Atlas Phẫu Thuật Vi Phẫu Mạch Máu (Atlas of Microvascular Surgery)

Enhancing the Donor Site after
Harvesting (Fig. 10–11)
To prevent herniation at the donor site, the defect in the
anterior sheath should be repaired with synthetic mesh
(5) such as Gor-Tex, Mersilene, Prolene, Marlex, or nylon.
LOWER TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS (TRAM) FLAP
529
Figure 10–11
Enhancing the donor site after harvesting.
5. Synthetic or alloplastic mesh
Note: The lower TRAM ap based on the superior epigastric vessels is commonly
applied in breast reconstruction by local transfer.

MODIFIED LOWER TRAM FLAP
Because the m ajor paraum bilical perforators are lo-
cated in the medial two thirds of the rectus muscle, the
lateral third of the rectus muscle and its anterior sheath
can be saved in situ without damage to the circulation
of the inferior TRAM ap. The defect can be closed di-
rectly, allowing for a more adequate closure.
Dividing the Muscle (Fig. 10–12)
Leaving the lateral third of the muscle and sheath in situ,
the medial portion (1) is divided superiorly and then
turned inferiorly to identify the vascular pedicle (3).
530
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Figure 10–12
Dividing the muscle.
1. Rectus abdominis m.
3. DIEA
2. Sheath of rectus
4. External oblique m.

Flap Elevation and Pedicle Dissection
(Fig. 10–13)
The pedicle of the deep inferior epigastric vessels (3) is
isolated. The medial portion of the muscle (1) is divided
at ~8 cm from the upper cut portion. The m odi ed
lower TRAM ap is raised.
MODIFIED LOWER TRAM FLAP
531
Figure 10–13
Flap elevation and pedicle dissection.
1. Rectus abdominis m.
2. Sheath of rectus
3. DIEA

THORACOUMBILICAL FLAP
The extended deep inferior epigastric ap is designed
on an axis between the umbilicus and the inferior angle
of the scapula. Its medial edge is placed on or over the
midline, running upward and laterally as far as the axil-
lary line or even the posterior axillary line. Flap width
ranges from 8 to 20 cm.
For drawing the design of the ap, see type D of the
rectus abdominis myocutaneous aps (Fig. 10–7).
Elevation of the Lateral Part of the
Flap (Fig. 10–14)
The lateral part of the ap is raised from the chest wall
and external oblique muscle (4) up to the lateral edge of
532
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Figure 10–14
Elevation of the lateral part of the ap.
1. Rectus abdominis m.
2. Sheath of rectus
4. External oblique m.
the rectus muscle (1). The fascial areolar layer on the
undersurface of the subcutaneous ap is preserved in
the ap.
A disk of the anterior sheath (2) through which the
paraumbilical perforators emerge is incised along the
upper and lower borders of the skin ap and beside
the midline and lateral edge of the rectus muscle, leaving
0.5 to 1.0 cm fringes on the medial and lateral borders for
later repair. Care should be taken to keep this disk with
both muscle and skin ap intact, and not to damage the
perforators between them. It is advisable that several
tacking stitches be made immediately after the disk of
anterior sheath is created.

Identi cation of the Vascular Pedicle
(Fig. 10–15)
A paramedian incision on the lower part of the rectus is
used to expose the muscle (1) and to identify the deep
inferior epigastric vessels (3). The rectus m uscle (1) is
divided along the upper border of the ap and dissected
down from its posterior wall.
THORACOUMBILICAL FLAP
533
Figure 10–15
Identi cation of the vascular pedicle.
1. Rectus abdominis m.
3. DIEA
2. Sheath of rectus
4. External oblique m.

Detaching the Muscle and Completing
the Flap (Fig. 10–16)
The muscle (1) can be retained in the vascular pedicle
(3), with its origin detached from the pubis, or sepa-
rated from the vascular stalk for a distance necessary to
avoid bulkiness. The rst m ethod is simple, rapid, and
safe. The defect of the anterior sheath superior to the
arcuate line does not require repair.
534
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Figure 10–16
Detaching the muscle and completing
the ap.
1. Rectus abdominis m.
2. Sheath of rectus
3. DIEA
4. External oblique m.

