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Chapter 13 • Tissue and Fascial Expansion of the Abdominal Wall 231
Crescenteric tissue expanders
(Initial 60-100 mL of saline
with methylene blue)
Midline skin defect
and hernia
Insertion incision
Remote port in
superficial plane
Figure 13-3.
232 Section V • Other Abdominal Wall Procedures
The patient shown in Figure 13-3 is lying prone with paired crescenteric tissue expanders
inserted lateral to the midline abdominal skin defect and hernia. The insertion incisions are
perpendicular to the long axis of the defect and will be incorporated into the final closure as
back cuts used to help advance the skin flaps. If a remote port is being used, a tunnel and
small pocket need to be created several inches away from the expander so that they can be
easily accessed (see Fig. 13-3). It is very important not to kink the tubing and also to place the
port in a relatively superficial plane (especially if the patient is obese). If the port is too deep,
it may not be easily felt or accessed. If it is too close to the expander, then there is a risk of
damaging the expander. If the tube is kinked, then the expansion is impossible and another
procedure will need to be performed. The methylene blue is useful because sometimes a
seroma forms around the expander and port. The blue ensures that the surgeon knows that
he has indeed accessed the expander and not just the seroma cavity. I recommend a remote
port in all obese patients because an integrated port may be difficult to locate through the
thick tissue, even with the magnetic finder provided by the manufacturer. Although I do not
like closed suction drains touching the expander, I also do not like seromas and feel that a
drain is usually warranted for several days. I try to remove them as soon as possible and keep
the patient on oral antibiotics for as long as the drains are in and then 48 hours after they are
removed. The wound is closed with deep and superficial absorbable monofilament sutures,
and Dermabond is applied. I then access the port and test it to make sure that it works. At
that time, I may choose to inject more saline into the expander, depending on how tight the
closure was. I like to use an abdominal binder to prevent tension on the wound for the first
7 to 10 days.
s
Progressive Fill of Expanders
Two weeks after the initial operation, the drains should be out and the wound well sealed.
I then begin inflation of the expander (or expanders as the case may be). The skin is prepped
with alcohol, and a long butterfly needle is used to access the port. A 60-mL syringe filled with
saline is attached to the needle, and the plunger is pulled back until methylene blue is seen in
the butterfly needle tubing. I then feel confident to push the 60 mL of saline into the expander
(Fig. 13-4). The amount to be injected varies by patient and size of expander. I like to feel the
skin over the expander and also listen to the patient’s subjective report of tightness. It is always
better to inject less than theoretically possible in order to minimize the risk of wound dehiscence or breakdown.
Skin tightens
over expander
Chapter 13 • Tissue and Fascial Expansion of the Abdominal Wall 233
60 mL of saline
gradually fills
expander
Drains removed and
incisions well sealed
Butterfly needle inserted
and expansion begun
Figure 13-4.
234 Section V • Other Abdominal Wall Procedures
s
Removal of Expanders and Closure of Skin Defect
When the expanders have been inflated to their desired amount, the final operation is planned
(see Fig. 13-2, C). The same antiseptic measures are taken, and then the wound is completely
excised. In the example shown, the skin graft is removed from the bowels, and the intervening
tissue between the tissue expanders and the defect is incised (see Fig. 13-2, D). The expanders and ports are removed (Fig. 13-5, A). This creates ready access to the lateral edge of the
rectus muscle, facilitating a separation-of-parts procedure. After the fascial defect is closed and
reinforced with biologic mesh (Fig. 13-5, B), the expanded skin and subcutaneous tissue are
advanced to the midline (Fig. 13-6). The body forms a capsule around the tissue expander and
this capsule contributes to the blood supply of the overlying skin. In general it is advisable to
leave the capsule alone, but frequently the edges of the capsule and sometimes the skin need
to be incised perpendicular to the line of the defect to allow easy advancement of the flap.
The capsule also may be serially scored to create an accordion effect and allow flap advancement. The surface of the abdominal wall on which the tissue expander rests also is covered
by capsule, and it is recommended to abrade this surface with electrocautery to generate
adhesions between the abdominal wall and the overlying flap of skin and fat. This helps limit
postoperative seromas. Drains are always placed and left in until total drainage is less than
30 mL/24 hours. An abdominal binder is placed, and the patient is advised to wear it at all
times for 3 months (this is also to take tension off of the hernia repair). The patient in Figure
13-5 is shown at 3 months with good reduction of the hernia and closure of the skin defect
(see Fig. 13-5, C and D).
