Lateral abdominal wall reconstruction

Abstract

Lateral abdominal wall (LAW) defects can manifest as a flank hernias, myofascial laxity/bulges, or full-thickness defects. These defects are quite different from those in the anterior abdominal wall defects and the complexity and limited surgical options make repairing the LAW a challenge for the reconstructive surgeon. LAW reconstruction requires an understanding of the anatomy, physiologic forces, and the impact of deinnervation injury to design and perform successful reconstructions of hernia, bulge, and full-thickness defects. Reconstructive strategies must be tailored to address the inguinal ligament, retroperitoneum, chest wall, and diaphragm. Operative technique must focus on stabilization of the LAW to nonyielding points of fixation at the anatomic borders of the LAW far beyond the musculofascial borders of the defect itself. Thus, hernias, bulges, and full-thickness defects are approached in a similar fashion. Mesh reinforcement is uniformly required in lateral abdominal wall reconstruction. Inlay mesh placement with overlying myofascial coverage is preferred as a first-line option as is the case in anterior abdominal wall reconstruction. However, interposition bridging repairs are often performed as the surrounding myofascial tissue precludes a dual layered closure. The decision to place bioprosthetic or prosthetic mesh depends on surgeon preference, patient comorbidities, and clinical factors of the repair. Regardless of mesh type, the overlying soft tissue must provide stable cutaneous coverage and obliteration of dead space. In cases where the fasciocutaneous flaps surrounding the defect are inadequate for closure, regional pedicled flaps or free flaps are recruited to achieve stable soft tissue coverage.

Keywords: biologic mesh; bioprosthetic mesh; bulge; component separation; hernia; lateral abdominal wall reconstruction.

Figure 1

A 46-year-old woman with a desmoid tumor invading the right lateral abdominal wall transverse abdominis and internal/external oblique muscle complexes. (A) Computed tomography (CT) scans show tumor extending to the inferior border of the liver. (B) The preoperative photo shows the planned margins for a full thickness lateral abdominal wall resection. The patient was reconstructed with an inlay mesh and fasciocutaneous advancement flaps. (C) Follow-up CT scans at 6 months show preservation of the curvilinear contour of the lateral abdominal wall. (D) Patient photo reveals aesthetic contour of the torso is preserved.

Figure 2

Schematic representation of diaphragmatic defect. (A) Chest wall and abdominal wall soft tissue are represented in yellow. Diaphragm represented in red. (B) Full-thickness resection of chest wall, abdominal wall, and diaphragm in lower rib with complete loss of the boundaries between the abdominal cavity and the thoracic cavity in addition to the musculoskeletal thoracoabdominal wall. (C) Reconstruction with mesh inlay serving to partition both the thoracic and abdominal cavity, in addition to reinforcing the musculoskeletal thoracoabdominal wall. Mesh represented in white. The mesh is inset below the diaphragm, which is elevated to the level of the next cephalad rib. Circumcostal sutures are placed in a mattress fashion first through the diaphragm then through the mesh, so that the mesh acts to reinforce the diaphragmatic repair as it is anchored to the chest wall.

Figure 3

A 58-year-old woman with recurrent liposarcoma and symptomatic flank hernia planned to undergo radical resection and hernia repair. (A) Computed tomography (CT) scans show tumor involving the lateral abdominal wall abutting the liver with a hernia involving the colon inferiorly. (B) Full-thickness thoracoabdominal wall defect including the diaphragmatic recess. The lung diaphragm and liver are seen in the base of the wound. (C) Bioprosthetic mesh inlay interposition repair combining diaphragmatic repair with lateral abdominal wall hernia repair. (D) 6-month follow-up CT scans. Note preservation of lateral abdominal wall contour and mesh support of liver, colon, and kidney. (E) Lateral and oblique views.

Figure 4

A 72-year-old woman developed a malignant peripheral nerve sheath sarcoma and will require adjuvant radiation therapy. (A) A preoperative computed tomography (CT) scan demonstrating involvement of the paraspinal muscle bundle and posterolateral abdominal wall. (B) Preoperative view of planned resection. Gluteal perforators and posterior intercostal perforators identified. (C) Full-thickness defect involving the posterolateral abdominal wall to the level of the Gerota fascia. (D) Mesh onlay repair of posterior retroperitoneal defect with support of the right kidney. Soft tissue reconstruction of a large volumetric defect of the posterolateral abdominal wall with pedicled superior gluteal artery perforator flap (SGAP). (E) Reverse latissimus flap (LD) transposed on a posterior intercostal artery perforator to obliterate the dead space in the superior pole of the wound. (F) Inset of the SGAP and LD flaps. (G) 12-month follow-up CT scans demonstrating preservation of the contour of the posterolateral abdominal wall and adequate soft tissue volume replacement. (H) Posterior and oblique photos.