DEEP INFERIOR EPIGASTRIC
PERFORATOR (DIEP) FLAP
This is a m odi cation at this donor site that excludes
the rectus m uscle and takes only the skin ap connect-
ing with the vascular pedicle by the paraum bilical per-
forators. The DIEP ap is less bulky; the rectus m uscle,
for the most part, is kept intact, reducing the abdominal
wall com plications to w hich the TRAM flap m ay be
subject.
Doppler Detection (Fig. 10–17)
Preoperatively, it is preferable to detect and mark the
location(s) of the paraum bilical perforator(s) (5) by
Doppler rheometer. First, the area of each rectus abdo-
DEEP INFERIOR EPIGASTRIC PERFORATOR (DIEP) FLAP
535
Figure 10–17
Doppler detection.
1. DIEA
2. Deep superior epigastric a.
3. Lateral branch of DIEA
4. Medial branch of DIEA
5. Paraumbilical perforator
6. Rectus abdominis m.
7. Sheath of rectus
8. External oblique m.
9. Super cial inferior epigastric v.
10. Branches of the 10th and 11th
intercostal n.
minis muscle (6) is identi ed and is then divided into
six regions by three longitudinal lines and two trans-
verse lines that equally divide the lines between the
xiphoid and pubis. The major perforators from the lat-
eral branch (5) of the deep inferior epigastric vessels (1)
are usually located in the m idlateral region, and the
largest perforator may be at the level of the umbilicus
or a little below in this region. Clinically, especially in
obese wom en, the lateral edge of the muscle may not
be palpable. Doppler detection can be performed in the
area at the level of and below the um bilicus within an
8-cm radius of the umbilicus.

Flap Design (Fig. 10–18)
Based on the paraumbilical area—the mid-third of the
rectus abdominis muscle—in which the major perforators
are included, a skin ap can be designed transversely,
longitudinally, or obliquely, as described for the rectus
abdominis myocutaneous ap. Even the size of each type
of DIEP ap can be comparable to the previously de-
scribed aps. Here, the transverse type of the DIEP ap is
presented as an example of harvesting technique.
536
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Figure 10–18
Flap design (see text for details).

Flap Elevation and Perforator
Identi cation (Fig. 10–19)
Flap elevation starts from its lateral portion at the side
with the DIEA proposed for the vascular pedicle. The
skin with a full layer of subcutaneous tissue is raised
from the deep fascia on the abdominal external oblique
muscle (8) and its aponeurosis. After reaching the lat-
eral border of the rectus sheath (7), the dissection
should be careful to identify the paraumbilical perfora-
tors (5) that are em erging from the anterior sheath.
Markings, which were done with Doppler detector pre-
operatively, are helpful in searching for these perfora-
tors, although they are not always correlated with
ndings during surgery. All the perforators found on
the lateral side are reserved for selection later.
DEEP INFERIOR EPIGASTRIC PERFORATOR (DIEP) FLAP
537
Figure 10–19
Flap elevation and perforator
identi cation.
5. Paraumbilical perforator
7. Sheath of rectus
8. External oblique m.
Figure 10–20
Opposite side ap elevation.
5. Paraumbilical perforator
7. Sheath of rectus
8. External oblique m.
9. Super cial inferior epigastric v.
Opposite Side Flap Elevation
(Fig. 10–20)
The skin ap is then elevated on the opposite side. After
reaching the m edial border of the rectus sheath (7),
care should be taken to nd the medial perforators (5).
It is suggested that the super cial inferior epigastric
vein (9) at the midpoint of the inguinal ligament on this
side be dissected and reserved for possible use in sub-
sequent ap salvage. Venous congestion may occur in
zone IV of this ap in some cases and may cause partial
necrosis.

538
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Selecting Perforators (Fig. 10–21)
Depending on the size of these paraumbilical perforators
(5), one or more of them in the lateral row are usually se-
lected because the lateral branch of the DIEA is dominant
in most cases. The medial row may be chosen only in the
case of very small perforators in the lateral row.
Generally, in the lateral row, a single m ajor perfora-
tor may be found in ~50% of cases, two in ~40%, and
three in ~10% of cases. It is preferable to select the per-
forator em erging from the tendinous intersection at
about the level of the umbilicus, if it exists, because it
is larger and m ore constant and has fewer m uscular
branches for dissection.
Figure 10–21
Selecting perforators.
5. Paraumbilical perforator
7. Sheath of rectus
8. External oblique m.
9. Super cial inferior epigastric v.
Figure 10–22
Flap elevation and pedicle
identi cation.
1. DIEA
5. Paraumbilical perforator
6. Rectus abdominis m.
7. Sheath of rectus
Flap Elevation and Pedicle
Identi cation (Fig. 10–22)
As soon as the perforator(s) (5) are selected, the remain-
ing perforators are ligated or cauterized, and the skin ap
is carefully detached from the abdominal wall, except for
the selected perforator(s) tethered to it.
The anterior rectus sheath (7) is incised around the
perforators, preserving a 0.5-cm rim around them, and
incision continues vertically between the selected per-
forators and inferiorly toward the lower lateral edge of
the sheath; the muscle is exposed.
The lateral sheath (7) is elevated and re ected lat-
erally, and the deep inferior epigastric vessel (1) is iden-
ti ed at the lower lateral border of the muscle (6) and
beneath it.

