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Chapter 15 • Rotational and Free Flap Closure of the Abdominal Wall 281
A
Figure 15-13.
Perforators
DIEA
dissected
from rectus
abdominis
External
iliac
B
282 Section V • Other Abdominal Wall Procedures
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3. Thoracoepigastric Flap
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Anatomy
Dissection proceeds until the lateral border of the rectus abdominis.
Care is taken to protect desirable perforators leading to the designed skin paddle.
Then a disk of the rectus abdominis and its sheath that encircle the perforators are isolated.
The sheath and muscle at the superior border are divided and the connections to the supe-
rior epigastric system are ligated.
A sparing amount of muscle and fascia is taken to facilitate closure and reduce donor site
morbidity.
Care is taken to incise the sheath above the arcuate line.
The sheath is then incised longitudinally and the rectus abdominis is dissected free.
The DIEA is dissected from the undersurface of the muscle.
The pedicle will then course inferolaterally to the external iliac and is ligated at this level.
The rectus sheath is repaired to prevent hernia formation or bulge.
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Flap Design
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The DIEA supplies the majority of the major perforating vessels leaving the rectus abdomi-
nis muscle and running laterally to the area of the latissimus in a suprafascial plane.
The superior epigastric artery is smaller than the DIEA, but it supplies the upper abdomi-
nal and thoracic flaps (Fig. 15-14, A).
The superior epigastric is derived mainly from the internal mammary artery but receives
contributions from the terminal branches of the intercostals and the SIEA.
The flap includes skin, subcutaneous tissue, and muscular fascia of the lateral thoracic and
upper abdomen.
It can be delayed for larger flaps (Fig. 15-14, B).
The base of the flap is the lateral border of the rectus sheath, and this is the point of
rotation.
The lateral border is the posterior axillary line or anterior edge of the latissimus dorsi
muscle. A delayed flap may extend to 5 cm within the dorsal midline.
The upper limit in men is the base of areola; in women, the upper limit is the inframam-
mary fold (IMF).
The base can be moved cranially or caudally as long as a perforator is included.
Flap width can be 10- to 15 cm, with some descriptions of up to 30 cm.
The donor site can be closed with a width of 16 cm in an obese patient and 10 cm in a thin
patient.
Chapter 15 • Rotational and Free Flap Closure of the Abdominal Wall 283
Anterior border
Superior epigastric
Rectus
abdominis
Lateral
perforators
Inferior epigastric
A B
Internal thoracic
Medial
perforators
of latissimus dorsi
Undelayed
flap limits
Small thoracoepigastric flap
Figure 15-14.
C
284 Section V • Other Abdominal Wall Procedures
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Marking and Dissection: (Fig. 15-14 C)
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4. Anterolateral Thigh
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Anatomy
The lateral border of the rectus abdominis is palpated and marked.
The flap is elevated in a lateral to medial fashion.
At the lateral aspect, the muscular intercostal perforators (usually over the serratus ante-
rior) are divided.
The elevation from axillary line to the lateral border of the rectus is in a subfascial plane to
protect the perforators.
There is no dissection medial to the lateral border of the rectus.
The perforating vessels may not ever be visualized, and a Doppler may be used for confir-
mation of perforator inclusion.
Posterolaterally, the flap is more random and can be suprafascial.
Closure is layered and over drains.
If the donor site cannot be closed, a split thickness skin graft can be used.
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Flap Design
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The skin and subcutaneous fat in the anterolateral thigh (ALT) can be thin.
The artery’s anatomy is variable with size ranging from 1 to 3 mm in diameter. The pedicle
can be as long as 7 or 8 cm. It is supplied by the descending branch of the lateral femoral
circumflex artery from the profunda femoris. The descending branch travels deep within
the space between the rectus femoris muscle and the vastus lateralis muscle.
The major draining vein is slightly larger than the artery. Two venae accompany the artery
and merge into one at their apex.
A major branch of the lateral cutaneous nerve of the thigh enters the flap at the superior
aspect.
The anterolateral thigh flap lies on the axis of the septum dividing the vastus lateralis and
the rectus femoris muscles.
The skin paddle can be as large as 8 × 25 cm with possible primary closure.
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Marking and Dissection
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The axis of the septum between the rectus femoris and the vastus lateralis is marked by a
line connecting the ASIS and the lateral patella (Fig. 15-15).
Chapter 15 • Rotational and Free Flap Closure of the Abdominal Wall 285
ASIS
Lateral circumflex
artery and vein
Junction one third
Junction two thirds
Lateral patella
Figure 15-15.
286 Section V • Other Abdominal Wall Procedures
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This line is divided into thirds. The junction of the proximal and middle third is often the
site of a perforator that pierces the TFL. It is incorporated for the rare circumstance when
the distal perforators are of poor quality or injured during dissection.
The junction of the middle and distal third is marked and is also incorporated into the flap
(Fig. 15-16).
The middle third of the axis line generally encompasses all substantial perforating vessels.
A pencil Doppler exam can confirm that perforators are present.
The anterior flap is elevated first, noting any vessels perforating the rectus femoris. Vessels
near the septum are preserved until the posterior flap is elevated.
Two perforators are found and preserved. The superior perforators may arise from the rec-
tus femoris muscle. The inferior perforators may arise either via the septum or through the
medial aspect of the vastus lateralis muscle.
