave the wound open and treat with local wound care until it is
cleaner, then proceed as above. Remove all sources of contamination if
possible.
• Full-thickness defect
Clean wound
Example:Ventral hernia with prior failed onlay repair with retracted edges
of abdominal wall
– Patients with a clean wound frequently present after having had some
type of closure method previously performed. It may be with in-
dwelling mesh, or they may have extensive split-thickness skin grafts
directly on the bowel. In midline wounds the peripheral edges of the
abdomen frequently have contracted and scarred fascial edges with in-
tact rectus muscles.
– Any scarring should be excised as necessary from retracted abdominal
wall tissues.
– Performing a good anatomic dissection to identify all remaining us-
able tissue is critical, since components separation may not be necessary
if all available tissue is found. Primary fascial repair should be done.
Components separation or local fascial ap methods may be helpful
to reduce tension on closure. Placing nonautologous prosthetic mesh in
an underlay or overlay fashion over the fascial repair is helpful. The
mesh should be covered with well-vascularized tissue.
– Previously placed prosthetic material should be removed if necessary,
although this can be dif cult and may yield negative returns in some
cases. Previous skin grafts should be removed. If the closure is under
tension or the defect is a recurrent issue then the closure should be
done over a permanent prosthetic mesh to decrease risk for late recur-
rence. In large recurrent ventral hernias with retracted fascial edges
Chronic Phase/ Relative Tissue De ciency/ Partial-Thickness Defect/
Deep Functional Loss—cont’d

our preferred technique is the GPRVS method of Stoppa.
Contaminated wound
Example: Prior mesh repair of ventral hernia with overlay Prolene per-
formed several years ago with no attempt to recruit abdominal wall edges
at rst surgery; now there is a chronic low-grade infection of the mesh
– First the source of contamination should be removed and the wound
cleaned as much as possible. In this setting the surgeon should avoid the
use of permanent mesh and use an autologous bioprosthetic for fascial
support. The skin is closed over the prosthetic material with drains.
Dirty wound
Example: An old Marlex repair of a ventral hernia with mesh; the patient
presents with erosion of mesh into underlying bowel
– Management is as above. The surgeon may need to leave skin open.
Absolute Tissue De ciency
Absolute de ciencies in the chronic phase consist of defects in which there has
been prior loss of abdominal wall components with previous repair such that
there is now skin closed over them. Past surgery consisting of previously repaired
abdominal wall loss such as debridement, traumatic loss, or tumor resection, now
with recurrent defects would be most common.
• Partial-thickness defect

Super cial loss and deep nonfunctional loss
These defects consist of previous injuries or defects from previous proce-
dures in which there is now absolute loss of the super cial layers but with
some type of skin covering over them that has allowed them to progress to
a stable, nonin amed state.
Clean wound
Example: Full-thickness burn of 200 cm2 to the abdominal area, now
healed after excision and grafting
– For wounds of a reasonable size to be amenable to reconstruction (i.e.
closed burn wounds skin grafted and healed would be in this category)
then local tissue would need to be recruited to obtain closure. In
smaller defects local aps or regional aps can be used depending on
the location of the defect. Larger defects would be the ideal indication
for tissue expansion techniques.
Contaminated wound
– Management is as described above. Tissue expanders are contraindi-
cated in the face of an adjacent contaminated site.
– Traumatic loss of skin and subcutaneous tissue and anterior rectus ab-
dominis fascia (above arcuate line) with adjacent stoma.
Dirty wound
Example: A healed wound of the abdomen with a stoma within the de-
fect and secondary soilage that is persistent
– The source of persistent soilage should be resolved, then proceed as
1797
Chapter 44 Reoperative Surgery of the Abdominal Wall

1798
PART V R EOPERATIVE SURGERY OF THETRUNK
described above.

Deep functional loss
Deep functional defects in the chronic setting are usually seen as eventra-
tions where there has been actual tissue loss, usually from a prior procedure
or injury. When the wound is symptomatic or represents a serious aesthetic
concern to the patient, it should be repaired.
Clean wound
Example: Eventration from failure of internal oblique repair with TRAM
ap donor site
– All anatomic components of the defect should be identi ed, with ex-
cision of scarred tissue; primary fascial closure should be done if ten-
sion is not excessive. Variations on components separation can be used
here, but extensive dissection can create a more extensive defect if fail-
ure occurs, so this is recommended only if closure can be very low
tension. Otherwise nonautologous prosthetic material can be used and
covered with well-vascularized tissue.
Contaminated wound
Example: Chronic sinus tract from low-grade infected mesh in a TRAM
ap donor site
– Management is as described above, except nonautologous prosthetic
material should not be used. If an overlay repair is needed, an autolo-
gous prosthetic such as AlloDerm should be used.
Dirty wound
Example: Acute onset of cellulitis in old mesh overlay repair of TRAM
ap donor site.
– The source of infection or soilage should be removed, and then one
can proceed as above. It may be necessary to leave the wound open.
• Full-thickness defect
Full-thickness defects in the chronic setting are a result of previous injury or
a repair procedure in which there has been a complete loss of myofascial sup-
porting layers of the abdominal wall with absolute tissue loss. Being in the
chronic phase implies that the skin is in some way intact.
Clean wound
Example: Prior loss of abdominal wall as a result of tumor resection with
reconstruction using onlay mesh 4 years ago; now the patient presents
with a large recurrent hernia around the mesh
– One should excise scarring and perform a thorough anatomic dissec-
tion of all peripheral wound elements. Regional muscle or fascial aps
may be helpful; however, in most cases application of a nonautologous
Chronic Phase/ Absolute Tissue De ciency/ Partial-Thickness
Defect—cont’d