DEEP INFERIOR EPIGASTRIC PERFORATOR (DIEP) FLAP
539
Intramuscular Dissection of
Perforators (Fig. 10–23)
After the perforators (5) are dissected and the sm all
muscular branches derived from them are ligated, the
rectus muscle (6) is split along the muscle bers. The
perforators (5) are traced to the lateral branch (3) and
the m ain trunk of the deep inferior epigastric vessel (1).
Because the course of the lateral branch is parallel to
the muscle bers, it can be exposed readily by separat-
ing them, with less damage to the rectus muscle.
Nerve Dissection (Fig. 10–24)
Beneath the rectus abdominis muscle (6), one or two
sensory branches (10) are derived from the 10th or 11th
intercostal nerves and may join the paraumbilical per-
forators to supply a limited area of the skin ap. In case
a sensory DIEP ap is needed, the sensory nerve branches
can be separated from their motor branches by retro-
grade dissection to obtain an adequate length.
The motor branch of the intercostal nerve, which
may cross the deep inferior epigastric vessels behind or
in front to supply the medial strip of the muscle, should
be carefully preserved. In m ost instances, it can be
maintained in its continuity; however, in a few cases, a
motor branch passes between two perforators, and it
should be divided and resutured after ap harvesting.
Figure 10–23
Intramuscular dissection of
perforators.
1. DIEA
3. Lateral branch of DIEA
5. Paraumbilical perforator
6. Rectus abdominis m.
7. Sheath of rectus
Figure 10–24
Nerve dissection.
1. DIEA
5. Paraumbilical perforator
6. Rectus abdominis m.
7. Sheath of rectus
10. Branches of the 10th and 11th intercostal n.

540
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Completion of Harvesting (Fig. 10–25)
After the branches (including the m edial branch) de-
rived from the lateral branch and m ain trunk of the
deep inferior epigastric vessels (1) are dissected and
ligated, the connection with the superior epigastric
vessels is divided, and the DIEP skin ap is elevated
with its pedicle passing through the gap of the rectus
muscle (6), to be tethered on the lower lateral wall of
the rectus sheath. Usually, the pedicle length is ~8 to 10
cm at this point, and a few centimeters m ore in length
can be obtained if dissection continues toward its ori-
gin on the external iliac vessels.
Once the recipient site is prepared, the vascular
pedicle is divided and pulled out through the cleavage
of the rectus muscle (6).
Figure 10–25
Completion of harvesting.
1. DIEA
3. Lateral branch of DIEA
5. Paraumbilical perforator
6. Rectus abdominis n.

MODIFIED DIEP FLAP
541
MODIFIED DIEP FLAP
To reduce the time-consuming dissection of the branches
from the perforator, this procedure is designed to take a
small piece of muscle intact with the perforator and the
skin ap.
Perforator Identi cation and Pedicle
Dissection (Fig. 10–26)
The ap can be designed in the same m anner as de-
scribed for the standard DIEP ap. After the largest pa-
raumbilical perforator (5) is identi ed and selected, the
anterior sheath (7) is divided, and the rectus m uscle (6)
is separated along the vertical line below the emerging
point of the perforator; the deep inferior epigastric ves-
sels (1) and their lateral branches (3) are dissected out.
Creating the Muscle Cuff (Fig. 10–27)
With care to protect the connection between the perfo-
rator (5) and the lateral branches (3), the anterior sheath
(7) and rectus muscle (6) are divided in a circle around
the perforator as a center, with a radius of ~1 cm.
Figure 10–26
Perforator identi cation and pedicle
dissection.
1. DIEA
3. Lateral branch of DIEA
5. Paraumbilical perforator
6. Rectus abdominis m.
7. Sheath of rectus
8. External oblique m.
Figure 10–27
Creating the muscle cuff.
1. DIEA
3. Lateral branch of DIEA
6. Rectus abdominis m.
7. Sheath of rectus

542
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Completion of Harvesting (Fig. 10–28)
After the continuation of the lateral branch (3) is ligated,
the modi ed DIEP skin ap, with a small 2 cm
2 cm
muscle segment, is ready for transfer.
Figure 10–28
Completion of harvesting.
1. DIEA
3. Lateral branch of DIEA
6. Rectus abdominis m.
7. Sheath of rectus

GREATER OMENTUM TRANSFER
543
GREATER OMENTUM TRANSFER
Anatomy (Fig. 10–29)
The largest peritoneal fold of the omentum is composed
of four layers. It always contains some adipose tissue
that is present in considerable quantity in obese pa-
tients. The two layers that descend from the stomach (1)
and beginning of the duodenum pass downward in front
of the small intestine for a variable distance. They then
fold over and ascend as far as the anterosuperior aspect
of the transverse colon. The function of the omentum is
to limit the spread of infection in the peritoneal cavity.
Measurements
Males
Females
Average
Range
Average
Range
Length (cm)
25
14–36
24
14–34
Width (cm)
35
23–46
33
20–46
Blood Supply
The right and left gastroepiploic arteries (6,5) are the
term inal branches of the gastroduodenal and splenic
arteries (3,4), respectively. They course along the greater
Figure 10–29
Anatomy for greater
omentum transfer.
1. Stomach
2. Spleen
3. Gastroduodenal a.
4. Splenic a.
5. Left gastroepiploic a.
6. Right gastroepiploic a.
7. Gastroepiploic arterial arch
8. Accessory omental a.
9. Right omental a.
10. Middle omental a.
11. Left omental a.

