|Year : 2016 | Volume
| Issue : 3 | Page : 549-553
The anterior rectus abdominis sheath flap for fascial closure in burst abdomen and midline incisional hernia
Soliman A El Shakhs1, Ahmed M Fawzy1, Bahaa A Mashaal2
1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 El Santa, Al Gharbia, Egypt
|Date of Submission||11-Feb-2015|
|Date of Acceptance||11-Apr-2015|
|Date of Web Publication||23-Jan-2017|
Bahaa A Mashaal
El Santa, Al Gharbia, 31511
Source of Support: None, Conflict of Interest: None
The aim of this study is to evaluate the effect of using the anterior rectus abdominis sheath flap in the repair of burst abdomen and midline incisional hernia.
Complex abdominal wall hernias can be challenging for the reconstructive surgeon. The use of autologous tissue is preferable when possible. This repair entails a single fascial incision releasing the anterior rectus sheath as a turnover flap for abdominal wall reconstruction. This allows large defects to be closed with autologous tissue alone in a two-layer fascial repair in a vest-over-pants manner in a simple, straightforward surgical approach.
Materials and methods
Thirty participants requiring open abdominal management over a 26-month period were reviewed who underwent the anterior rectus abdominis sheath flap which released by lateral incision that meeting in midline as open book closing the defect ± the mesh. Hospital and office-based charts were reviewed.
Thirty patients included in this study have risk factors such as anaemia (14:46.7%), malnutrition (11:36.7%), smoking (17:56.7%), obesity (16:53.3%), malignancy (17:56.7%), diabetes (8:26.7%) and chest complications (chronic obstructive pulmonary disease) (12:40%), with the cause of primary lesion divided into intestinal obstruction (6:20%), gastrointestinal tract malignancy (10:33.34%), miscellaneous (gynaecological and urological) (7:23.33%) and traumatic laparatomy (7:23.33%). Postoperative complications were wound infection (6:20%), seroma (5:16.6%), skin necrosis (3:10%), recurrence (1:3.3%), haematoma (1:3.3%) and no fistula. The average length of follow-up was 6-26 months.
The use of the anterior rectus abdominis sheath flap is an important technique for fascial closure in burst abdomen and midline incisional hernia; it is a simple and natural technique and provides a fascial closure with low recurrence and acceptable complications.
Keywords: anterior rectus abdominis sheath, burst abdomen, midline incisional hernia
|How to cite this article:|
El Shakhs SA, Fawzy AM, Mashaal BA. The anterior rectus abdominis sheath flap for fascial closure in burst abdomen and midline incisional hernia. Menoufia Med J 2016;29:549-53
|How to cite this URL:|
El Shakhs SA, Fawzy AM, Mashaal BA. The anterior rectus abdominis sheath flap for fascial closure in burst abdomen and midline incisional hernia. Menoufia Med J [serial online] 2016 [cited 2020 Mar 30];29:549-53. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/549/198698
| Introduction|| |
The burst abdomen is a serious postoperative complication that concerns many surgeons. The disruption of the wound tends to occur between the sixth and eighth day. Serosanguinous (pink) discharge from the wound is the most pathognomonic sign of impending wound disruption. Poor closure techniques, deep wound infections, increasing intra-abdominal pressure in the early postoperative period and poor metabolic state of the patient are the most common predisposing factors .
An incisional hernia is a diffuse reducible bulging of the whole length of the incision in midline with a cough impulse, and it may be complicated if it is not repaired. It usually starts as a symptomless partial disruption of the deeper layers of a laparotomy wound during the immediate or very early postoperative period  .
An incisional hernia occurs when all the layers except the skin fail to heal. It is one of the most common conditions requiring major surgery, despite advances in surgical techniques and suture material  .
Despite advances in surgical techniques, surgical skills, antimicrobial therapy and intensive care support, fascial dehiscence after laparotomy remains a potentially fatal complication. The reported incidence of fascial dehiscence after emergency laparotomy ranges from 18 to 38% .
