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124
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G. Patanis et al.
13.5 Flap Raise/Elevation: AStep-by-Step
Guide
• For open approach, the vertical laparotomy incision
allows access to the abdominal cavity through the linea
alba (Fig.13.1a, blue marking; Fig.13.1b, black vertical
laparotomy marking). The laparotomy incision requires
to be slightly longer in obese patients to allow ease to
access the bowel, and most times it requires infraumbilical extension.
• Exploration of the small bowel and identication of the
proximal origin at the mesentery where the ligament of
Treitz is located. The origin of the segmental pedicles and
their orientation at a distance greater than 30cm from the
ligament of Treitz is located and carefully examined
extracorporeally (Fig. 13.2). The maximum segment of
the jejunum could be up to 25–30cm depending on the
pedicle blood supply and the reconstructive defect.
• The segmental pedicle of choice along with the arcades
branching toward the vasa recti is carefully chosen to
match the defect length. The mesentery circular sector is
marked along with the jejunum transection margins.
• The pedicle of interest from the segmental origin toward
the arcades that supply the jejunum segment is separated
from the remaining vascular branches via the loopligation hand tie technique. The authors prefer not to use
any modern energy-based tools (i.e., harmonic scalpel)
for these ligations to minimize collateral heat damage
(Figs.13.3 and 13.4).
• When the jejunum sector wedge’s blood supply is islanded
on the chosen segmental artery pedicle, the bowel has to
be prepared for resection. Two bowel clamps are used to
isolate the jejunum segment after gentle push over of any
bowel content proximal and distal to the chosen jejunum
ap. Anastomotic linear stapling devices can be used;
however, care should be invested in identifying a small
gap between two consecutive vasa recti, to allow best possible jejunum ap edge perfusion. The authors prefer
sharp bowel transection with blade which would be followed by a manual double layer Vicryl suture bowel anastomosis to reconstruct small bowel continuity (Fig.13.5).
• The jejunum ap is only transected when the recipient
vessels are fully prepared and ready for microvascular
anastomoses to minimize ischemic time. Careful and
ideal transxion suture ligation of the segmental artery on
the donor site is performed to avoid catastrophic hemorrhage. The free jejunum ap is then washed carefully and
transferred to the defect site (Figs.13.6 and 13.7).
Fig. 13.1 The vertical laparotomy incision allows access to the abdominal cavity through the linea alba
13 Bowel Flaps - Jejunum Flap
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Fig. 13.2 The maximum segment of the jejunum ap could be up to
25–30 cm depending on the pedicle blood supply and the reconstructive
defect
125
Fig. 13.5 When the jejunum sector wedge’s blood supply is islanded
on the chosen segmental artery pedicle, the bowel has to be prepared for
resection
Fig. 13.3 The pedicle of interest from the segmental origin toward the
arcades that supply the jejunum segment is separated from the remaining vascular branches via the loop-ligation hand tie technique
Fig. 13.4 The jejunum ap pedicle is dissected to its origin
• For hypopharyngeal and esophageal defects, a nasogastric feeding tube is inserted to allow easy identication of
the neo-pharyngeal lumen and enable easier jejunum
bowel anastomosis (Fig.13.8).
Fig. 13.6 The free jejunum ap is then washed carefully
• The microvascular anastomoses are performed under the
microscope (i.e., superior thyroid, internal mammary or
transverse cervical arteries). The jejunum inset and position should not cause any tension to the microvascular
pedicle, and ideally a full-thickness fasciocutaneous skin
ap deep to deep subcutaneous fascia should be able to
cover the microvascular anastomosis for protection
(Fig.13.9a, b). Jejunum ap requires primary skin closure
to allow wound healing; however, the authors have previously used split thickness skin grafting on the antimesenteric border of the bowel in extremely complex
cases.
126
G. Patanis et al.
a
Fig. 13.7 The free jejunum ap is then transferred to the defect site
and secured proximally
b
Fig. 13.8 A nasogastric feeding tube is inserted to allow easy identication of the neo-pharyngeal lumen and enable easier jejunum bowel
anastomosis
• The mesentery is sutured and examined to avoid internal herniation or other bowel-related complications.
Abdominal wall mass closure is performed with a loop
permanent 1–0 monolament suture.