4. Pearls/Pitfalls
1. Managing the Infected or Extruded Tissue Expander
If the expander extrudes or becomes infected early in the expansion, then it is recommended
to remove it, allow the wound to heal for at least 6 weeks, and then try again. Ideally 3 months
should go by between efforts. Sometimes the wound breaks open, but there is no infection present. In this case, I have sometimes attempted to take the patient to the OR, clean the wound,
irrigate the pocket with antibiotic, and then close the wound while leaving the expander in
place. Much of the volume is removed from the expander to allow easy closure of the dehiscence. When this works, I feel lucky, not skilled. In the setting of infection, I do not believe it is
possible to rescue the expander.
If the expansion is almost complete and the skin breaks down to reveal the expander, I place
the patient on antibiotics; have them apply topical mafenide acetate (Sulfamylon), a powerful
topical antimicrobial, to the wound; and plan to electively take them to the OR for expander
removal and definitive closure of the defect. If the expander becomes infected, I perform the
same procedure but take them to the OR as soon as possible.
Chapter 13 • Tissue and Fascial Expansion of the Abdominal Wall 235
Expanded skin flaps
A
C
Figure 13-5.
Serial scores in capsule
(accordian effect)
B
D
after expander removal
Electrocautery
abradement
of capsule
covering
abdominal wall
Biologic mesh
reinforcement
Separation of parts
procedure
External oblique
fascia
Figure 13-6.
Midline repair of
facial defect
236 Section V • Other Abdominal Wall Procedures
2. Estimating When Skin Expansion Is Adequate
There is no magic rule for determining when the tissue expansion is complete, but in general,
the height of the expander or expanders must equal the width of the defect. The height is difficult to gauge, especially since some have argued that the height should include both the edge
adjacent to the defect and the opposite edge. One way of estimating is to take a tape measure
and place it at the base of the lateral edge of the expander, pass it over the maximum projection
of the dome, and measure to the edge of the advancing edge of expanded tissue. The base width
of the expander is then subtracted from this arc length to estimate the degree of advancement.
Ultimately it is better to err on the side of overexpansion. Excess tissue can always be removed
and will facilitate a tension-free closure.
5. Fascial Expansion
1. Indication and Analysis of Fascial Defect
As mentioned previously, it is difficult in some cases to determine preoperatively whether a
patient will require serial excision of mesh to facilitate closure of the fascial defect. In some
patients the defect is so large, the need is obvious (see Fig. 13-1, B and Fig. 13-7, A and B). As
outlined in Chapter 8, the best method of closure of large fascial defects is the separation of
component parts of the abdomen with biologic or prosthetic mesh reinforcement. At the time of
the initial take down of the hernia, the decision is made as to whether to proceed with definitive repair or to stage the repair. It is important not to perform the separation of parts until the
final procedure. The patient should be informed preoperatively and give consent to any and all
staged procedures necessary to close the fascial defect.
I find that the best response to reverse fascial expansion is in patients who have had midline
incisions with loss of abdominal domain. Patients who have lost fascia and or parts of the rectus
abdominis musculature due to trauma, infection, or cancer have less of a response to the expansion. Additionally, the fascial closure is less secure, and the risk of recurrence is greater because
the paired innervated rectus muscles are not symmetric and in the midline. If one rectus is gone,
then it is the edge of the external and internal obliques that are being pulled to the midline.
While it is possible to do this, the muscles are not oriented in the same direction as the opposing
rectus, and the forces working to pull the fascial repair apart are greater.
Chapter 13 • Tissue and Fascial Expansion of the Abdominal Wall 237
A
C
Figure 13-7.