mesh covered with vascularized tissue is best.
Contaminated wound
Example: The same defect as just described, but with chronic low-grade
infection in the mesh repair
– Again, the source of the contamination should be addressed as much as
possible. In this setting for fascial support, one should avoid the use of
permanent mesh and instead use AlloDerm covered with well-vascu-
larized tissue.
Dirty wound
Example: Prior abdominal wall resection and GPRVS repair using Mar-
lex 10 years ago; now the patient presents with erosion of mesh into the
colon and an enterocutaneous stula
– The source of soilage or infection should be removed, then one can
proceed as above.
SELECTED CASE STUDIES
PATIENT EXAMPLE
Classi cation: Acute Phase/ Absolute Tissue De ciency/
Partial-Thickness Defect/ Deep Nonfunctional Loss/ Clean Wound
1799
Chapter 44 Reoperative Surgery of the Abdominal Wall
This patient had extensive resection of a large desmoid tumor extending down to
the anterior rectus sheath. The wound was reexcised and closed with autologous
tissue using a reverse abdominoplasty ap and a rotation ap with resection and
reclosure of an old cholecystectomy scar to advance the lateral ap.

1800
PART V R EOPERATIVE SURGERY OF THETRUNK
PATIENT EXAMPLE
Classi cation: Acute Phase/ Absolute Tissue De ciency/
Full-Thickness Defect/ Clean Wound
This 56-year-old woman was referred for abdominal wall reconstruction 9 years af-
ter the resection of a huge desmoid tumor of the abdominal wall. She was free of
recurrence but had a hernia that involved approximately 60% of the anterior ab-
dominal wall.
Intraoperatively the abdominal viscera and hernia sac were dissected from the sub-
cutaneous fat, leaving an enormous musculofascial defect. The inguinal ligament
had been previously resected. A sheet of Prolene mesh was sutured to the under-
surface of the surrounding fascial rim medially and laterally, the costal margin su-
periorly, and the iliac periosteum inferiorly. The repair was pulled taut to reduce the
circumference of the residual defect.

Three months postoperatively, the patient was well healed and considerably more
comfortable.
1801
Chapter 44 Reoperative Surgery of the Abdominal Wall
However, 3 years postoperatively, after considerable weight gain, the patient pre-
sented with a small hernia in the left groin, which was intermittently tender. This
defect was repaired by resuturing the mesh to the periosteum of the ilium. The
correction has been maintained.

1802
PART V R EOPERATIVE SURGERY OF THETRUNK
PATIENT EXAMPLE
Classi cation: Acute Phase/ Absolute Tissue De ciency/
Full-Thickness Defect/ Clean Wound
This patient was left with a massive lower abdominal wall defect after the resection
of bladder carcinoma that involved the abdominal wall. Rectus femoris musculocu-
taneous aps were elevated for transfer into the abdominal defect.
Complete abdominal wall competence was ob-
tained, as shown here 9 months postoperatively.
I (G.B.C.) would not perform this procedure in
the same way today because of the extensive
donor site morbidity. A better choice would be
the use of Gore-Tex dual mesh with GPRVS
technique, with mesh covered by well-vascular-
ized tissue consisting of local advancement of
separating components and if necessary, a free
tissue transfer from a less morbid donor site (for
example, the latissimus dorsi).

PATIENT EXAMPLE
Classi cation: Acute Phase/ Absolute Tissue De ciency/
Full-Thickness Defect/ Contaminated Wound
1803
Chapter 44 Reoperative Surgery of the Abdominal Wall
A gunshot wound left this patient with an extensive left upper quadrant defect
with exposed viscera seen 1 week after the injury when the patient presented for
a plastic surgery consultation. The open wound had been managed with sterile
wet-to-dry dressings during the interim period while the patient was being stabi-
lized. (This case occurred before the development of wound VAC technology.)
Wound closure was achieved with an extended latissimus dorsi ap covered with a
skin graft. The result is shown 3 months postoperatively. Excellent abdominal wall
competence has been obtained. Future tissue expansion for aesthetic re nement is
planned.

1804
PART V R EOPERATIVE SURGERY OF THETRUNK
PATIENT EXAMPLE
Classi cation: Subacute Phase/ Relative Tissue De ciency/
Full-Thickness Defect/ Contaminated Wound
This 64-year-old patient had previous onlay Gore-Tex repair for a large ventral
hernia. The wound became infected, requiring removal of the Gore-Tex. The un-
derlying viscera are covered with granulation tissue. The current recommendation
for management would be placement of the wound VAC device. However, this pa-
tient was treated before VAC therapy was available.
The patient is shown after control of contamination by excision of the wound and
repair of a giant ventral hernia using GPRVS technique over Prolene mesh. This
patient has been followed for 5 years, and there has been no recurrence.