Despite a better understanding of wound healing and good suturing techniques, the incidence of various wound complications, including a burst abdomen and incisional hernia, in later stages is quite high in the case of an emergency laparotomy .
| Materials and methods|| |
The study was approved by the ethical committee of the college and an informed written consent was obtained from all the participants. This study was conducted on 30 patients who underwent laparotomy and were suffering from either burst abdomen, seven patients (23.33%), or midline incisional hernia, 23 patients (76.66%); the patients came to Department of General Surgery in Menoufia University and General Mahla Hospital during the period from October 2012 to November 2014, with the period of postoperative follow-up of the patients ranging from 6 to 26 months.
The patients included 21 men (70%) and nine women (30%), with age ranging from 23 to 65 years with a mean of 42.65; the patients' complications were repaired by using anterior rectus abdominis sheath flap with or without the mesh.
The patients included in this study had the following risk factors: anaemia in 14 patients (46.7%), malnutrition in 11 patients (36.7%), smoking in 17 patients (56.7%), obesity in 16 patients (53.3%), malignancy in 17 patients (56.7%), diabetes in eight patients (26.7%) and chest complications [chronic obstructive pulmonary disease (COPD)] in 12 patients (40%). The causes of primary lesions were intestinal obstruction in six patients (20%), traumatic laparatomy in seven patients (23.33%), gastrointestinal tract malignancy in 10 patients (33.34%) and miscellaneous (gynaecological and urological) in seven patients (23.33%).
The patients were operated upon after debridement, and all attenuated tissues were excised leaving behind a healthy fascial margin and a cleaned wound bed in cases of burst abdomen. In cases of midline incisional hernia, the procedure was started by midline incision with excision of the previous scar and then the underlying adipose tissue was elevated from the anterior rectus sheath as a flap, the base of which is just beyond the lateral border of the rectus muscle; it is important to avoid carrying this dissection too far laterally, as this may jeopardize the vascularity of the medial skin flap, as in [Figure 1].
Once this has been completed, the procedure begins by incising the anterior sheath of the rectus muscle along the entire length about 2-3 mm medial to its lateral border; this entry point is chosen carefully to avoid entering at the conjoined point of the semilunar line, which may lead to potential weakness and subsequent hernia formation. The anterior sheath is then dissected from lateral to medial, thereby freeing it from the rectus muscle; the linea alba is kept intact and it serves as the medial hinge.
The fascial flap is then reflected like the page of an open book; during this dissection, care must be taken not to damage the anterior sheath, especially along the tendinous intersections, because at these areas the sheath is found to be more adherent to the muscle. The planes can be difficult to identify in the multiply reoperated abdomen, and therefore we recommend beginning the dissection in an area where there is less scarring to more easily identify the anterior sheath and not to exceed too much in elevating the adipocutaneous flaps to avoid medial edge flap ischaemia, simultaneous hernias and wound-healing complications. After dissection of both the anterior rectus sheaths from the rectus muscle, they are rotated medially and meet in the midline, allowing for complete coverage of the fascial defect. In patients with a small defect, we close the rectus sheath in a double-breasted (vest-over-pants) technique by prolene 1, as in [Figure 2].
|Figure 2: The fascial flap is then reflected like the page of an open book, and then closed in a double-breasted (vest-over-pants) technique by prolene 1 in a small defect; black arrow shows the tendinous intersections.|
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We closed the sheath in a large defect in a single layer, in which we used a mesh in midline incisional hernia, which reinforces the repair, as in [Figure 3].
|Figure 3: The rectus sheath is closed in a single layer with mesh in a large defect.|
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We did not use a mesh in burst abdomen because an infection may occur. We put a suction drain on the mesh and closed the subcutaneous fat in two layers and then the skin by subcuticular or vertical mattress suture; next, we applied an abdominal binder, as in [Figure 4].