544
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
curvature of the stomach (1) and anastomose with each
other, forming the gastroepiploic arterial arch (7) that
lies about a ngerbreadth from the greater curvature
between its anterior two layers.
From the gastroepiploic arterial arch (7), several short
branches arise upward to the greater curvature of the
stomach, and the three major omental arteries—right (9),
middle (10), and left (11)—go downward to the greater
omentum. The middle omental artery (10) at its terminal
portion branches into right and left terminal segments that
anastomose with the corresponding branches of the right
and left omental arteries (9,11) to form the arterial network
of the great omentum. On the right side, there is an acces-
sory omental artery (8) that branches from the right gas-
troepiploic artery and does not join the arterial network.
The right gastroepiploic artery is the dominant vessel.
Measurements
Diameter (mm)
Average
Range
Right gastroepiploic
Artery
2.8
1.5–2.5
Vein
3.2
1.5–4.5
Left gastroepiploic
Artery
1.8
1.0–3.0
Vein
2.4
1.0–4.5
The greater om entum has an abundant blood supply
and lymphatic circulation. It therefore can eliminate or
limit infection and, when used as a donor, can improve
circulation at the recipient site, as in the treatment of
radionecrotic lesions. A large amount of soft tissue is
available, and sizeable defects can be reconstructed. A
single procedure using a split-thickness skin graft to
cover the transfer is also possible. In addition, the
omental transfer is especially useful in lling depressed
areas such as occur in hemifacial microsomia. With a
clear and constant anatomy, harvesting is easy and an
excellent vascular pedicle allows facile transfer with
microsurgical techniques. Postoperative atrophy of the
transplanted om entum is not a usual expectation.
The compound ap of stomach and om entum pro-
vides a vascularized tube with a plenitude of soft tissue,
especially useful in reconstructing pharyngoesophageal
defects with heavily irradiated surrounding tissue. Re-
m oval of the gastric ap may reduce the stom ach to a
diam eter of 2.5 cm , but without functional conse-
quences. Still, the acid secretion of the gastric ap may
irritate the lower esophagus.
Despite its advantages, use of the omentum may
not be a rst choice. Laparotomy can lead to complica-
tions such as peritonitis, adhesion, or even volvulus. On
occasion, the omentum may not incorporate with re-
cipient soft tissue; several pull-out bolster sutures are
advisable in augmentation procedures to prevent grav-
itational pull from m oving the transfer. Other con-
traindications are a history of abdom inal disease or
previous abdominal surgery.
COMMENT AND INSIGHTS

FREE OMENTUM TRANSFER
545
FREE OMENTUM TRANSFER
Incision (Fig. 10–30)
An upper middle abdominal incision is m ade.
Delivering the Omentum (Fig. 10–31)
The greater omentum is delivered from the abdom inal
cavity, and the stom ach (2) and right and left gastroepi-
ploic vessels (4,5) are identi ed.
Figure 10–31
Delivering the omentum.
2. Stomach
4. Right gastroepiploic a.
5. Left gastroepiploic a.
6. Accessory omental a.
7. Right omental a.
8. Middle omental a.
9. Left omental a.
Figure 10–30
Incision.
1. Transverse colon
2. Stomach
3. Small intestine
4. Right gastroepiploic a.
5. Left gastroepiploic a.
6. Accessory omental a.
7. Right omental a.
8. Middle omental a.
9. Left omental a.

546
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Separation from the Colon
(Fig. 10–32)
All the short branches from the gastroepiploic arterial
arch to the greater curvature of the stom ach (2) are
ligated and divided. The om entum is separated from
the transverse colon (1) in an avascular plane.
Figure 10–32
Separation from the colon.
1. Transverse colon
2. Stomach
3. Small intestine
4. Right gastroepiploic a.
5. Left gastroepiploic a.
6. Accessory omental a.
7. Right omental a.
8. Middle omental a.
9. Left omental a.

FREE OMENTUM TRANSFER
547
Isolating the Omentum on the Pedicle
(Fig. 10–33)
The left gastroepiploic vessels (5) are ligated, and an
om ental ap is isolated on the right gastroepiploic ves-
sels (4) with a pedicle length of 9 to 12 cm.
Figure 10–33
Isolating the omentum on the pedicle.
1. Transverse colon
2. Stomach
3. Small intestine
4. Right gastroepiploic a.
5. Left gastroepiploic a.

548
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
EXTENDING GREATER OMENTUM
Tailoring Route (Fig. 10–34)
If it is necessary to cover a long defect at the recipient
site, or for local transfer, om ental length can be ex-
tended using the following technique.
The gastroepiploic arterial arch (5) is ligated and
divided between the origins of the right and m iddle
omental arteries (6,7). The middle omental artery (7) is
ligated and divided at a point before it gives off the
right and left terminal branches.
Figure 10–34
Tailoring route.
1. Stomach
2. Right gastroepiploic a.
3. Accessory omental a.
4. Left gastroepiploic a.
5. Gastroepiploic arterial arch
6. Right omental a.
7. Middle omental a.
8. Left omental a.