Fig. 13.9 The microvascular anastomoses are performed under the
microscopic magnication without tension during jejunum ap inset
13.6 Core Surgical Techniques inFlap
Dissection
• During careful examination of the mesentery; the transil-
lumination is a very helpful way to allow clear visualization of vascular pedicles especially when there is a larger
amount of fat between the double layers of the mesentery.
13 Bowel Flaps - Jejunum Flap
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127
• It is very useful for hypopharyngeal and esophageal
reconstruction while marking the length of the jejunum to
add few centimeters of excess length to allow trimming
and provide healthy viable edges prior to neo-pharyngeal
anastomosis.
• A satellite segmental pedicle branch could be separated
from the jejunum ap to supply a small segment of jejunum <5cm in length to enable externalization during skin
inset for ap monitoring.
• During arcades and mesenteric branching, ligation– extra
care and meticulous hemostasis– can prevent postoperative intra-abdominal bleeds. The author-preferred ligation
technique is via Vicryl 2/0 or 3/0 double loop ligations
and for larger branches Vicryl transxion sutures. Energybased vessel ligation is recommended to be avoided.
• When the amount of mesentery fat is profuse, bi-digital
gentle pressure of the double layer of mesentery peritoneum allows thinning of the fat tissue at the mesenteric
transection wedge lines and also enables easier ligation of
the arcade branches.
• Split jejunum ap modication: The jejunum tube is
sharply divided to allow a split sero-mucosa at design.
This could be performed during inset while evaluating the
exact patch pharyngoesophageal defect measurements;
however, careful calculations are required to allow enough
jejunum length.
• The jejunum segmental vessel pedicle is short. There is a
limited arc of rotation or transposition of the jejunum during inset, and therefore this should be taken into consideration during ap length markings. The authors suggest
that the recipient vessels are in the very immediate area of
the esophageal defect and ideally in the middle of its
length for tension-free ap inset.
• The authors choose to perform the proximal bowel anastomosis rst before the microvascular anastomoses; however, this should not compromise the survival of ap due
to extended ischemia time. Immediate after the microvascular anastomosis, the jejunum ap should be allowed to
be perfused for few minutes, which would demonstrate an
elongating effect. Only then the distal bowel anastomosis
can be performed.
lon free ap reconstruction, due to the risk for future development of colon cancer in the reconstructed neck. The defect
of the pharynx, cervical esophagus, and upper part of the
trachea with loss of the larynx is demonstrated in Fig.13.10.
The segment of the free jejunum ap is demonstrated during
ap dissection, and the chosen pedicle is conrmed with
transillumination (Fig. 13.11). The jejunum free ap of
equivalent length was transferred to reconstruct the esophageal defect (15cm) (Fig.13.12). Figure13.13 demonstrates
the postoperative esophagogram with smooth passage of the
contrast medium from the mouth through the jejunum ap
toward thoracic esophagus.
Fig. 13.10 The defect of the pharynx, cervical esophagus, and upper
part of the trachea with loss of the larynx
13.7 Clinical Scenarios
Case 1: Free Jejunum Flap for Hypopharyngeal
Reconstruction
A 54-year-old male patient had hypopharyngeal carcinoma
for which he underwent total laryngo-pharyngectomy and
bilateral lymph node dissections. He had a family history of
colorectal cancer, and therefore, not a candidate for ileoco-
Fig. 13.11 The segment of the jejunum ap is identied and the chosen pedicle is conrmed with transillumination
128
Fig. 13.12 The jejunum free ap of equivalent length following bowel
transection and the microvascular pedicle fully dissected to its origin
G. Patanis et al.
Case 2: Free Ileocolon Flap for Total
Laryngopharyngeal Reconstruction
A 55-year-old male patient with hypopharyngeal cancer
had a previous tracheostomy due to difculty in breathing due to progressive airway obstruction. Total laryngopharyngectomy, bilateral lymph node dissection with
postoperative radiotherapy, and chemotherapy were the
management of choice (Fig.13.14). Figure13.15 demonstrated the expected pharyngeal defect, cervical esophagus,
as well as laryngeal defect. An ileocolon free ap reconstruction was designed for total larynx and pharynx reconstruction (Fig. 13.16). The ileocolon free ap was after
dissection, demonstrating a segment of ascending colon,
along with the cecum and the ileocolic valve, that would
allow simultaneous reconstruction of the pharynx and cervical esophagus. The segment of the ileum with ileocecal
valve can be optimized to provide functional reconstruction
of voice (Fig.13.17). At immediate postoperative period, a
swallowing function test showed continence of the swallowing tube, in the shape of the terminal ileum and colon
ap (Fig.13.18).
