Abdominal wall reconstruction with Two-step Technique (TST): a prospective study in 20 patients

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1 International Wound Journal ISSN ORIGINAL ARTICLE Abdominal wall reconstruction with Two-step Technique (TST): a prospective study in 20 patients Marwan Al Zarouni 1, Mario A. Trelles 2 & Franck M. Leclère 3 1 Department of Plastic and Reconstructive Surgery, Rashid University Hospital of Dubai, Dubai, United Arab Emirates 2 Instituto Médico Vilafortuny, FUNDACION ANTONI DE GIMBERNAT, Cambrils, Spain 3 Department of Plastic Surgery and Handsurgery, Inselspital Bern, University of Bern, Bern, Switzerland Key words Abdominal wall defect; Compartment syndrome; Inner layer reconstruction; VAC Correspondence to Franck Marie Leclère, MD, PhD Department of Hand and Plastic Surgery Inselspital Bern University of Bern Freiburgstrasse Bern 3008 Switzerland franckleclere@yahoo.fr doi: /iwj Al Zarouni M, Trelles MA, Leclère FM. Abdominal wall reconstruction with Two-step Technique (TST): a prospective study in 20 patients. Int Wound J 2015; 12: Abstract Abdominal wall defects continue to be a challenging problem for reconstructive surgeons. The aim of our study was to report a 3-year experience using a simple Two-step Technique (TST) to treat abdominal wall defects. Between January 2008 and December 2010, 20 patients with abdominal wall defects were treated by TST. Patients had a mean age of 37 5 ± 14 9 years (range: years); 5 were women and 15 were men. The size of the defects was prospectively analysed. Early and late complications were recorded. Hospital stay, post-procedure downtime and patient overall satisfaction were systematically assessed. A secondary defect resulting from self-manipulation and an infection were responsible for a complication rate of 10%. Both underwent successful surgical revision which led to full resolution. The average hospital stay was 11 2 ± 4 9 weeks for the series. Long-term complications were scar hyperpigmentation in 11 cases, scar hypertrophy in 5 cases and scar widening in 3 cases. Mean patient satisfaction was 8 3 ± 0 5 [visual analogue scale (VAS) 0 10]. Average downtime post surgery was 4 1 ± 1 2 weeks. The mean follow-up was 24 6 ± 6 7 months. Reconstruction of abdominal wall defect with the TST is a reliable and reproducible technique. This technique provides excellent outcomes, and we anticipate that it will become widespread in the near future. Introduction Abdominal wall defects continue to be a challenging problem for reconstructive surgeons (1 4), as they are often the results of predisposing factors combined with congenital malformations, trauma, infections, compartment syndrome, tumour resection or as a complication of previous abdominal surgery. The defects can be complete, involving the entire abdominal wall and exposing the bowels, or incomplete with a thin layer covering the abdomen. Factors to be considered when choosing the appropriate surgical treatment are (i) size of the defect (ii) area involved, (iii) presence or absence of infection, (iv) prior surgery, (v) experience of the surgical team, (vii) associated injuries and (viii) prior illness of the patient. In most cases of acquired abdominal wall defects, a primary closure is generally not feasible and a temporary abdominal closure with vacuum-assisted closure (VAC) (5 10) is Key Messages the TST is able to treat small/intermediate abdominal wall defects this technique includes VAC (step one) and inner layer reconstruction with edges de-epidermisation and inversion (step two) the defects were scanned and compared with the help of the Sigmascans software so as to obtain an objective interpretation however, the Opsites were scanned before VAC therapy (step one) after this first step, it is known that these defects were smaller in size. We can easily imagine that in case of larger defects, an alternative technique of reconstruction would have been necessary International Wound Journal 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd 173

