Use of the bilateral anterior rectus fascia turnover method and the components separation method for a difficult abdominal closure after transplantation

Abstract

TO THE EDITORS:Primary closure of the abdomen in patients undergoing liver, intestinal, and multivisceral transplantation can be extremely difficult at times. 1-3 A variety of techniques, including pedicle flaps, free fascia grafts, skin grafts, synthetic meshes, vacuum-assisted fascial closure with an open abdomen, and abdominal wall transplantation, have been used in this situation. Here we describe our positive experience with the use of plastic surgery techniques, including the anterior rectus sheath turnover (ART) method and the components separation (CS) method, for difficult abdominal closure after transplantation.The ART technique 4,5 uses the ART as a flap pedicled to the medial edge of the rectus muscle. The procedure is started with the separation of the skin and the adipose tissue. An important anatomic point must be made with respect to the rectus sheath. An incision in the rectus sheath (1-2 cm medial to the lateral muscle border) must be maintained. After the anterior fascia is mobilized, a separate flap on each side of the rectus muscle is turned over the fascia to the midline from the right and left sides. The fascia is sutured together with interrupted and continuous sutures (Fig. 1A,B). The liver and intestine are covered, and then subcutaneous skin, undermining to the anterior axillary lines, is added bilaterally to make a skin flap; after this, the skin is primary closed. This technique also can be modified to be used for a transverse abdominal incision closure in a transverse fashion unilaterally or bilaterally.We use the CS method 6-8 as follows. In the subcutaneous plane, in front of the rectus abdominis edge, we expose anteriorly on the right and left sides the anterior rectus fascia to the anterior axillary line all the way across the external oblique fascia. We place several clamps along the anterior rectus sheath and proceed to make an external oblique incision (Fig. 1C). Then, we extend the incision proximally and distally on each side. By making the external oblique relaxing incision bilateral, we advance the rectus abdominis flaps by a distance of approximately 2.5 cm on each side. As mentioned earlier, we do not cut deeply into the internal oblique from the transverse oblique. Next, we perform a posterior rectus incision proximally and distally each side (Fig. 1D). When the rectus is separated from its posterior sheath, this layer of the abdominal wall may be advanced medially up to 3 cm on each side (Fig. 1E). We use the locked-looped suture technique for abdominal wall closure. In short, this technique is implemented out to the anterior axillary line and the posterior rectus sheath, and only incisions are released in each of the fascia.We used these procedures in 3 patients during the early postoperative period and in 1 patient during the late postoperative period. All 4 patients are doing well. We present one adult case and one pediatric case here.Case 1 was a 52-year-old male presenting with hepatic artery thrombosis and septic shock after liver transplantation. The decision w...

Anterior Rectus Sheath Turnover Method for Abdominal Wall Reconstruction in a Trauma Patient

“…However if the defect is large, the anterior rectus sheath turnover method can be a useful way to achieve abdominal wall reconstruction as in the present case. Some reports describe the use of the anterior rectus sheath turnover method for closure of a large abdominal wall defect after liver transplantation, for large hernias of the abdominal wall, or in trauma patients with a difficult abdomen (1)(2)(3)(4). This procedure allows the closure of large defects without synthetic …”