PATIENT EXAMPLE
Classi cation: Chronic Phase/ Adequate Tissue/
Full-Thickness Defect/ Clean Wound
Recurrent lumbar hernias are uncommon and require reconstruction based on the
cause of the recurrence. Gels and Salatta71 reported that most recurrences involved
previously placed prosthetic mesh, which is indicated for the initial repair of lum-
bar hernia. However, in a patient with risk of infection in whom prosthetic mate-
rial should be avoided, an autogenous fascial substitute is preferable and can be ob-
tained from local, regional, or distant aps.
1805
Chapter 44 Reoperative Surgery of the Abdominal Wall
In this patient a Grynfelt-type lumbar hernia was present (left). Delineation of the
peritoneal sac is shown (right). It was ligated and reduced.
A Marlex mesh inlay patch was used to repair the fascial defect. The latissimus dorsi
muscle ap was reapproximated over the patch to complete the reconstruction.
C
o
u
r
t
e
s
y

R
.

R
e
a
d
,

M
D
C
o
u
r
t
e
s
y

R
.

R
e
a
d
,

M
D
C
o
u
r
t
e
s
y

R
.

R
e
a
d
,

M
D

1806
PART V R EOPERATIVE SURGERY OF THETRUNK
PATIENT EXAMPLE
Classi cation: Chronic Phase/ Relative Tissue De ciency/
Full-Thickness Defect/ Clean Wound
Following aortofemoral graft placement, this patient had a relative tissue de ciency
and we were unable to close the fascia primarily in the acute phase without undue
tension. She therefore underwent closure with a Gore-Tex patch. Later, in the
chronic phase, this patient presented with what was assumed to be a ventral hernia;
however, at surgery she was found to have a periprosthetic collection of old blood
from a hematoma.
The relative tissue de ciency was now resolved, so the Gore-Tex was easily re-
moved and the defect was closed with primary fascial closure.

PATIENT EXAMPLE
Classi cation: Chronic Phase/ Relative Tissue De ciency/
Full-Thickness Defect/ Clean Wound
1807
Chapter 44 Reoperative Surgery of the Abdominal Wall
In our experience with this technique for ventral herniation we have observed no
complications and only one recurrence. This patient presented with an extensive
ventral hernia from a previous laparotomy that was performed for abdominal
trauma and splenectomy. Abdominal wall fascia was present but retracted and
scarred.
At surgery a giant prosthetic reinforcement of the defect was obtained with the
placement of Prolene mesh after complete anatomic dissection.

1808
PART V R EOPERATIVE SURGERY OF THETRUNK
Eight months after the repair, there is no evidence of recurrence. Follow-up is now
10 years with no recurrence.
PATIENT EXAMPLE
Classi cation: Chronic Phase/ Adequate Tissue/
Full-Thickness Defect/ Contaminated Wound
A massive parastomal recurrent ventral hernia developed in this patient from im-
proper placement of the stoma site with ureterostomy lateral to the rectus abdom -
inis muscle.

After takedown of the ureterostomy, the extent of the parastomal hernia was appar-
ent. The stoma was sewn shut and the contamination controlled at surgery.
1809
Chapter 44 Reoperative Surgery of the Abdominal Wall
The patient is shown 1 year postoperatively. The parastomal hernia was repaired us-
ing right unilateral giant prosthetic reinforcement of the visceral sac with Prolene
mesh. The stoma was moved to the opposite side of the abdomen and placed
through the rectus abdominis muscle. There is no evidence of recurrence.

1810
PART V R EOPERATIVE SURGERY OF THETRUNK
PATIENT EXAMPLE
Classi cation: Chronic Phase/ Relative Tissue De ciency/
Full-Thickness Defect/ Clean Wound
This patient had a large midline ventral hernia after resection of a bladder carci-
noma years earlier. The initial repair was with the Stoppa technique using GPRVS
with Gore-Tex dual mesh.
Note lysis of adhesions to the hernia sac.

The enterotomy or serosal injury was repaired as indicated. A complete anatomic
dissection was done to separate and identify the abdominal wall components.
1811
Chapter 44 Reoperative Surgery of the Abdominal Wall
A giant panel of Gore-Tex dual mesh was use to reinforce the visceral sac. The ab-
dominal wall was closed over this with primary fascial repair using running Nova l
suture. The urostomy was sterilized with antibiotics preoperatively and sutured shut
for the case over a closed Foley system. The muscular layers were closed over the
mesh. Abdominal wall perforators to overlying skin aps were left in place as much
as possible.

1812
PART V R EOPERATIVE SURGERY OF THETRUNK
This repair was successful, but the patient developed persistent high daily fevers
1 week postoperatively. An infectious disease consultation implicated the wound,
since no other source could be found. At surgery the prosthetic was found to be
clean with no purulence, and results of cultures were negative. However, the Gore-
Tex was removed and a Prolene mesh was placed in an underlay position and the
wound left open, assuming it to be dirty. After surgery the source of fever was found
to be septicemia with a positive preoperative blood culture for Candida albicans,
presumably from prolonged antibiotic therapy. Antifungal therapy resolved the issue
and the wound was left open to heal. The wound was now in the subacute phase
and so it was allowed to reach the chronic phase before repair was undertaken.
The defect was repaired in the chronic phase by resection of the scarred tissue and
primary closure. The patient is shown 6 months after closure. There has been no evi-
dence of recurrence or infection.

PATIENT EXAMPLE
Classi cation: Chronic Phase/ Absolute Tissue De ciency/
Partial-Thickness Defect/ Deep Functional Loss/ Clean Wound
1813
Chapter 44 Reoperative Surgery of the Abdominal Wall
This 55-year-old patient presented 8 years after bilateral mastectomies and imme-
diate conventional TRAM reconstruction. She required postoperative radiother-
apy to the left reconstructed breast and chest wall, which resulted in a painful, rm
left breast. In addition, she was left with a huge abdominal hernia and near com-
plete relaxation of the musculofascial abdominal wall.
The operative plan is shown, with the outline of the palpable fascial rim marked on
the abdomen. We also planned to excise fat necrosis and attempt to reshape the
TRAM aps by mobilizing them into a higher, rounder shape.