EXTENDING GREATER OMENTUM
549
Extending the Omentum (Fig. 10–35)
Referring to the arrow line in Fig. 10–34, omental length
can be increased without damage to the blood supply.
Figure 10–35
Extending the omentum.
2. Right gastroepiploic a.
4. Left gastroepiploic a.
5. Gastroepiploic arterial arch
7. Middle omental a.
8. Left omental a.

550
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
COMPOSITE FLAP OF STOMACH
AND OMENTUM
Exposure of the Posterior Wall of
Stomach (Fig. 10–36)
The greater omentum (7) is separated from the trans-
verse colon (1) and mesocolon, and the left gastroepi-
ploic vessel (5) is ligated. The posterior wall of the
stomach (3) is exposed.
Figure 10–36
Exposure of the posterior wall of stomach.
1. Colon
6. Lesser sac
2. Small intestine
7. Greater omentum
3. Stomach
8. Omental a.
4. Right gastroepiploic a.
9. Gastroepiploic arterial arch
5. Left gastroepiploic a.

COMPOSITE FLAP OF STOMACH AND OMENTUM
551
Cross-Sectional Diagram (Fig. 10–37)
The preceding procedure is diagrammed in cross section.
Figure 10–37
Cross-sectional diagram.
1. Colon
3. Stomach
6. Lesser sac
7. Greater omentum
8. Omental a.
9. Gastroepiploic arterial arch

552
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Clamping the Stomach (Fig. 10–38)
The right gastroepiploic vessel (4) is isolated, and the
stomach (3) is clamped on the body and fundus, paral-
lel to the greater curvature. The distance between the
edge of the curvature and the clamp is 4 cm. The largest
available dimensions of the stomach ap are ~13 cm in
length and 8 cm in width.
Figure 10–38
Clamping the stomach.
3. Stomach
4. Right gastroepiploic a.
7. Greater omentum
9. Gastroepiploic arterial arch

COMPOSITE FLAP OF STOMACH AND OMENTUM
553
Excision of the Stomach (Fig. 10–39)
The gastric ap (3) is excised in continuity with the
greater om entum (7), preserving the short gastric ves-
sels that supply the ap at this level. The stomach is
closed in two layers with deep interrupted extramu-
cosal sutures and running super cial sutures.
Figure 10–39
Excision of the stomach.
1. Colon
2. Small intestine
3. Stomach
7. Greater omentum

554
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Prefabrication to a Tube (Fig. 10–40)
The ap is immersed in a chilled heparinized solution
and is stitched into a tube before transfer to the recipi-
ent site.
Figure 10–40
Prefabrication to a tube.
3. Stomach
4. Right gastroepiploic a.
7. Greater omentum
9. Gastroepiploic arterial arch

FREE JEJUNUM TRANSFER
555
FREE JEJUNUM TRANSFER
Anatomy (Fig. 10–41)
The duodenal jejunal exure is located to the left of the
aorta at the level of the upper border of the second
lum bar vertebra. It is xed by a brom uscular band,
termed the ligam ent of Treitz, that arises from the right
crus of the diaphragm , close to the right side of the
esophagus. The jejunum comprises the rst two fths
of the 7 cm length from the duodenal jejunal exure to
the ileocecal valve. Jejunal diameter is ~4 cm.
The mesentery is fan-shaped and its vertebral root
is ~15 cm long. It is attached to the posterior abdominal
wall along a line running from the left side of the sec-
ond lumbar vertebral body to the right sacroiliac joint.
The average width from the vertebral to the intestinal
border is ~20 cm, but it is widest in the middle.
Blood Supply
There are an average of ve jejunal branches (7) from
the superior mesenteric artery (6), with a total of ~12 to
15 branches to the jejunum and ileum (2). They run
almost parallel to one another between the mesenteric
Figure 10–41
Anatomy for free jejunum
transfer.
1. Stomach
2. Small intestine (jejunum and ileum)
3. Colon
4. Duodenum
5. Aorta
6. Superior mesenteric a.
7. Jejunal branch
8. Arterial arcade
9. Vasa recta