Perfect haemostasis was performed before putting the mesh in midline incisional hernia or closure of the abdomen in burst abdomen. Placement of drains helped to limit haematoma and seroma formation, which may lead to poor wound healing and infectious complications. Patients were extubated while under anesthesia in a deep plane in an attempt to minimize airway stimulation with subsequent coughing and straining.
| Results|| |
The patients included in this study were 21 men (70%) and nine women (30%), with age ranging from 23 to 65 years with a mean ± SD of 42.65 ± 2.42, postoperative follow-up ranging from 6 to 26 months, and hospital stay ranging from 5 to 10 days. Seven patients (32.33%) presented with burst abdomen, 23 patients (76.66%) presented with midline incisional hernia, and mesh was used in about 23 patients (76.66%). Characteristics of patients undergoing closure with the anterior rectus abdominis sheath flap are summarized in [Table 1].
|Table 1 Characteristics of patients undergoing closure with the anterior rectus abdominis sheath flap |
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Postoperative complications were as follows: wound infection in six patients (20%), seroma in five patients (16.6%), skin necrosis in three patients (10%), recurrence in one patient (3.3%), haematoma in one patient (3.3%) and no fistula, as in [Table 2] and [Figure 5].
|Table 2 Number and percentage distribution of postoperative complications |
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| Discussion|| |
Burst abdomen is a serious complication in any abdominal surgery with very high mortality rate and no single cause; rather, it is a multifactorial problem  .
The ventral hernia is a common surgical complaint. Prevention is the better treatment in the form of meticulous dissection and proper postoperative care. The presence of a ventral hernia is itself an indication for repair when no substantial comorbid conditions exist. Elective ventral and incisional hernia repair are undertaken largely to alleviate symptoms and to prevent hernia incarceration with subsequent strangulation of the intestine  .
Despite advances in many fields of surgery, incisional hernia still remains a significant problem. There is a lack of general consensus among surgeons regarding optimal treatment. A surgeon's approach is often based on tradition rather than on clinical evidence. The surgeon's treatment plan should be comprehensive, with attention focused not merely on restoration of structural continuity. An understanding of the structural and functional anatomy of the abdominal wall and an appreciation of the importance of restoring dynamic function are necessary for the successful reconstruction of the abdominal wall .
The goals of abdominal wall reconstruction are to restore the integrity of the abdominal wall, provide dynamic support, protect the abdominal contents and minimize complications  . The eradication of the infection and providing a stable coverage of the abdominal contents with well-vascularized tissues are added purposes of any reconstruction of abdominal defects  .
In this study, the main risk factors that are significant with burst abdomen and midline incisional hernia are anaemia in 14 patients (46.7%), malnutrition in 11 patients (36.7%), smoking in 17 patients (56.7%), obesity in 16 patients (53.3%), malignancy in 17 patients (56.7%), diabetes in eight patients (26.7%) and chest complication (COPD) in 12 patients (40%), and this is different from the study conducted by Mericli et al.  , which reported hypertension (50%), diabetes (14%), smoking (17%) and COPD (14%) as risk factors.
We distribute the primary lesion of patients into intestinal obstruction (20%), gastrointestinal tract malignancy (33.3%), miscellaneous (gynaecological and urological) (23.3%) (nontraumatic 76.6%) and traumatic laparatomy (23.3%), and this is not in agreement with the study conducted by Mericli et al.  , which distributes them into penetrating trauma (23%), blunt trauma (23%) (trauma 46%) and nontrauma (54%).
We noticed that the percentages of postoperative complications among the studied groups (30 patients), which were wound infection in six patients (20%), seroma in five patients (16.6%), skin necrosis in three patients (10%), recurrence in one patient (3.3%), haematoma in one patient (3.3%) and no fistula occurring postoperatively, were nearly similar to the study reported by Ennis et al.  , which reported the following postoperative complications among the studied groups (10 patients), in which five patients (50%) had complications - cellulitis in one patient (10%), skin necrosis in one patient (10%), infected mesh in two patients (20%) and recurrent hernia in one patient (10%).