1814
PART V R EOPERATIVE SURGERY OF THETRUNK
Intraoperatively we encountered a previously placed sheet of Prolene mesh. We
mobilized the internal oblique muscles and brought them together on top of the
existing mesh. We then mobilized external oblique advancement aps and sutured
them over the top of a large sheet of Prolene mesh that covered the internal oblique
muscle and fascia extending from anterior axillary line to anterior axillary line.
The patient is shown 18 months postoperatively with a stable, competent abdom-
inal wall and a modest improvement in breast shape.

COMPLICATIONS
In my (G.B.C.’s) series of 92 abdominal wall repairs, all of which were giant ven-
tral hernias, all treated by GPRVS (giant prosthetic repair of the visceral sac), late re-
currence of ventral hernia has been very low (1.5%). Patients have been followed
from 1 year to 14 years. Two patients have developed chronic pain syndromes. One
was repaired with a giant Prolene mesh and the other with a giant Gore-Tex dual
mesh. Neither patient has felt the pain was bad enough to warrant reexploration.
Two patients developed small bowel obstructions and in both the operating surgeon
felt the obstruction was unrelated to the mesh, although in one patient (Prolene
mesh), the surgeon reported the bowel was adherent to the mesh and dissection was
dif cult. Enterotomy at surgery was encountered in two patients at the time of the
initial GPRVS but due to a meticulous bowel prep and primary repair with no
contamination, we were able to still perform GPRVS. There have been no infec-
tions. One hematoma has occurred. One patient underwent reoperation for fever
with suspected prosthetic infection which turned out to be negative and the infec-
tion was found to be systemic fungal in nature. One complication I was repeatedly
warned about which has not occurred was erosion of Prolene mesh into bowel. In
many patients before the development of Gore-Tex dual mesh I frequently had to
place the mesh directly on the bowel in absence of suf cient omentum. Prior re-
ports of low complications of this nature with Prolene mesh were encouraging,
and subsequently, we have had no incidence of this occurring. Recurrence rate in
this series has been 1.5% occurring in one patient at the edge of the Prolene mesh.
SPECIFIC COMMON PROBLEMS AND
THEIR CLASSIFICATION
The following are common problems seen with abdominal wall reconstruction and
the classi cation of each. Referral to the decision charts and the text above will
demonstrate the recommended course of action for each one.
Acute Wound Dehiscence
Acute Phase/ Relative Tissue De ciency/ Full-Thickness Defect/ Clean Wound
– This is technically a contaminated wound if there is any delay in recognition
and repair and the skin is open. If skin closed and myofascial layers dehisced
then wound is still clean, however a high index of suspicion for deep infec-
tion should be maintained. (See the discussion of management of a burst ab-
domen.)
Inability to Close at Laparotomy
Acute Phase/ Relative Tissue De ciency/ Full-Thickness Defect/ Clean Wound
– See chart (p. 1772) and text (p. 1777).
Open Laparotomy Wound Still Open Several Days to Weeks
After the Initial Event
Subacute Phase/ Relative Tissue De ciency/ Full-Thickness Defect/ Contaminated Wound
– See chart (p. 1782) and text (p. 1787).
1815
Chapter 44 Reoperative Surgery of the Abdominal Wall

1816
PART V R EOPERATIVE SURGERY OF THETRUNK
Ventral Hernia
Chronic Phase/ Relative Tissue De ciency/ Full-Thickness Defect (Skin Intact)/
Clean Wound
– The cause of incisional herniation is multifactorial. Contributing factors can
be divided into those that are mechanical (local wound factors or technical
factors) and constitutional problems with the patient. Among the latter, the
most common are obesity, advancing age, malnutrition, male sex, pulmonary
disease, and sepsis. Mechanical factors include local wound problems (for ex-
ample, decreased blood supply from prior surgery or radiation), abdominal
distention (for example, from ascites or paralytic ileus), wound infection,
hematoma, or local tissue de ciency resulting in increased tension. Technical
factors consist of inadequate suture technique, improper placement of the
incision, use of absorbable sutures, use of drains enterotomies, long duration
of the operation, and excessive tension during closure.
– Of these contributing factors, the most important is proper technique. Since
the adoption of the mass closure technique by Jones, Newell, and Brubaker,
which supplanted the layered closure of Halsted, there has been a signi cant
reduction in the incidence of wound dehiscence and incisional hernia. How-
ever, many surgeons still insist on closing the abdomen in layers. Whether or
not to close the peritoneum as a separate layer remains controversial. The
peritoneum has been shown by one group to be particularly prone to adhe-
sions if closed as a separate layer or included in the mass closure method. In
addition, overzealous suturing techniques can result in ischemia and tissue
necrosis. Sutures that are too tight may cut through tissues, resulting in local-
ized areas of weakness. Placement of sutures in infected or necrotic wound
margins is also a technical error.
– The most common presentation of incisional hernia is caused by a second-
ary subclinical fascial dehiscence that occurs late (usually within 6 months)
after a previous operation and may be asymptomatic in some patients. The
natural history of this type of hernia is one of continued enlargement. As
the hernia ring enlarges, the threat to the patient’s life is lessened, since the
risk of incarceration or strangulation decreases. It is recommended that such
hernias be repaired unless the patient’s medical condition prevents it. In obese
individuals small incisional hernias may be camou aged, presenting as only a
localized area of abdominal wall tenderness. If incarceration or strangulation
occurs, frank bowel obstruction may result, with vomiting, intermittent
cramping, abdominal pain, distention, and obstipation. Large ventral hernias
cause the intestinal viscera to become displaced to some degree outside the
abdominal cavity. This in turn causes secondary sequelae such as paradoxical
respiration, problems with micturition, back pain, splanchnic venous stasis,
and distention and atony of the hollow viscera. In addition, the skin may be-
come atrophic, hypoxic, and devoid of subcutaneous fat. Spontaneous ulcer-
ations may occur in the thin overlying skin.

