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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_731_Библиотеки_им_академика_М_И_Перельмана.pdf
Figure 14-4.
Chapter 14 • Progressive Preoperative Pneumoperitoneum 251
Air wall unit
Filter
Laparoscopic
insufflation tubing
Hernialoss of abdominal domain
Peritoneal
dialysis
catheter
Figure 14-5.
Perioperative peritoneum
252 Section V • Other Abdominal Wall Procedures
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Repeat CT Scan to Determine Suitability for Stage III
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3. Stage III
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Abdominal Wall Reconstruction
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After 7 days of daily PPP, a CT scan is performed to determine the suitability of the abdomi-
nal wall for repair.
The CT should demonstrate that the herniated contents have fallen back into the native
abdominal cavity and now lie below an imaginary line drawn across the hernial orifice
(Figs. 14-6 to 14-9).
If the bowel has not fallen back into the abdominal cavity and the volume of the abdomen
does not look to have increased significantly, then pneumoperitoneum should continue for
4-5 more days and a repeat CT performed. If at this point there is no change, it is unlikely
PPP will work as a pneumatic tissue expander and consideration should be given to either
saline tissue expansion or myofascial pedicled flap closure of the abdominal wall.
Once the patient is ready for reconstruction, the surgeon should use the technique with
which he or she is most comfortable.
Every effort should be made to ensure rectus abdominis reapproximation in the midline
with ventral fascial closure overtop the mesh.
Our preferred method for abdominal wall reconstruction in these patients is the Rives-
Stoppa retromuscular hernia repair technique with or without the addition of a posterior
components separation (PCST).
Chapter 14 • Progressive Preoperative Pneumoperitoneum 253
Figure 14-6.
Figure 14-8.
Figure 14-7.
Figure 14-9.
254 Section V • Other Abdominal Wall Procedures
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Rives-Stoppa with PCST
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After a complete lysis of adhesions a towel is placed intraperitoneally to protect the under-
lying viscera.
The posterior rectus sheath is divided vertically 1 cm or less from the edge of the linea alba
and the division continues 5 cm cephalad to the hernia defect edge and 5 cm caudal to it
(Fig. 14-10).
The posterior rectus sheath is reflected posteriorly under tension and the rectus muscle is
gently dissected off the ventral aspect of the sheath (Fig. 14-11).
A similar dissection is performed on the contralateral side.
If it does not appear that the posterior rectus sheath will reapproximate in the midline
under little to no tension, a posterior components separation technique (PCST) will be
required.
For the PCST, the dissection is carried to the lateral most extent of the rectus sheath.
With a Richardson retractor reflecting the rectus laterally at this lateral extent, a subtle
ridge becomes evident. This ridge is formed by the rolled over anterior leaf of the internal
oblique aponeurosis as it fuses with the transversus abdominis aponeurosis to form the
posterior rectus sheath (Fig. 14-12).
By incising the fascia 1 to 2 mm medial to this ridge, the interparietal plane between inter-
nal oblique and transversus abdominis muscle is accessed, and the incision is continued
for the entire length of the skin incision and beyond (Fig. 14-13).
The interparietal plane is dissected far out laterally. This dissection disconnects the trans-
versus abdominis muscle from the anterior components, allowing medial advancement of
the posterior rectus sheath for complete peritoneal closure and medial rectus advancement
for total abdominal wall reconstruction. PCST provides a well-vascularized and wide space
for mesh placement with similar advancement to the Ramirez component separation with-
out the need for a subcutaneous skin dissection and its attendant morbidity.
The protective towel, which was placed intraperitoneally, is removed now, and the poste-
rior rectus sheath is reapproximated in the midline with a slow-absorbing monofilament
suture.
The synthetic mesh is placed in the retromuscular space and fixated with full-thickness
permanent transabdominal sutures utilizing the Reverdin needle (Fig. 14-14).
The anterior sheath is closed in the midline ventral to the mesh, using a slow-absorbing
monofilament suture and a 4:1 suture-to-wound-length ratio.
Chapter 14 • Progressive Preoperative Pneumoperitoneum 255
External oblique
Internal oblique
Transversus
abdominis
Figure 14-10.
Anterior rectus sheath
Posterior
rectus sheath
Attenuated
midline fascia
Herniated contents
progressively returned
to native
abdominal cavity
Rectus muscles
Anterior rectus sheath
External oblique
Internal oblique
Transversus
abdominis
Figure 14-11.
Cut edge of
linea alba
Divided
posterior
rectus sheath
Midline
laparotomy
Rectus muscles
Dissected
posterior
rectus sheath
256 Section V • Other Abdominal Wall Procedures
Cut edge of
Rectus muscle
reflected laterally
Lateral cutaneous branches
of intercostal nerve
External oblique
Internal oblique
Transversus
abdominis
linea alba
(interparietal plane)
Posterior rectus sheath
(reflected)
Anterior cutaneous branches
of intercostal nerves
Anterior rectus sheath
Subtle ridge:
Anterior leaf of
internal oblique
aponeurosis
fused with transversus
abdominis aponeurosis
Cut here
(1-2 mm medial to ridge)
Dissect here
Figure 14-12.
Lateral cutaneous branches
of intercostal nerve
External oblique
Internal oblique
Transversus
abdominis
Anterior branch
of intercostal nerve
Anterior cutaneous branches
of intercostal nerves
Figure 14-13.
Divided
posterior
rectus sheath
Anterior branch
of intercostal nerve
Interparietal plane
accessed between
internal oblique and
transversus abdominis
muscles
Chapter 14 • Progressive Preoperative Pneumoperitoneum 257
Anterior rectus sheath
closed in midline
Posterior rectus sheath
reapproximated in midline
Figure 14-14.