The posterior flap is elevated toward the septum only after localization of a substantial
perforator. If there is no usable perforator or if it is damaged during dissection, the flap is
sutured back down to the donor bed.
The lower perforator can be seen to travel through the vastus and should be dissected
toward the descending branch of the lateral circumflex femoral artery (LCFA).
The septum is identified and any septal perforators are noted. If an adequate perforator is
noted, then the flap can be based upon it. Anterior elevation can continue until the septum
is isolated both medially and laterally.
If the blood supply is entirely septal, the descending branch of the LCFA is found at the
base of the septum between the rectus femoris and vastus lateralis and dissected proxi-
mally (Fig. 15-17).
If the perforator courses in a transmuscular course, it must be dissected through to the
descending branch.
A light circumferential pressure dressing can be applied to the thigh postoperatively.
Closed suction is used.
The patient is allowed to ambulate as soon as clinically indicated for the flap reconstruction.
Chapter 15 • Rotational and Free Flap Closure of the Abdominal Wall 287
Junction one third
Junction two thirds
Figure 15-16.
Vastus lateralis
Descending branch
of LCF vessels
Rectus femoris
Figure 15-17.
288 Section V • Other Abdominal Wall Procedures
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Flap Variations
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Flap variations include an anterolateral thigh adipofascial flap and an anterolateral thigh
4. Postoperative Care
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Patients are allowed to ambulate at differing times, depending on the type of flap used.
Support by an abdominal binder may be used if applied properly. A binder that is too tight
Diets are advanced as tolerated, based on the amount of intestinal manipulation required
Drains are maintained until their drainage is <20 to 30 mL per drain per 24-hour period
The patient may require monitoring in an intensive care unit for free tissue monitoring and
fascial flap.
Free tissue transfer may preclude earlier ambulation to protect the anastomosis.
may cause perfusion problems.
during opening of the hernia and lysis of adhesions.
depending on the site.
increased pulmonary restriction after decreasing the abdominal volume. In addition, many
patients requiring closure of the abdominal wall have other severe comorbidities.
5. Pearls/Pitfalls
Chapter 15 • Rotational and Free Flap Closure of the Abdominal Wall 289
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Selected References
Gottlieb JR, Engrav LH, Walkinshaw MD, Eddy AC, Herman CM: Upper abdominal wall defects: immediate or staged reconstruction?
Plast Reconstr Surg 86(2):281–286, 1990.
Mansberger AR Jr, Kang JS, Beebe HG, Le Flore I: Repair of massive acute abdominal wall defects, J Trauma 13(9):766–774, 1973.
Mathes SJ, Steinwald PM, Foster RD, Hoffman WY, Anthony JP: Complex abdominal wall reconstruction: a comparison of flap and mesh
closure, Ann Surg 232(4):586–596, 2000.
Rohrich RJ, Lowe JB, Hackney FL, Bowman JL, Hobar PC: An algorithm for abdominal wall reconstruction. Plast Recon Surg 105(1):
202–216.
Steinwald PM, Mathes SJ: Management of the complex abdominal wall wound, Adv Surg 35:77–108, 2001.
Strauch B, Vasconez LO, Hall-Findlay EJ, editors: Grabb’s Encyclopedia of Flaps, ed 2, Philadelphia, 1998, Lippincott- Raven.
Yeh K, Saltz R, Howdieshell T: Abdominal wall reconstruction after temporary abdominal wall closure in trauma patients, Southern Medi-
cal Journal 89(5):497–502, 1996.
If a pedicled flap is not adequate, then free tissue transfer may be the next step.
As previously stated, not all the described pedicled flaps are good options for free tissue
transfer. There are limitations in vessel match, length of pedicle, size and type of tissue to
be transferred.
For perforator based flaps, such as the ALT flap, the size and location of the perforator
determines whether an additional vessel is needed.
Vessels can be temporarily clamped with micro clamps to determine inflow dominance.
Closure of the abdominal defect with a combination of flap and synthetic or biologic mesh
may be required.
Each flap choice needs to be assessed for potential morbidity.
1. Clinical Anatomy
Management of the open abdomen does not depend so much on recognition of the anatomy of
the abdominal wall but on the maintenance of the anterior peritoneal space (Fig. 16-1). If this
space is maintained, there is the potential to continue to work toward closure of the abdominal
wall. If this space is lost, then the surgeon must move on to protecting the viscera from the
external environment and trying to obtain skin closure over the bowel.
C HAPT E R
16
Managing the Open
Abdomen
Daniel Vargo, MD
2. Preoperative Considerations
1. Resuscitation
Patients who require open abdomens usually fall into one of two categories: those who still
have an acute process ongoing (Fig. 16-2) and those who are in the stable phase and are in the
process of having their abdomens closed (Fig. 16-3).
Those in the acute phase need to have physiologic abnormalities—acidosis, hypothermia,
and coagulopathy—corrected. Providing crystalloid and blood products will accomplish this,
although volume resuscitation can itself have adverse effects, specifically on intraabdominal
pressure and the development of abdominal compartment syndrome (ACS). Even if the abdomen has a temporary covering in place, intraabdominal pressures need to be monitored. This
is typically done with monitoring of bladder pressure. If bladder pressure is elevated or if the
patient is clinically developing ACS, then the closure that was placed on the abdomen needs to
be loosened to allow the viscera to expand and take pressure off of the vena cava, kidneys, and
lungs.
290