– The most formidable challenge in treating ventral hernias is the patient who
presents with inadequate tissue peripherally for primary closure. Many times
previously these patients have had open wounds that began initially as acute
wound dehiscences or infections. These wounds usually were treated by an
open approach, and by the time the plastic surgeon is consulted, the abdom-
inal wall components are widely separated, with thin skin grafts over the ab-
dominal viscera. The skin grafts may even have prosthetic mesh underneath.
Associated problems may include bowel stula, mesh extrusion, and reherni-
ation around the edge of the mesh from improper closure. These complica-
tions are more common in patients who have undergone repair with Marlex
mesh; these patients may present to the reconstructive surgeon with such
problems years after placement of the mesh. Options for reclosure in patients
who have tissue de ciency are discussed later.
Recurrent Groin Hernia
– Management is the same as for a ventral hernia (see p. 1816).
Parastomal Hernia
Chronic Phase/ Relative Tissue De ciency/ Full-Thickness Defect/ Contaminated Wound
– See chart (p. 1793) and text (p. 1797).
TRAM Flap Eventration in the Lower Abdomen
Chronic Phase/ Relative Tissue De ciency/ Partial-Thickness Defect/ Clean Wound
– See chart (p. 1792) and text (p. 1795).
Traumatic Loss of Abdominal Wall From Gunshot
– A traumatic gunshot injury to the abdominal wall can present to the recon-
structive surgeon at any phase with any depth of injury but technically will
always be considered contaminated.
UNANSWERED QUESTIONS
At present the cause of the long-term recurrence rate after VAC therapy is still
unanswered, especially when VAC is used as the only modality in full-thickness
defects. Some of the newer materials, both autologous and nonautologous, require
long-term studies to determine recurrence rates after hernia repairs. The gold stan-
dard for treatment of a recurrence at this time is the use of permanent nonautolo-
gous prosthetic mesh in an underlay GPRVS fashion.
Endoscopic surgery has been used successfully in a limited number of cases in com-
ponents separation techniques since the last writing of this chapter; however, this
approach is still in the development stage.
1817
Chapter 44 Reoperative Surgery of the Abdominal Wall

1818
PART V R EOPERATIVE SURGERY OF THETRUNK
There have also been more reports of tissue expansion, which has played a limited
role in abdominal wall reconstruction but may have limited indications.
Microneurovascular techniques have allowed better functional muscle transfers, and
this method continues to hold promise for optimal autologous reconstruction in se-
lected defects.
One area that has not been given a lot of interest has been the importance of re-
ning the reconstruction aesthetically. Why would we give any less importance to
the abdomen in this regard than we would to the breast? More needs to be done
to make this an important goal in the reconstruction of the abdominal wall after the
functional goals are met.
References—With Key Annotated References
1. Core GB, Grotting JC. Reoperative surgery of the abdominal wall. In Grotting JC, ed. Reop-
erative Aesthetic and Reconstructive Plastic Surgery. St Louis: Quality Medical Publishing,
1995, pp 1327-1375.
2. Hurwitz DJ, Hollins RP. Reconstruction of the abdominal wall and groin. In Cohen M, ed.
Mastery of Plastic and Reconstructive Surgery. Boston: Little Brown, 1994, pp 1349-1359.
3. Rohrich RJ, Lowe JB, Hackney FL, et al. An algorithm for abdominal wall reconstruction.
Plast Reconstr Surg 105:202-216, 2000.
4. Bengston BP, Ringler SL, George PR, et al. Capsular tissue: A new local ap. Plast Reconstr
Surg 91:1073-1079, 1003.
5. Scarpa A. Sull’ernie Memorie Anatomico—Chirurgiche. Mellon: Della Reale, 1809.
6. Lockwood TE. Super cial fascial system (SFS) of the trunk and extremities: A new concept.
Plast Reconstr Surg 87:1009-1018, 1991.
7. Woodburne RT. Essentials in Human Anatomy, 9th ed. New York: Oxford University Press,
1994.
8. Condon RE. Surgical anatomy of the transversus abdominis and transversalis fascia. Ann Surg
173:1-5, 1971.
9. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep
epigastric systems. Plast Reconstr Surg 73:1-16, 1984.
10. Carramenha e Costa MA, Carrequiry C, Vásconez LO, et al. An anatomical study of the venous
drainage of the transverse rectus abdominis musculocutaneous ap. Plast Reconstr Surg 79:208-
217, 1987.
11. Krupski WC, Sumchai A, Effeney DJ, et al. The importance of abdominal wall collateral blood
vessels. Arch Surg 119:854-857, 1984.
12. Byrd HS, Cierny G, Tebbets JB. The management of open tibial fractures with associated soft
tissue loss: External pin xation and early ap coverage. Plast Reconstr Surg 68:73-82, 1981.
13. Mathes SJ, Steinwald PM, Foster RD, et al. Complex abdominal wall reconstruction: A com-
parison of ap and mesh closure. Ann Surg 232:586-596, 2000.
14. Voyles CR, Richardson JD, Bland KI, et al. Emergency abdominal wall reconstruction with
polypropylene mesh. Ann Surg 194:219-223, 1981.
15. Stone HH, Fabian TC, Turkelson ML, et al. Management of acute full-thickness losses of the
abdominal wall. Ann Surg 193:612-618, 1981.