Synthetic mesh fixed between
internal oblique and
transversus abdominis muscle
258 Section V • Other Abdominal Wall Procedures
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Intraperitoneal Onlay of Mesh (IPOM) Repair
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4. Pearls/Pitfalls
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If the retromuscular space is inaccessible because of inflammation, fibrosis, or rectus mus-
cle absence, then an alternate technique for abdominal wall closure should be employed.
To ensure medial rectus reapproximation, a traditional Ramirez components separation
may be performed.
A tissue-separating mesh is deployed in the intraperitoneal position, and suture-fixated
circumferentially with a wide overlap (greater than 5 cm) utilizing full-thickness perma-
nent transabdominal sutures, placed with the Reverdin needle.
The anterior sheath is closed in the midline ventral to the mesh, using a slow-absorbing
monofilament suture and a 4:1 suture-to-wound-length ratio.
Not identifying loss of abdominal domain preoperatively can place the surgeon in a diffi-
cult position intraoperatively where they may be unable to relocate the herniated contents
back into the abdominal cavity and close the hernia defect.
The Silo technique with sequential mesh excision can be helpful in the aforementioned
scenario.
A large piece of Dualmesh (W.L. Gore, Elkton, MD) is circumferentially sewn to the fascial
edge of the hernia defect, and the skin is closed temporarily over the top of the mesh.
Every 3 days, the patient returns to the operating room where a central ovoid shape of the
mesh is excised and the cut mesh edges reapproximated. This technique slowly pulls the
abdominal wall muscles to the midline.
Once the remaining fascial gap is less than 5 cm, the mesh is completely excised and a
Ramirez components separation is performed with fascial reinforcement (synthetic, bio-
logic, or bioabsorbable) for complete abdominal wall reconstruction
Subcutaneous emphysema: Subcutaneous emphysema occurs almost uniformly in
patients undergoing PPP because air leaks out along the tract of the insufflation catheter
into the subcutaneous tissue. This is self-limited and, in our experience, has not required
any intervention.
Nutrition: Patients undergoing PPP typically experience early satiety and even anorexia
as a result of their increased intraabdominal pressure. Although every attempt should be
made to encourage enteral alimentation, parenteral nutrition may be necessary while the
patients are hospitalized for their insufflations.
Physiologic collapse during pneumoperitoneum: It is possible that a patient may
become hemodynamically unstable during PPP. For this reason patients are kept in a close
observation unit while they undergo insufflation, and vital signs are monitored closely.
Should physiologic collapse occur at any point, the pneumoperitoneum may be promptly
evacuated from the catheter, using wall suction.
Selected References
Carbonell A, Cobb WS, Chen SM: Posterior components separation during retromuscular hernia repair, Hernia: the journal of hernias and
abdominal wall surgery 12(4):359–362, 2008.
Mcadory RS, Cobb WS, Carbonell AM: Progressive preoperative pneumoperitoneum for hernias with loss of domain, The American sur-
geon 75(6):504–508, 2009:discussion 508–509.
Moreno: Chronic eventrations and large hernias. Preoperative treatment by progressive pneumoperitoneum-original procedure, Surgery
22:945–953, 1947.
Tanaka EY, Yoo JH, Rodrigues AJ, Utiyama EM, Birolini D, Rasslan S: A computerized tomography scan method for calculating the hernia
sac and abdominal cavity volume in complex large incisional hernia with loss of domain, Hernia 14(1):63–69, 2010.
Christopher G. Zochowski, MD and Hooman Soltanian, MD, FACS
1. Preoperative Considerations
C HAPT E R
15
Rotational and Free
Flap Closure of the
Abdominal Wall
1. Comorbidities
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2. Open Wound Management
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Skin and subcutaneous fat may be of varying thicknesses and qualities in patients because
of body habitus, scarring, steroid use, malnutrition, advanced age, and other factors.
Bleeding tendencies should be addressed preoperatively.
Conversely, a thrombogenic state will put any flap at risk and may warrant a hematologist
to assist in the pre- and postoperative care.
The timing of the closure of abdominal wounds is on a case-by-case basis.
Appropriate dressings should be applied to the wound before surgery to prevent desicca-
tion of the soft tissues and intraabdominal contents.
Negative pressure dressings allow for easier management of large abdominal wounds, but
the wound must be monitored closely when the dressing is applied over exposed bowel.
Some wounds require frequent debridements to determine the extent of viable tissue and
clearance of infection.
Open wounds increase the nutritional and fluid requirements of the patient.
Chronic open wounds should be converted to acute clean wounds before closure.
259
260 Section V • Other Abdominal Wall Procedures
3. Timing
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4. Defect Assessment and Flap Selection
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Optimize the patient before closure of the abdominal wall in regard to nutrition, cardiovas-
cular status, and pulmonary function. The closure may lead to prolonged intubation, and
this risk is increased in patients with chronic obstructive pulmonary disease (COPD) and
smokers.
Closure should be timed after bowel edema has subsided (stage if needed).
Avoid intraoperative nitrous oxide use. Consider a nasogastric tube.
Assess the extent of missing or aberrant structures and define the anatomical region of the
tissue loss.
Assess the quality of remaining structures and loss of domain.
Take note of an ostomy position if present.
Assess for enterocutaneous fistulae.
Rule out previous damage to the blood supply of any potential flaps.
Pedicled flaps are limited by their arc of rotation and the size and location of the defect.