Tissue Rearrangement Techniques and Regional Flaps
Extirpative gynecologic cancer surgery may result in partial or full-thickness defects of the abdominal wall. Although minor defects can be repaired primarily, large or composite defects present a significant challenge requiring careful planning to obtain a successful reconstruction. A multidisciplinary team, including gynecologic oncology, urology, general, and plastic surgery, may be required for treatment of the patient with gynecologic cancer. Goals of abdominal wall reconstruction in these patients are to restore structural integrity of the abdominal wall musculofascial system and provide stable wound coverage.
Repair of complex abdominal wall defects can be divided into 2 main modalities: autologous tissue or nonautologous (prosthetics or biomaterials). Depending on the clinical situation, either or both modalities may be required. This chapter delineates preoperative and anatomic considerations that factor into reconstructive decision-making, with an emphasis on techniques of autologous tissue repair. Prosthetics and biomaterials are discussed in Chapter 20.
INDICATIONS AND CLINICAL APPLICATIONS
Functions of the abdominal wall include protection of intra-abdominal organs, provision of dynamic support for respiration and upright posture, and assistance in Valsalva for coughing, urination, and defecation. Difficulty performing these functions due to abdominal wall discontinuity will not only impact function, but health-related quality of life as well. Gross herniation of intra-abdominal contents can create obvious difficulty in social situations. By contrast, small hernias, while not as visible, are at greater risk for incarceration and strangulation. Indications for reconstruction of abdominal wall defects thus range from functional to aesthetic.
Few absolute contraindications to abdominal wall repair exist. Hemodynamically unstable patients can be temporarily closed using negative pressure wound dressings or large intravenous bag coverage with definitive closure performed at a later date. In patients desiring elective repair of chronic ventral hernias or wounds, thorough preoperative evaluation and counseling must be performed. These patients often have significant medical comorbidities; thus, the benefits of major abdominal surgery must be weighed before undertaking repair. Such procedures can cause significant cardiopulmonary embarrassment both intraoperatively and postoperatively, particularly for chronic ventral hernias with a significant loss of domain. Asymptomatic, high-risk medical patients at low risk for incarceration may be managed conservatively with observation.
Abdominal wall defects requiring reconstruction may result from tumor extirpation, incisional hernia, abdominal wound infection, or a combination thereof. Malignant pelvic tumors extending to the anterior abdominal wall may require wide resection of myofascial structures, subcutaneous tissue, and/or skin, depending on the extent of tumor invasion. Incisional hernia following prior laparotomy has a reported incidence of 2% to 11%.1,2 Risk factors for developing this complication include elderly age, morbid obesity, malnourishment, immunosuppression, and previous abdominal surgery. Medical conditions such as connective tissue disorders and those associated with increased intra-abdominal pressure (eg, chronic cough, constipation, ascites) also predispose to incisional hernia development. Soft tissue infections of the abdominal wall ...