16. Jones JW, Jurkovich GJ. Polypropylene mesh closure of infected abdominal wounds. Am Surg
55:73-76, 1989.
17. Fry DE, Osler T. Abdominal wall considerations and complications in reoperative surgery. Surg
Clin North Am 71:1-11, 1991.
18. Stoppa RE. The treatment of complicated groin and incisional hernias. World J Surg 13:545-
554, 1989.
The author considers the general features and diagnostic and technical consequences of the repair of
groin and incisional hernias. The treatment of strangulating hernias, usually an emergency operation,
has not seen any recent technical progress. Huge and recurrent hernias, however, usually allow time for
adequate surgical preparation. These hernias are also amenable to modern prosthetic repairs. The state
of hernial surgery has advanced to the point that one must consider the systematic surgical cure of all
diagnosed hernias.
19. Stoppa RE. Personal communication, 1995.
20. Larson GM, Vandertoll DJ. Approaches to repair ventral hernia and full-thickness losses of the
abdominal wall. Surg Clin North Am 64:335-349, 1984.
21. Read RC. Recurrent and incisional hernias. In McQuarrie DG, Humphrey EW, eds. Reoper-
ative General Surgery. St Louis: Mosby, 1992, pp 485-494.
22. LeVeen HH. Tissue reaction to plastics used in surgery with special reference to Te on. Ann
Surg 129:74, 1949.
23. Epply BL. Alloplastic implantation. Plast Reconstr Surg 104:1761-1783, 1999.
24. Godin MS, Waldman SR, Johnson CM Jr. Nasal augmentation using Gore-Tex. A 10-year ex-
perience. Arch Facial Plast Surg 1:118-121; discussion 122, 1999.
25. Veith FJ, Gupta SK. Expanded polytetra uoroethylene vascular grafts. In Rutherford RB, ed.
Vascular Surgery, 2nd ed. Philadelphia: WB Saunders, 1984, pp 394-403.
26. Wantz GE. Abdominal wall hernias. In Schwartz SI, Shires GT, Spencer FC, eds. Principles of
Surgery, 6th ed. New York: McGraw-Hill, 1994, pp 1538-1539.
27. Livesay SA, Herndon DN, Hollyoak MA, et al. Transplanted acellular autograft dermal matrix.
Potential as a template for the reconstruction of viable dermis. Transplantation 60:1-9, 1995.
28. Harper C. Permacol: Clinical experience with a new biomaterial. Hosp Med 62:90-95, 2001.
29. Butler CE, Langstein HN, Kornowitz SJ. Pelvic, abdominal, and chest wall reconstruction with
AlloDerm in patients at increased risk for mesh-related complications. Plast Reconstr Surg
116:1263-1275, 2005.
The use of polypropylene mesh in the reconstruction of trunk defects increases complication rates when
the mesh is placed directly over viscera or the operative site has been irradiated or contaminated with
bacteria. An alternative is AlloDerm (decellularized human cadaveric dermis), which becomes vascu-
larized and remodeled into autologous tissue after implantation. When used for fascial reconstruc-
tion, AlloDerm forms a strong repair, causes minimal abdominal adhesions, and resists infection. They
did a retrospective study of cancer patients at increased risk for mesh-related complications who under-
went trunk reconstruction with AlloDerm. The indications, defect characteristics, reconstructive tech-
niques, complications, and surgical outcomes were evaluated.AlloDerm can be used successfully in re-
constructions for large, complex pelvic, chest, and abdominal wall defects even when placed directly over
viscera and when the operative eld is irradiated and/or contaminated with bacteria.
30. Ueno T, Picket LC, de la Fuente SG, et al. Clinical application of porcine small intestinal sub-
mucosa in the management of infected or potentially contaminated abdominal defects. J Gas-
trointest Surg 8:109-112, 2004.
31. Buinewicz B, Rosen B. Acellular cadaveric dermis (AlloDerm): A new alternative for abdom-
inal hernia repair. Ann Plast Surg 52:188-194, 2004.
32. Hirsch EF. Repair of an abdominal wall defect after a salvage laparotomy for sepsis. J Am Coll
Surg 198:324-328, 2004.
33. Glasberg SB, D’Amico RA. Use of regenerative human acellular tissue (AlloDerm) to recon-
struct the abdominal wall following pedicle TRAM ap breast reconstruction surgery. Plast
Reconstr Surg 118:8-15, 2006.
1819
Chapter 44 Reoperative Surgery of the Abdominal Wall