556
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
layers, each vessel dividing into two, which unite with
adjacent branches to form a series of arcades (8). From
the term inal arcade, numerous vasa recta (9) pass to the
mesenteric border of the jejunum. Usually, the upper
portion of the jejunum contains a single arcade giving
off long vasa recta; the lower portion contains two to
three arcades giving off shorter vasa recta; and the ter-
m inal ileum contains four arcades giving off m uch
shorter vasa recta.
The rst intestinal branch is usually not selected as
a vascular pedicle for the following reasons. As a varia-
tion, it frequently has a common stem with the inferior
pancreatic duodenal artery. The pedicle length is short
and its origin much too high and deep. Also, the length
of the intestinal segment it supplies is short and some-
times lacks an arcade.
The second, third, and fourth intestinal branches
are preferred choices, and the m ost common choice is
the second.
Measurements
Intestinal Branches of
Superior Mesenteric Vessels
#1
#2
#3
#4
Average diameter (mm)
Artery
3.5
3.8
4.0
4.3
Vein
5.0
5.0
5.0
5.0
Length of pedicle (cm)
25
36
4.5
4.3
Average no. arcades
1.5
2.4
2.7
3.2
Length of intestinal
37
53
60
100
segment supplied (cm)
The main application of free jejunum transfer remains
the reconstruction of defects following extensive exci-
sion of the hypopharynx and cervical esophagus, as
well as the replacem ent of oral mucosa. The removal of
a jejunal segment does not affect digestive or absorbent
functions.
Earlier reports endorsed the application of free
ileum , colon, or gastric antrum for reconstruction of
conduits in the hypopharynx and esophagus. However,
these procedures have lost favor because the removal of
ileum may result in a malabsorption syndrome. In addi-
tion, the dimensions of the colon and gastric antrum
are too large to match the esophagus, and there is also a
higher risk in colon surgery.
With the use of the free jejunum transfer, compli-
cations following laparotomy may include peritonitis or
adhesions, am ong other sequelae. Contam ination
should be stringently avoided throughout the proce-
dure. Needless to emphasize, the clinician should be
well experienced in all aspects of abdominal surgery.
COMMENT AND INSIGHTS

FREE JEJUNUM TRANSFER
557
Harvesting Technique
Incision (Fig. 10–42)
Depending on the surgeon’s preference, an upper mid-
line incision is made, or a paramedian or transverse in-
cision may be used.
Figure 10–42
Incision.
1. Jejunum
2. Duodenal jejunal exure
3. First jejunal branch
4. Second jejunal branch
5. Third jejunal branch
Delivering the Jejunum (Fig. 10–43)
The abdomen is entered, the upper part of the small in-
testine is delivered, and the duodenal jejunal exure (2)
is identi ed. The intestinal branches (3,4,5) of the supe-
rior mesenteric vessels are carefully inspected, and the
second intestinal branch (4), with its arcades and vasa
recta, is identi ed and evaluated.
Figure 10–43
Delivering the jejunum.
1. Jejunum
2. Duodenal jejunal exure
3. First jejunal branch
4. Second jejunal branch
5. Third jejunal branch

558
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Emptying and Clamping the Jejunum
(Fig. 10–44)
Depending on the main distribution of the second in-
testinal branch (4) and recipient site requirements, 10
to 20 cm or more of jejunum (1) can be harvested. The
jejunum is emptied manually.
Figure 10–44
Emptying and clamping the jejunum.
1. Jejunum
2. Duodenal jejunal exure
3. First jejunal branch
4. Second jejunal branch
5. Third jejunal branch

FREE JEJUNUM TRANSFER
559
Dividing the Jejunum, and Pedicle Dissection
(Fig. 10–45)
Intestinal clamps are applied to both sides of the jejunal
segment (1) and it is divided. The mesentery is sepa-
rated between the vasa recta and between the rst, sec-
ond, and third intestinal branches (3,4,5). The arcades
beyond the jejunal segm ent are ligated. The vascular
pedicle can be dissected up to its origin at the superior
mesenteric artery.
Figure 10–45
Dividing the jejunum, and pedicle dissection.
1. Jejunum
2. Duodenal jejunal exure
3. First jejunal branch
4. Second jejunal branch
5. Third jejunal branch

560
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Restoration of the Jejunum (Fig. 10–46)
The free jejunal segment (1) is then bathed in saline
slush solution for 5 to 10 minutes before transfer to the
recipient site. Intestinal continuity is restored with an
end-to-end jejunal anastomosis.
Figure 10–46
Restoration of the jejunum.
1. Jejunum
4. Second jejunal branch
Note: The proximal end of the jejunal segment should be marked to insure isoperistaltic
anastomosis at the recipient site and to avoid regurgitation. Also, only the antimesenteric
border can be incised for enlarging the proximal stoma of the jejunal segment, to reconstruct
a pharyngeal defect or to create a free intestinal patch to replace intraoral lining.