Fig. 13.13 Postoperative esophagogram (swallow test) of the contrast
medium from the mouth through the jejunum ap toward thoracic
esophagus
Fig. 13.14 Ileocolon ap design and markings
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Fig. 13.15 Total layngopharyngectomy defect
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Fig. 13.17 The Ileocolon free ap following dissection
Fig. 13.16 The ileocolon ap design with the pedicle markings
Fig. 13.18 Postoperative swallow test demonstrating the smooth pas-
sage of the dye through the ileocolon ap
130
Case 3: Free Ileum Flap for Urethral Reconstruction
A 34-year-old male patient had severe hypospadias. He
underwent several previous operations utilizing local scrotal
skin; however, he still had urethral stricture and was suffering several episodes of urinary infections and difculty in
voiding. Figure13.19 shows a lateral view with a contracture
of ventral side skin of the penis. Figure13.20 demonstrates
intraoperative dissection and resection of the contracture
which was removed leaving a 7cm urethral defect. A segment of free ileum ap was transferred for reconstruction of
the urethra. A smooth passage of urine after surgery is demonstrated with the patient in standing position (Fig.13.21).
Fig. 13.19 Contracted penis and urethra from multiple revision hypospadias reconstructive procedures
Fig. 13.20 Intraoperative dissection and resection of the contracture
which left a 7 cm urethral defect
G. Patanis et al.
Fig. 13.21 A smooth passage of urine through the ileum ap in standing position
13.8 Pearls andPitfalls
Pearls
• The jejunum segment should be made ideally at a
distance 30 cm distal from the ligament of Treitz
but should also be distal enough to allow accessible
pedicle length and mesentery along with the adequate length of the jejunum ap to cover the defect.
• The choice of the segmental artery should be placed
after careful examination of the anastomotic
arcades. This would dictate the exact jejunum segment with the most robust mesenteric vascular supply, especially at its edges where healing of the
bowel anastomosis will take place.
• A marking suture should be placed at the peristaltic
direction of motion during harvesting to ensure
appropriate inset for the neo-esophagus.
• The jejunum anastomosis is preferred to be performed with a two-layer suture closure, and if an
anastomotic staple is used, an extra overlay seromuscular Vicryl mattress suture layer should be
performed to reduce leaks.
• The jejunum serves as an excellent tubular structure option for reconstruction of vaginal defects;
it offers a self-lubricated tube with peristalsis and
has benets over fasciocutaneous aps for vaginal
reconstructions.
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Pitfalls
• The vasa recta, the distal branches of the arcade pedicles of the jejunum ap, are approximately 5cm in
length and enter the mesenteric border of the jejunum
to supply a zone of approximately 1cm of bowel–
forming the vasa recti unit. This is paramount in ap
manipulation as these vessels are very delicate, especially the veins. Care should be considered during
harvesting and while deciding the level of jejunum
transection to allow optimal edge perfusion.
• Surgical ow and ap harvest are simple and quick
but should be performed with extra care in every
step. All recipient vessels must be prepared before
the ap is disconnected to avoid troublesome delay
in microvascular anastomosis.
• The most difcult bowel anastomosis in the defect
should be performed rst, prior to microvascular
anastomosis, and this should be quick to reduce
ischemia time.
• The jejunum does not tolerate venous congestion as
other fasciocutaneous aps do; therefore, extra care
should be put into optima microvascular suture line
for the venous anastomosis. The authors prefer to
complete the venous anastomosis rst. If the arterial anastomosis has been performed rst, the clamp
should not be removed while performing the venous
anastomosis as this will cause intra-ap congestion.
• Strictures and stenosis are recognized complications of neo-pharyngeal reconstruction with jejunum ap, especially in the inferior anastomotic line.
Spatulating the jejunum lower edge allows larger
circumference and lowers the risk for constriction
during healing. Similarly, a double-barrel jejunum
superior conguration may allow larger opening in
the oropharyngeal anastomosis. Always aim for
watertight closure.
13.9 Selected Readings
• Kim EKF, Mardini S, Salgado CJ, Chen H-C.Esophagus
and hypopharyngeal reconstruction. Sem Plast Surg.