1820
PART V R EOPERATIVE SURGERY OF THETRUNK
34. Nyhus LM. The recurrent groin hernia: Therapeutic solutions. World J Surg 13:541-544, 1989.
35. Richards PC, Balch CM, Aldrete JS. Abdominal wound closure. Ann Surg 197:238-243, 1983.
36. Ger R, Duboys E. The prevention and repair of large abdominal wall defects by muscle trans-
action: A preliminary communication. Plast Reconstr Surg 72:170-175, 1983.
Abdominal wall defects, whether occurring as perioperative or postoperative phenomena, have been var-
iously managed. Where the defect cannot be repaired by the use of the patient’s own tissues, synthetic
material is commonly used. Where both the preceding are unsuccessful, closure by means of muscles
transferred from the thigh should be considered. Muscles have distinct advantages over fascial grafts or
synthetic materials; they are dynamic structures that are effective in controlling hernias, may relieve
symptoms in symptomatic scoliosis resulting from the muscle loss, and may improve bowel action by
improving expulsive abdominal efforts. Preliminary experience is presented, together with details of the
operative technique.
37. Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal
wall defect: An anatomic and clinical study. Plast Reconstr Surg 86:519-526, 1990.
Closure of large abdominal wall defects usually requires the transposition of remote myocutaneous aps
or free tissue transfers. The purpose of this study was to determine whether separation of the muscle
components of the abdominal wall would allow mobilization of each unit over a greater distance than
possible by mobilization of the entire abdominal wall as a block. This study suggests that large ab-
dominal wall defects can be reconstructed with functional transfer of abdominal wall components with-
out the need for resorting to distant transposition of free muscle aps.
38. Thomas WO, Parry SW, Rodning CD. Ventral/incisional abdominal herniorrhaphy by fascial
partition/release. Plast Reconstr Surg 91:1080-1086, 1993.
39. Dibello JN Jr, Moore JH Jr. Sliding myofascial ap of the rectus abdominus muscles for the clo-
sure of recurrent ventral hernias. Plast Reconstr Surg 98:464-469, 1996.
40. Shestak KC, Edington HJ, Johnson RR. The separation of anatomic components technique for
the reconstruction of massive midline abdominal wall defects: Anatomy, surgical technique,
applications, and limitations revisited. Plast Reconstr Surg 105:731-738, 2000.
41. Lowe JB, Garza JR, Bowman JL, et al. Endoscopically assisted components separation for clo-
sure of abdominal wall defects. Plast Reconstr Surg 105:720-729, 2000.
42. Maas SM, van Engel M, Leeksma NG, et al. A modi cation of the components separation
technique for the closure of abdominal wall defects in the presence of an enterostomy. J Am
Coll Surg 189:138-140, 1999.
43. Houston GC, Drew GS, Vazquez B, et al. The extended latissimus dorsi ap in repair of ante-
rior abdominal wall defects. Plast Reconstr Surg 81:917-924, 1988.
44. Given K. Personal communication, July 1993.
45. Ohtsuka H, Ochi K, Seike H. Reconstruction of the large lateral abdominal wall defect with
an iliolumbar bipedicle ap. Br J Plast Surg 37:327-329, 1984.
46. Bostwick J III, Hill HL, Nahai F. Repairs in the lower abdomen, groin, or perineum with myo -
cutaneous or omental aps. Plast Reconstr Surg 63:186-194, 1979.
47. Hershy FB, Butcher HP. Repair of defects after partial resection of the abdominal wall. Am J
Surg 107:586, 1964.
48. Sensoz O, Ustuner TE, Taner OF. Use of a sartorius myocutaneous ap for reconstruction of
a large full-thickness abdominal wall defect. Ann Plast Surg 25:193, 1990.
49. Core G, Kline R, Finan M. The turbo gracilis ap for perineal reconstruction. Presented at the
Annual Meeting of the American Society of Reconstructive Microsurgery, Kansas City, MO,
Sept 1993.
50. Caffee H. Reconstruction of the abdominal wall by variations of tensor fascia lata ap. Plast Re-
constr Surg 71:348-351, 1983.
51. O’Hare PM, Leonard AG, Brenneb MD. Experience with the tensor fasciae latae free ap. Br
J Plast Surg 36:98-104, 1983.
52. Song YG, Chen GZ, Song YL. The free thigh ap: A new free ap concept based on the septo -
cutaneous artery. Br J Plast Surg 37:149-159, 1984.