We found that no enterocutaneous fistula or abdominal abscess occurred, which is in agreement with the study reported by Kushimoto et al.  and not in agreement with the study conducted by Ennis et al. .
Voyles and colleagues (1981) reported long-term mesh extrusion or fistula formation to be 78 and 22%, respectively. Later, Karakousis and colleagues (1995) confirmed these data, documenting a fistula occurrence rate of 23% after abdominal wall repair with synthetic mesh, which is not in agreement with our study; this may be because of development of surgery and the quality of meshes during this period, which may be rejected by the body , .
| Conclusion|| |
It is important to understand the risk factors for the development of midline incisional hernia and burst abdomen; an increase in these factors leads to increasing postoperative complications and vice versa.
Prevention of visceral eventration, incorporation of the remaining abdominal wall in the repair, provision of dynamic muscular support, decreasing postoperative infection and restoration of abdominal wall continuity in a tension-free manner are the important goals of abdominal wall reconstruction in this technique.
Therefore, the use of the anterior rectus abdominis sheath flap is an important technique for fascial closure in burst abdomen and midline incisional hernia, which is a simple and natural procedure and provides a fascial closure with low recurrence and less postoperative complications.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Kingsnorth AN, LeBlanc KA. Management of abdominal hernia. Bailey and Love's 2008; 25 th
Nyhus LM, Condon RE. Hernia, Bailey and Love's 2008; 25 th
HM Goda El-Santawy, ABE-A El-Sisy, AS El-Gammal, AF El-Kased, HM Sultan. Evaluation of retromuscular mesh repair technique for treatment of ventral incisional hernia. Menoufia Med J 2014; 27
Marwah S, Marwah N, Singh M, Kapoor A, Karwasra RK. Addition of rectus sheath relaxation incisions to emergency midline laparotomy for peritonitis to prevent fascial dehiscence. World J Surg 2005; 239
Rohrich RJ, Lowe JB, Baty JD, Hackney FL, Bowman JL, Hobar PC. An algorithm for abdominal wall reconstruction. Plast Reconstr Surg 2000; 105
Doreswamy Mahimanjan singh SR. Clinical study and management of ventral hernias 2011: p: 1-2.
Shell DHIV, J de la Torre, P
Andrades, LO Vasconez. Open repair of ventral incisional hernias. Surg Clin N Am 2008; 88
Lowe JB. Updated algorithm for abdominal wall reconstruction. Clin Plast Surg 2006; 33
Cohen M. Management of abdominal wall defects resulting from complications of surgical procedures. Clin Plast Surg 2006; 33
Mericli Alexander F, D Bell, BR DeGeorge, DB Drake. The single fascial incision modification of the 'open-book' component separation repair. Ann Plast Surg 2013; 71
Ennis LS, Young JS, Gampper TJ, DB Drake. The 'open-book' variation of component separation for repair of massive midline abdominal wall hernia. Am Surg 2003; 69
Kushimoto S, Y Yamamoto, J Aiboshi, F Ogawa, Y Koido, R Yoshida, et al.
Usefulness of the bilateral anterior rectus abdominis sheath turnover flap method for early fascial closure in patients requiring open abdominal management. World J Surg 2007; 31
Voyles CR, Richardson JD, Bland KI, Tobin GR, Flint LM, Polk HCJr. Emergency abdominal wall reconstruction with polypropylene mesh: short-term benefits versus long-term complications. Ann Surg 1981; 194
Karakousis CP, Volpe C, Tanski J, Colby ED, Winston J, Driscoll DL. Use of a mesh for musculoaponeurotic defects of the abdominal wall in cancer surgery and the risk of bowel fistulas. J Am Coll Surg 1995; 181
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]