The long-term outcomes of early abdominal wall reconstruction by bilateral anterior rectus abdominis sheath turnover flap method in critically ill patients requiring open abdomen

Abstract

Background: In a previous study, we reported the usefulness of early abdominal wall reconstruction using bilateral anterior rectus abdominis sheath turnover flap method (turnover flap method) in open abdomen (OA) patients in whom early primary fascial closure was difficult to achieve. However, the long-term outcomes have not been elucidated. In the present study, we aimed to evaluate the procedure, particularly in terms of ventral hernia, pain, and daily activities.

Methods: Between 2001 and 2013, 15 consecutive patients requiring OA after emergency laparotomy and in whom turnover flap method was applied were retrospectively identified. The long-term outcomes were evaluated based on medical records, physical examinations, CT imaging, and a ventral hernia pain questionnaire (VHPQ).

Results: The turnover flap method was applied in 2 trauma and 13 non-trauma patients.In most of cases, primary fascial closure could not be achieved due to massive visceral edema. The turnover flap method was performed for abdominal wall reconstruction at the end of OA. The median duration of OA was 6 (range 1-42) days. One of the 15 patients died of multiple organ failure during initial hospitalization after the performance of the turnover flap method. Fourteen patients survived, and although wound infection was observed in 3 patients, none showed enteric fistula, abdominal abscess, graft infection, or ventral hernia during hospitalization. However, it was found that 1 patient developed ventral hernia during follow-up at an outpatient visit. Nine of 14 patients were alive and able to be evaluated with a VHPQ (follow-up period: median 10 years; range 3-15 years). Seven out of nine patients were satisfied with this procedure, and none complained of pain or were limited in their daily activities.

Conclusions: Based on the results of this study, early abdominal reconstruction using the turnover flap method can be considered to be safe and effective as an alternative technique for OA patients in whom primary fascial closure is considered difficult to achieve.

Keywords: Abdominal compartment syndrome; Abdominal wall reconstruction; Negative pressure wound therapy; Open abdomen.

Fig. 1

Schematic illustration of the technique for bilateral anterior rectus abdominis sheath turnover flap method. a First, the skin and subcutaneous tissue are separated from the anterior rectus sheath as a flap bilaterally beyond the lateral border of the rectus abdominis sheath. A longitudinal incision is then made in each anterior rectus sheath ≥ 1 cm inside the lateral border. After confirming the presence of the rectus abdominis muscle, the incision is extended the entire length of the anterior rectus sheath. The anterior rectus sheath is then dissected from the lateral to medial face, freeing it from the rectus abdominis muscles. b It is reflected medially and approximated with interrupted absorbable sutures to cover the abdominal contents. The skin is closed primarily or secondarily

Fig. 2

The CT findings and views of the abdominal wall. The upper panels show images obtained 6 years after performing the turnover flap method (a, b, c). The lower panels show images obtained 10 years after turnover flap method (d, e, f). The CT scans show that the appearance of flaps created using bilateral anterior rectus abdominis sheath looks similar to after onlay mesh repair (a, d). Anteroposterior views (b, e) and lateral views (c, f) of the abdominal wall in the standing position. Although slight lower abdominal bulging can be observed in the lateral views of both patients, no abdominal hernia is evident