53. Kimata Y, Uchiyama K, Sekiido M, et al. Anterolateral thigh ap for abdominal wall reconstruc-
tion. Plast Reconstr Surg 103:1191-1197, 1999.
54. Sasaki K, Nozaki M, Nakazawa H, et al. Reconstruction of a large abdominal wall defect us-
ing combined free tensor fasciae latae musculocutaneous ap and anterolateral thigh ap. Plast
Reconstr Surg 102:2244-2252, 1998.
55. Ninkovic M, Stenzl A, Hess M, et al. Free innervated latissimus dorsi muscle ap for recon-
struction of full-thickness abdominal wall defects. Plast Reconstr Surg 101:971-978, 1998.
56. Koshima I, Nanba Y, Tutsui T, et al. Dynamic reconstruction of the abdominal wall using a
reinnervated free rectus femoris muscle transfer. Ann Plast Surg 43:199-203, 1999.
57. Clement R, Young LV, Marsh JL. Use of greater omentum as a vascular supply for free ap
transfer. Plast Reconstr Surg 74:131, 1984.
58. Earle AS, Feng LJ, Jordan RB. Long saphenous vein grafts as an aid to microsurgical reconstruc-
tion of the trunk. J Reconstr Microsurg 62:165-169, 1990.
59. Scott BG, Feanny MA, Hirschberg A. Early de nitive closure of the open abdomen: A quiet
revolution. Scand J Surg 94:9-14, 2005.
Contrary to the management strategy previously recommended, temporarily covering the open ab-
domen with an absorbable mesh or a plastic sheath without preserving the peritoneal space is no
longer considered in the patient’s best interest. The use of the VACuum pack, in conjunction with
VACuum-assisted wound management and new biological prostheses now offer patients with an
open abdomen a better and simpler alternative to the giant “planned ventral hernia.”The new con-
cepts and technologies presented in this review, when widely adopted, will rapidly translate into safer
and better management of the patient with an open abdomen.
60. Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum-assisted closure: A new method
for wound control and treatment. Animal studies and basic foundation. Ann Plast Surg 38:553-
562, 1997.
61. Weed T, Ratliff C, Drake D. Quantifying bacterial bioburden during negative pressure wound
therapy: Does the wound VAC enhance bacterial clearance? Ann Surg 52:276-280, 2004.
62. Herscovici D Jr, Sanders RW, Scaduto JM, et al. Vacuum-assisted wound closure (VAC therapy)
for the management of patients with high-energy soft tissue injuries. J Orthop Trauma 17:683-
688, 2003.
63. Stone PA, Hass SM, Flaherty SK, et al. Vacuum-assisted closure for patients with abdominal
trauma. J Trauma 57:1082-1086, 2004.
64. Byrd HS, Hobar TC. Abdominal wall expansion and congenital defects. Plast Reconstr Surg
84:347-352, 1989.
65. Hobar PC, Rohrich RJ, Byrd HS. Abdominal wall reconstruction with expanded musculofas-
cial tissue in a post-traumatic defect. Plast Reconstr Surg 94:379-383, 1994.
66. Flint LM, Vitale GC, Richardon JD, et al. The injured colon. Relationships of management to
complications. Ann Surg 193:619, 1981.
67. Sugrue M. WSACS Consensus de nitions for abdominal compartment syndrome. Curr Opin
Crit Care 11:333-338, 2005.
68. Fagnieze PL, Hay JM, Lacaine F, et al. Abdominal midline incision closure. Arch Surg 120:
1351-1353, 1985.
69. Wissing J, Van Vroonhoven ThJMV, Schattenkerk ME, et al. Fascia closure after midline lapa -
rotomy: Results of a randomized trial. Br J Surg 74:738-741, 1987.
70. Greenberg C, Saik P, Peskin GW. Wound dehiscence—pathophysiology and prevention. Arch
Surg 189:345-352, 1979.
71. Gels WP, Salatta JD. Lumbar hernia. In Nyhus LM, Condon RD, eds. Hernia, 3rd ed. Philadel-
phia: JB Lippincott, 1989, pp 401-415.
1821
Chapter 44 Reoperative Surgery of the Abdominal Wall

1822
PART V R EOPERATIVE SURGERY OF THETRUNK
1. Classify the following defect: A 12 cm resection of dermato brosarcoma protu-
berans in a lumbar triangle area, including deep fascia and muscle.
a. Acute phase/absolute tissue de ciency/partial-thickness defect/deep non-
functional loss/clean wound
b. Acute phase/relative tissue de ciency/partial-thickness defect/deep func -
tional loss/clean wound
c. Acute phase/absolute tissue de ciency/partial-thickness defect/deep func -
tional loss/clean wound
d. Acute phase/absolute tissue de ciency/partial-thickness defect/deep non-
functional loss/contaminated wound
e. None of the above
2. Classify the following defect: An open abdominal wound 2 weeks status post -
laparotomy for blunt abdominal trauma with inability to close at laparotomy
and secondary enterocutaneous stula.
a. Chronic phase/absolute tissue de ciency/ full-thickness defect/dirty
wound
b. Subacute phase/relative tissue de ciency/ full-thickness defect/dirty
wound
c. Subacute phase/absolute tissue de ciency/partial-thickness defect/deep
functional loss/contaminated wound
d. Chronic phase/absolute tissue de ciency/ full-thickness defect/dirty
wound
e. None of the above
3. Which of the following materials are tolerant to infection in the wound envi-
ronment?
a. Mersilene mesh
b. Porcine intestinal submucosa (SIS)
c. Prolene mesh
d. Gore-Tex dual mesh
e. None of the above
4. Which method of repair would yield the least likelihood of a recurrence for giant
ventral hernia with loss of domain?
a. Components separation method
b. Primary fascia closure with running Nova l suture
c. Component separation method reinforced with overlay Prolene mesh
d. Giant prosthetic reinforcement of the visceral sac with Gore-Tex dual
mesh
e. Expanded tensor fasciae latae ap with secure fascial closure in an inter-
rupted fashion
R EVIEW QUESTIONS

1823
Chapter 44 Reoperative Surgery of the Abdominal Wall
5. Application of VAC wound therapy has been shown to be effective in which set-
ting?
a. Acute wound dehiscence from laparotomy
b. Open abdominal wound after debridement from necrotizing fasciitis with
12 cm full-thickness injury
c. Partial-thickness defect of skin subcutaneous tissue and nonfunctional fas-
cial component after removal of infected Prolene mesh
d. All of the above
e. None of the above

(Trang không có chữ)