2010.
The authors reviewed the literature on esophageal
reconstruction. The most common methods used are gastric pull-up, pectoralis major ap, colon interposition,
fasciocutaneous aps (radial forearm free ap or anterolateral thigh ap), and free jejunum and colon aps. The
stricture rates, stula rates, morbidity, and mortality of
each ap were also reviewed.
131
• Razdan SN, Albornoz CR, Matros E, Paty PB, Cordeiro
PG. Free jejunal ap for pharyngoesophageal reconstruction in head and neck cancer patients: an evaluation of donor-site complications. J Reconstr Microsurg.
2015.
This article portrays the authors’ critical appraisal on
free jejunal transfer for pharyngoesophageal reconstruction and the associated donor site morbidity. Conversely,
they discuss on the argument that support the use of fasciocutaneous aps, given their low incidence of donor
site complications. This study documented donor site
complication rate with free jejunal aps for pharyngoesophageal reconstruction, in the hands of an experienced surgeon. They concluded that free jejunal transfer
is associated with minimal and acceptable donor site
complication rates. The choice of ap for pharyngoesophageal reconstruction should be determined by the type of
defect, potential recipient site complications, and the surgeon’s familiarity with the ap. Potential donor site
complications should not be a deterrent for free jejunal
aps given the low rate described in this study.
• Chen H-C, Rampazzo A, Gharb BB, Wong MTC,
Mardini S, Chen H-Y, Salgado CJ.Motility differences
in free colon and free jejunum aps for reconstruction of the cervical esophagus. Plast Reconstruct Surg,
2008;122(5):1410–6.
In this study the free colon and jejunal aps are
described as reliable and safe conduits for pharyngoesophageal reconstruction. According to the authors,
compared with free colon aps, free jejunum aps have a
smaller diameter and intrinsic peristaltic movement, both
of which are considered possible causes of dysphagia.
The authors evaluated the motility differences in free jejunum and colon aps using radionuclide esophageal scintigraphy. Although neither ap showed normal swallowing
characteristics, free jejunum aps displayed greater
esophageal clearance and should represent the rst
choice in hypopharyngeal reconstruction. Free colon and
ileocolon aps should be reserved for very proximal oropharyngeal defects and when simultaneous voice reconstruction is desired.
• Disa JJ, Pusic AL, Hidalgo DA, Cordeiro PG.
Microvascular reconstruction of the hypopharynx: defect
classication, treatment algorithm, and functional outcome based on 165 consecutive cases. Plast Reconstr
Surg. 2003;111(2):652–60.
The aims of this study were threefold: to develop a
scheme for classication of hypopharyngeal defects, to
establish a reconstructive algorithm based on this system,
and to assess the functional outcome of such reconstruction. The authors report a retrospective review of a
14-year experience with 165 consecutive microvascular
132
G. Patanis et al.
reconstructions of the hypopharynx in 160 patients. Their
overall free ap success rate was 98%. They also report a
treatment algorithm for microvascular hypopharyngeal
reconstruction based on the type of defect with partial
defects with radial forearm aps, circumferential defects
reconstructed with free jejunal aps, and extensive, multilevel defects reconstructed with rectus abdominis myocutaneous aps. This article concludes that microvascular
reconstruction of pharyngeal defects is highly successful
with few postoperative complications.
• Chen H-C, Kim EKF, Salgado CJ, Mardini S.Methods of
voice reconstruction. Semin Plast Surg. 2010.
The authors reviewed methods of voice reconstruction. Nonsurgical methods of voice reconstruction include
electrolarynx, pneumatic articial larynx, and esophageal
speech. Surgical methods of voice reconstruction include
neoglottis, tracheoesophageal puncture, and prosthesis.
Tracheoesophageal puncture can be performed in patients
with pedicled aps such as colon interposition, jejunum,
or gastric pull-up or in free aps such as the perforator
aps, jejunum, and colon aps. Other aps for voice reconstruction include the ileocolon ap and jejunum. Laryngeal
transplantation was also reviewed and discussed.
References
1. Seidenberg B, Rosenak SS, Hurwitt ES, Som ML. Immediate
reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Ann Surg. 1959;149(2):162–71.