B
D
238 Section V • Other Abdominal Wall Procedures
2. Fascial Expansion and Closure of Abdominal Wall Midline Defect
Once the decision to perform serial closure of the fascia is made, the defect is carefully measured and photographed. The hernia is completely separated from the overlying abdominal
wall, and a large sheet of Gore-Tex Dual mesh (WL Gore and Associates, Flagstaff, AZ) is sewn
under moderate tension to the edges of the defect (see Fig. 13-7, C and D). Ideally the skin is
viable and healthy enough to close over the Gore-Tex. If the skin is of poor quality, then the
Gore-Tex can be covered by a VAC (vacuum-assisted closure) (see accompanying video). In this
case the skin and the fascia must be advanced together, and the risk of skin necrosis and wound
dehiscence is much higher. One way to approach this is to begin to undermine the skin edges
at the level of the fascia during each subsequent operation with the ultimate goal of elevating
it beyond the lateral edge of the rectus muscles. This is necessary anyway to perform the final
separation-of-parts repair. Care should be taken to identify rectus perforators to the skin and
preserve them as much as possible. This gradual process of elevating the skin acts to “delay” the
skin flap, meaning that the ultimate blood supply is augmented by virtue of the body’s response
to mild ischemia. This technique is tricky to perform, and it is easy to develop skin edge necrosis by going too fast.
The patient is kept in the hospital and no further surgery is performed until normal bowel function returns. At that time it can be decided whether to perform the subsequent operations as an
inpatient or outpatient. A typical operative sequence is every Monday, Thursday until the defect
is ready for definitive closure.
The second phase of the surgery involves the serial excision of the Gore-Tex in the midline with
moderate to tight closure. The patient is brought to the OR and the skin is opened (or VAC
removed, as the case may be). The Gore-Tex is assessed for tightness, and a pinch test is performed in the midline with the patient paralyzed (see video). Unless the closure was very loose
at the initial operation, I do not recommend removing more than a 4-cm wide strip of central
Gore-Tex. The two edges of the cut Gore-Tex are then sewn together with a running locking
permanent suture, such as a #1 Prolene. The skin is then closed securely with deep stitches
and superficial staples (drains are always placed), and a binder is applied. One trick I sometimes
perform is to take a large adhesive, occlusive sheet and use it to take tension off of the skin closure. This is done by applying the adhesive sheet to the lateral aspect of one side of the abdomen,
manually pushing the skin towards the midline, and then draping the sheet over the incision
to the other side of the abdomen. The patient in Figure 13-8 has been taken back to the OR for
serial excision of the Gore-Tex mesh. Figure 13-8, A shows the patient just before her first excision with a measured 30-cm fascial defect. In Figure 13-8, B, a midline 4-cm strip of Gore-Tex is
being removed. The cut ends of the Gore-Tex are reapproximated with a running locking suture
(C). Figure 13-8, D shows the patient now with a 21-cm wide defect, having undergone another
excision of Gore-Tex. The excisions will proceed until the width of the Gore-Tex is no greater
than 4 to 6 cm. Figure 13-9 shows the patient’s abdomen with the patient supine. The GoreTex mesh has been placed previously and a central strip of Gore-Tex is being removed to allow
reduction of the width of the mesh with gradual stretching of the fascia and rectus muscles back
to the midline of the abdomen.
Chapter 13 • Tissue and Fascial Expansion of the Abdominal Wall 239
A
C
Figure 13-8.
B
D
New incision line of
Gore-Tex strip removal
(<4 cm)
from previous serial strip closure
Figure 13-9.
Hernia
Gore Dualmesh Plus
biomaterial sewn to
fascial edges
Central strip of Gore-Tex
being removed (<4 cm)
Running locking sutures
240 Section V • Other Abdominal Wall Procedures
Once the Gore-Tex is down to its last few centimeters, the final operation is planned. The final
strip of Gore-Tex is removed, and the bowel is separated from the lateral abdominal wall (Fig.
13-10). You will find that there is a capsule over the bowel where the Gore-Tex was in contact
with it. Under the lateral edge of the abdominal wall there is no capsule and the bowel should
be freed completely. It is important to break down adhesions on the lateral abdominal wall at
each stage of the procedure to prevent fusion of the visceral block to the abdominal wall which
will prevent medialization during final reconstruction. A separation of parts is performed, and
then an underlay of mesh is placed. The fascial closure can even be further reinforced with an
overlay of biologic mesh (Fig. 13-11). Figure 13-12, A on page 243 depicts the final operation
in which the remaining Gore-Tex is removed, a separation of component parts is performed,
and the fascia is closed. The first sheet of biologic mesh has been laid across the repair, and the
entire fascial repair has been reinforced by biologic mesh in Fig. 13-12, B, p. 243. In Figure
13-12, C and D, on page 243, the patient is shown 3 weeks after the completion of her repair.
Drains should be placed and left in for a long time to prevent seroma and subsequent infection.
An abdominal binder is placed, and the patient is advised to wear it at all times for 3 months
or longer.