RECIPIENT SITE EXPOSURES
561
RECIPIENT SITE EXPOSURES
Deep Inferior Epigastric Artery
Incision (Fig. 10–47)
A param edian incision below the um bilical level is
made, extending inferomedially to the pubic symphysis.
Exposure of the Rectus Sheath (Fig. 10–48)
The anterior sheath (2) of the rectus abdom inis and
aponeurosis of the oblique abdominis (1) are identi ed.
Care should be taken not to injure the spermatic cord
(3) in the lower part of the incision.
Figure 10–47
Incision.
1. Oblique abdominis (aponeurosis and muscle)
2. Rectus sheath
3. Spermatic cord
4. Rectus abdominis m.
5. DIEA and v.
6. Arcuate line
7. External iliac a. and v.
Figure 10–48
Exposure of the rectus sheath.
1. Oblique abdominis (aponeurosis and
muscle)
2. Rectus sheath
3. Spermatic cord

562
III.10 TRUNK: ABDOMINAL WALL AND CAVITY
Exposure of the Rectus Muscle
(Fig. 10–49)
The anterior wall of the rectus sheath (2) is divided lon-
gitudinally near its lateral border, and the rectus abdo-
minis (4) and its lateral edge are then exposed.
Identi cation of DIEA (Fig. 10–50)
Using sharp and blunt dissection behind the rectus ab-
dominis muscle (4), its lateral edge is ipped and the
DIEA and vein (5) are visualized behind the lower edge
of the muscle.
Figure 10–49
Exposure of the rectus muscle.
1. Oblique abdominis (aponeurosis and muscle)
2. Rectus sheath
4. Rectus abdominis m.
Figure 10–50
Identi cation of DIEA.
4. Rectus abdominis m.
5. DIEA and v.
6. Arcuate line

RECIPIENT SITE EXPOSURES
563
Dissection of DIEA (Fig. 10–51)
The deep inferior epigastric vessels (5) are dissected to
their origin from the external iliac vessels (7).
Figure 10–51
Dissection of DIEA.
4. Rectus abdominis m.
5. DIEA and v.
7. External iliac a. and v.

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LATISSIMUS DORSI FLAP
Anatomy
Description of Latissimus Dorsi Muscle
(Figs. 11–1, 11–2)
Origin. The origin of the muscle is the spinous processes
T7-12, L1-5, and sacrum; the posterior part of the iliac
crest; and the external surface of the four inferior ribs.
Insertion. In the axilla, the m uscle spirals 180°
around the teres major and inserts on the intertubercu-
lar groove in front of the proximal humerus.
Functions of the muscle include extension, adduc-
tion, rotation of the arm m edially, and drawing the
shoulder downward and backward.
The muscle is at, broad, and triangular. Its length
is 38 cm, its width is 20 cm, and its thickness is 0.8 cm.
Blood Supply
Anatomy of the Thoracodorsal Vessels
The dominant blood supply to the muscle is the thora-
codorsal artery (3), the continuation of the subscapular
artery (2), which arises from the third portion of the ax-
illary artery (1). At ~3 cm from its origin, the subscapular
artery divides into the circum ex scapular artery (4) that
courses posteriorly through the triangular space, and the
thoracodorsal artery (3) that continues inferiorly to sup-
ply the latissimus dorsi (7) as a dominant vessel.
The entrance of the thoracodorsal artery (3) to the
muscle is located, on average, 8.7 cm (range, 6.0 to 11.5
cm) distal to the origin of the subscapular artery, and
~2.6 cm (range, 1 to 4 cm) medial to the lateral border
of the muscle. After its entrance, the thoracodorsal ar-
tery im m ediately divides into the lateral and m edial
branches (5,6). The lateral branch (5) is usually the
larger; it courses parallel to the lateral border of the
m uscle, keeping ~2.1 cm m edial to the border. Within
the distal part of the muscle, the lateral branch gives off
one or more branches that parallel the m edial branch.
The m edial branch (6) courses parallel to the upper bor-
der of the muscle, remaining ~3.5 cm below and paral-
lel to the upper border at a 45° angle to the lateral
branch.
Before its entrance to the muscle, the thoracodor-
sal artery gives off a branch to the serratus anterior
m uscle. (Refer to Chapter 9 for details.) Between the cir-
cum ex scapular artery and the branch to the serratus
anterior muscle, there is an angular artery, which m ay
arise from the thoracodorsal artery or from the branch
to the serratus anterior, going toward the lateral border
of the scapula. (See Fig. 11–5 for details.)
There is only a single vena comitans accompanying
the thoracodorsal artery.
The latissimus dorsi is also supplied segm entally
by a minor pedicle from the intercostal and lum bar ar-
teries that enter the deep surface of the posterior part
of the muscle.
11
Back

572
III.11 TRUNK: BACK
Figure 11–1
Overview of the latissimus dorsi muscle and its blood supply.
1. Axillary a.
5. Lateral branch of thoracodorsal a.
2. Subscapular a.
6. Medial branch of thoracodorsal a.
3. Thoracodorsal a.
7. Latissimus dorsi m.
4. Circum ex scapular a.
8. Teres major m.