2. Razdan SN, Albornoz CR, Matros E, Paty PB, Cordeiro PG.Free
jejunal ap for pharyngoesophageal reconstruction in head and
neck cancer patients: an evaluation of donor-site complications. J
Reconstr Microsurg. 2015;31(9):643–6.
Thoracodorsal Artery Flap: Latissimus
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Dorsi Flap
MohammedFarid, DariushNikkhah, andJeremyRawlins
14
14.1 Introduction
The latissimus dorsi (LD) is a muscle name originated from
Latin (latus=broad, dorsum=back) which means the “broadest muscle of the back” [1]. One of the rst descriptions for
LD use as a ap was apparent from drawings by anatomist and
physician Vesalius (sixteenth century) who demonstrated the
muscle division from origin and lateral rotation [2]. The LD
ap was rst reported as a pedicled ap (axial pattern) for a
mastectomy defect by Tansini in 1906 [3]. Then, the clinical
application was sporadic until Olivari in 1976 used LD for
chest wall defects post-radiation exposure [4]. A year later in
1977, Schneider elaborated the concept to use LD ap with an
implant-based breast reconstruction following radical mastectomy, which helped replace breast tissue and restore shape [5].
The year 1978 witnessed a number of advancements in LD ap
reconstruction. Bostwick developed the principle for an islandbased LD ap in breast reconstruction [6]. The versatile nature
of the LD ap marked its use as a pedicled ap in head and
neck reconstruction by Quillen. This was a rotational island
ap tunnelled above pectoralis major muscle to reconstruct the
lateral neck and cheek defects from resection of a mandibular
defect [7]. Maxwell was the rst who used the LD muscle as a
free ap for scalp reconstruction [8]. A year later in 1979, May
reported the use of free LD aps in lower limb reconstruction
Supplementary Information The online version contains supplementary
material available at https://doi.org/10.1007/978- 3- 031- 07678- 7_14.
M. Farid (*)
Department of Plastic Surgery, Royal Stoke University Hospital,
Stoke-on-Trent, UK
D. Nikkhah
Department of Plastic, Reconstructive and Aesthetic Surgery,
Royal Free Hospital, London, UK
J. Rawlins
Department of Plastic Surgery, Royal Perth Hospital,
Perth, WA, Australia
[9]. In 1982, one of the rst free LD reported cases in upper
limb for hand reconstruction was performed by Bailey [10].
The further renement of microsurgical concepts led to the
expansion and diverse use of LD aps over the past 40years.
14.2 Anatomy
The latissimus dorsi is the most supercial and largest muscle
of the posterior trunk [1]. The superomedial part is covered by
trapezius muscle, and LD muscle covers part of the paraspinal
and majority of serratus anterior muscle [11]. The origin is
from the lower six thoracic vertebrae, tenth to 12th posterior
ribs, superior angle of scapula, lower sacral vertebrae, thoracolumbar fascia and posterior iliac crest forming the roof of the
superior lumbar triangle [12, 13]. The bres span as a triangular and at muscle to become a broad tendon [11]. The muscle
has an aponeurotic attachment to the lower border of the serratus anterior and meets the teres major superiorly forming the
posterior axillary fold before inserting into the lesser tubercle
and the intertubercular groove of the humerus [13].
According to the Mathes and Nahai classication, the LD
is a type V muscle with a dominant artery (thoracodorsal
(TD)) and secondary segmental vessels from lumbar (medial
paraspinal) and posterior intercostal (lateral) perforators
[14]. The thoracodorsal artery is a branch of the subscapular
artery forming a pedicle to enter the LD muscle 8–12 cm
proximal to the humeral insertion. The neurovascular bundle
is on the deep surface of LD muscle found 4cm distal to inferior border of the scapula and 2.5cm lateral to medial border
of LD muscle [15]. At this point, the pedicle then divides
into two branches (medial and lateral) parallel to the superior
and anterior edge of the LD muscle. This concept forms the
basis of splitting the LD muscle. Within the muscle, these
branches divide into smaller ones which anastomose with
lumbar and intercostal perforators [12, 14, 16]. The pedicle
length is 8cm on average (range 6–12cm) and has a mean
diameter of 3 mm (range 2–4 mm). The venous drainage
© Springer Nature Switzerland AG 2023
D. Nikkhah et al. (eds.), Core Techniques in Flap Reconstructive Microsurgery, https://doi.org/10.1007/978-3-031-07678-7_14
133
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