LATISSIMUS DORSI FLAP
573
Figure 11–2
Anatomic relationship of the subscapular-thoracodorsal artery
and branches in the axilla.
1. Axillary a.
9. Branch to serratus anterior
2. Subscapular a.
10. Angular a.
3. Thoracodorsal a., v., and n.
11. Subscapularis m.
4. Circum ex scapular a.
12. Lateral thoracic a., v., and n.
7. Latissimus dorsi m.
13. Pectoralis major m.
8. Teres major m.
14. Pectoralis minor

Anatomy of the Perforators (Fig. 11–3)
The myocutaneous perforators penetrating the latissimus
dorsi muscle are originated mostly from the lateral branch
of the thoracodorsal artery at its varied levels, and 2 to 5
cm posterior to the lateral border of the latissimus dorsi
muscle. There may be one to ve perforators. Usually, the
proximal one is larger in diameter than the distal. Gener-
ally, the perforator bundle, which consists of an artery and
its venae comitantes, has a diameter of 1 to 2 mm.
The rst perforator, which is usually the largest,
arises ~3 cm below the hilus of the thoracodorsal ves-
sels and is present in 95% of cases. The second one
arises ~3 cm distal to the rst and is present in ~80% of
cases. The third is given off ~2 cm distal to the second
and is present in 55% of cases.
Occasionally, a direct cutaneous branch m ay be
given off from the thoracodorsal artery or even from
the subscapular artery. It goes around the lateral border
of the muscle to supply the skin. Actually, this direct cu-
taneous branch is part of the pattern for the lateral tho-
racic ap, as described in Chapter 9. If it is larger, the
perforators would be smaller.
Variations in Branching of the
Thoracodorsal Neurovascular Bundle
(Fig. 11–3)
A. Typical branching pattern (86% of cases).
B. No identi able medial branch, but the lateral branch
gives off several smaller vessels coursing from lateral
to medial (14% of cases).
574
III.11 TRUNK: BACK
Figure 11–3
Variations in branching of the thoracodorsal neurovascular bundle and anatomy of the musculocutaneous
perforators (see text for details).

Variations of the Subscapular Artery and
Vein (Fig. 11–4)
A. Typical origin and branching of the subscapular
artery and vein (3,4) (62% of cases).
B. The circum ex scapular artery (7) arises directly
from the axillary artery (4% of cases).
C. The circum ex scapular vein (8) arises directly from
the axillary vein (12% of cases).
D. Double circum ex veins (8) (14% of cases).
E. Double circum ex arteries (7) (8% of cases).
LATISSIMUS DORSI FLAP
575
Figure 11–4
Variations of
the subscapular artery and vein
(see text for details).
1. Axillary a.
2. Axillary v.
3. Subscapular a.
4. Subscapular v.
5. Thoracodorsal a.
6. Thoracodorsal v.
7. Circum ex scapular a.
8. Circum ex scapular v.

Anatomy and Variations of the Angular
Artery (Fig. 11–5)
A. Angular artery origin from the thoracodorsal a. (50%
of cases).
B. Angular artery arising from the serratus branch (50%
of cases).
This vessel can branch directly from the thora-
codorsal artery or can arise from the serratus branch.
At about the m iddle third of the lateral edge of the
scapula, the angular artery with a vena comitans con-
sistently enters the soft tissue, which covers the sub-
scapularis and infraspinatus m uscles on the lateral
border of the scapula and runs along the lateral border
toward the inferior angle of the scapula. The latissim us
dorsi ap can com bine with a lower lateral segment of
576
III.11 TRUNK: BACK
Figure 11–5
Anatomy and variations of the angular artery (see text for details).
1. Thoracodorsal a.
2. Angular a.
3. Serratus branch
the scapular bone and the angular artery as a composite
osteomuscular ap.
Innervation
Anatomy of the Thoracodorsal Nerve
(Fig. 11–2)
The thoracodorsal nerve arises from the posterior
cord of the brachial plexus and travels lateroinferiorly
behind the axillary artery and vein. It usually is
located 3 cm m edial to the origin of the subscapular
artery in the axilla. It then runs to join the vasculature
w ithin 3 to 4 cm . The nerve divides into lateral and
m edial branches 1.3 cm proxim al to the neurovascular
hilum . Each branch runs w ith its vascular counter-
part.

Anatomy of the Sensory Nerves
(Fig. 11–6)
The sensation of the skin on the latissimus dorsi m uscle
is supplied segm entally by the lateral cutaneous
branches of the intercostal nerves; that is, ventral rami
of the thoracic spinal nerves, T8 to T10, in its lateral por-
tion, and by the dorsal ram i of the thoracic spinal
nerves (T7 to T11) in its medial portion.
According to the anatom ic location of the latis-
simus dorsi myocutaneous ap or thorocodorsal artery
perforator (TAP) ap, the T7 or T8 lateral cutaneous
branch of the intercostal nerve and the T7 or T8 lateral
cutaneous branch of the dorsal thoracic nerve have
been reported for a sensate cutaneous ap.
Measurements
Diameter (mm)
Subscapular
Artery
3–4
Vein
3.5–4.5
Thoracodorsal
Artery
1.5–3.0
Vein
2.5–4.5
Nerve
1.5–2.1
LATISSIMUS DORSI FLAP
577
Figure 11–6
Anatomic distribution of the sensory nerves of the skin on the latissimus
dorsi muscle.