2 Abdominal wall reconstruction with Two-step Technique indicated in order to avoid mortality. The literature offers several options for definitive abdominal closure: synthetic mesh (11), porcine dermis (12), human acellular dermal matrix (13), human dura mater allograft (1), non-vascularised fascial grafts, rotation flaps (3), myocutaneous pedicle flaps (14,15), free flaps, components separation of the rectus muscle with or without release of the interface between the external and internal oblique fascias (16 19) and tissue expansion (20). However, all these are usually associated with complications including subsequent adhesion formation, recurrence, enterocutaneous fistulas, intestinal obstruction or infection. The aim of our study was to report a 3-year experience using a simple Two-step Technique (TST) to treat abdominal wall defects. This technique, which includes VAC (step one) and inner layer reconstruction with edges de-epidermisation and inversion (step two), is described and documented. Materials and methods Patients Between January 2008 and December 2010, 20 patients were treated using our TST. All patients were informed of the purpose and the possible outcomes of the study, signed forms of consent and agreed to clinical photography. Exclusion criteria were the following: history of coagulation disorders, diabetes, defect size bigger than 850 cm 2 and body mass index (BMI) >35 kg/m 2. Patients had a mean age of 37 5 ± 14 9 years (range: years), 5 were women and 15 were men. Nine patients were smokers. Fifteen patients had a BMI <30 kg/m 2 and five patients had a BMI between 30 and 35 kg/m 2 (Table 1). Abdominal defects The aetiologies of the abdominal wall defects were carefully noted. The wound was initially debrided. Ulcer size and shape were then plotted planimetrically by copying their shape on an Opsite foil with a waterproof marker. The Opsite was then placed on a graphic table and layouts were transferred to a computer with the help of the Sigmascans software. This software automatically calculates the perimeter and area of the abdominal defect in pixels. Digital photographs were also realised. Surgical technique During the first stage of the technique, a Mepithel Silicon Sheet (Molnlycky, Gotenberg, Sweden) was applied to the wound (Figure 1A) and covered with a VAC device so as to stimulate the formation of granulation tissue and to decrease the oedema (Figure 1B). The dressing was changed twice a week for 3 weeks creating a thick, strong layer of fibrotic tissue formation at the peripheral edge of the wound (Figure 1C). During the second stage, 3 cm of the wound border was de-epidermised (Figure 2A and B). The outer border of the raw area was incised deep into the muscle fascia (Figure 2C). The de-epidermised skin was then inverted in order to cover the central defect acting as a new fasciocutaneous inner layer (Figure 2D). The skin was then closed directly over the reconstructed inner layer (Figure 3A and B). Postoperative care M. Al Zarouni et al. Postoperatively, patients were monitored closely for complications. The drains were removed, and when less than 20 ml it was drained over a 24-hour period. Patients were mobilised as soon as possible and discharged once the drains had been removed. Patients were regularly evaluated until fully healed. Duration of hospital stay and downtime were recorded. Postoperative follow-up Early complications were defined as seroma, haematoma and infection. We defined seroma as fluid collections that required drainage. Patient pain during the perioperative management was evaluated by a questionnaire using a visual analogue score (0 10), with 10 being the worst possible pain experienced during the perioperative management. Late follow-up Late complications were defined as recurrence, hernias, hypertrophic scar or keloids and alteration in sensitivity. Recurrence was defined as any abnormal protrusion or defect at the site of the previous surgery. Patient satisfaction at the last follow-up was recorded using a visual analogue score (0 10), with 0 being the worst and 10 being the best aesthetic result. Statistical analysis This prospective study included 20 patients with abdominal wall defect. The different measurements are reported in Table 1. Data are presented as mean standard error of the mean. Results Twenty abdominal complete central defects were covered with our TST in 20 patients. The mean size of the defects was ± 245 0cm 2. Aetiologies were traumatic in 10 cases, infections in 4 cases, fistulae in 3 cases, ulcer in 2 cases and congenital in 1 case. Perioperative follow-up For one patient, the reconstructed inner layer was too weak and a prolen mesh was laid to strengthen the anterior abdominal wall. A secondary defect due to self-manipulation and an infection by another patient were responsible for a complication rate of 10%. Both underwent successful surgical revision, which led to complete wound healing. The postoperative period was incident-free for the other patients. The drains were removed after an average of 1 9 days. Mean patient pain was 2 4 ± 0 5. The average hospital stay was 11 2 ± 4 9 weeks for the series. Long-term evaluation Long-term complications were scar hyperpigmentation in 11 cases, scar hypertrophy in 5 cases and scar widening in 174 International Wound Journal 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd

3 M. Al Zarouni et al. Abdominal wall reconstruction with Two-step Technique Table 1 Our series of 20 patients with abdominal defect reconstructed with our TST Smoking status (cigarettes N Age Sex per day) BMI ASA Type of defect Number of previous abdominal operations Aetiology of the defect Size of the defect (cm 2 ) Postoperative short-term complications Patient perioperative pain (VAS 0 10) Hospital stay related to surgery (weeks) Long-term complications Downtime after operation (weeks) Patient satisfaction (VAS 0 10) Follow-up (months) 1 37 M Complete 11 Acute portal vein thrombosis + intestinal fistulas Scar hypertrophy M Complete 5 Polytrauma Scar hyperpigmentation M Complete 7 Perforated duodenal ulcer Scar hyperpigmentation M Complete 4 Perforated terminal ileum + enterocutaneous fistula 5 41 M Complete 6 Abdominal Trauma + small bowel fistula formation Scar widening M Complete 5 Perforated duodenal ulcer 547 Infection M Complete 10 Abdominal trauma Scar hypertrophy M Complete 4 Gangrenous and perforated appendicitis with peritonitis and gangrenous omentum 9 22 M Complete 9 Abdominal trauma X-shaped wound Scar hyperpigmentation Secondary defect due to self manipulation 2 23 Scar hypertrophy F Complete 8 Polytrauma F Complete 5 Polytrauma Scar hyperpigmentation F Complete 10 Gangrenous and perforated appendicitis with peritonitis and gangrenous omentum Scar hyperpigmentation F Complete 6 Polytrauma M Complete 5 Polytrauma Scar hyperpigmentation M Complete 4 Old abdominal trauma repaired with abdominal hernia formation F Complete 2 Infected abdominal wound post abdominoplasty M Complete 3 Perforated small bowel + fistula Scar hyperpigmentation Scar widening & hyperpigmentation Scar hypertrophy M Complete 3 Abdominal & chest infection Scar hypertrophy & hyperpigmentation M Complete 7 Congenital diaphragm hernia with bowel in left chest Scar widening & hyperpigmentation M Complete 8 Polytrauma Scar hyperpigmentation ASA, American Society of Anesthesiologists; BMI, body mass index; TST, Two-step Technique; VAS, visual analogue scale. International Wound Journal 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd 175

4 Abdominal wall reconstruction with Two-step Technique Figure 1 First step of the surgical technique. (A) The complete abdominal wall defect. (B) A mepithel silicon sheet is applied to the defect and covered by a vacuum-assisted closure (VAC) devise; (C) The wound three weeks after VAC therapy. 3 cases. There were no recurrences, hernia or infection in the series. Mean patient satisfaction was 8 3 ± 0 5. Average downtime post final surgery was 4 1 ± 1 2 weeks. Mean follow-up was 24 6 ± 6 7 months. Discussion In our series, 20 abdominal wall defects were treated using our TST. In one patient, the reconstructed inner layer was too weak and a Prolen mesh was necessary to complete reconstruction. Postoperative complications occurred in 10% of cases. Long-term complications were minor and included scar M. Al Zarouni et al. hypertrophy, hyperpigmentation and scar widening. Moreover, our results from the visual analogue scale (VAS) scores suggest that patients experienced minimal discomfort, underlining the safety and efficacy of the surgical TST. As shown in numerous published articles, open abdomens still present a therapeutic challenge to reconstructive surgeons. The type of defect can be classified as partial when skin, subcutaneous tissue and part of muscle/fascia are lost or complete when all the layers are involved. Based on the dimensions, Rodrich et al. (21) have classified tissue loss into small size defects (<5 cm), intermediate size (5 15 cm) and large size (>15 cm) defects. Because the size of the defect has a major impact on the surgical therapy, we were careful to evaluate it more precisely using the Opsite method, previously reported to be effective (22). In our study, the Opsite was scanned and compared with the help of the Sigmascans software so as to obtain an objective interpretation of the results. This software automatically calculates the perimeter and area of the defect in pixels. The defects were of intermediate or large size so that direct cover was not possible. For this reason, we decided first to reduce the size with VAC therapy for the first 3 weeks. This therapy offers many advantages (23 26): (i) It is easily performed and managed. (ii) It allows for a temporary abdominal closure so as to avoid mortality and prevent contamination of the peritoneal cavity. (iii) Furthermore, the silicone sheet prevents adhesions between the viscera and the peritoneum, allowing for the abdominal wall to glide over the viscera and offers easy abdominal access should complications occur. (iv) This therapy allows for the wound fluid to be drained out of the abdominal cavity. (v) It stimulates the granulation process, thus reducing the size of the defect. Finally, (vi) it allows for the planning of the second step in a normal surgical programme. The second step is technically simple: The edge of the wound is de-epidermised and inverted in order to reconstruct an inner layer. The edges of the defect are then easily prepared to cover the reconstructed inner layer. Given the Figure 2 Second step of the surgical technique. (A, B) De-epidermisation of the wound border. (C) The outer border of the de-epidermised area is incised deep into the muscle fascia. (D) The de-epidermised skin is then inverted in order to cover the central defect acting as new fasciocutaneous inner layer. 176 International Wound Journal 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd

5 M. Al Zarouni et al. Abdominal wall reconstruction with Two-step Technique Figure 3 (A, B) The skin is closed directly over the reconstructed inner layer. richness of the vascularisation in this region (27), the risk of necrosis of the reconstructed inner layer is very low. If this fails, another reconstruction technique is always possible. Despite our excellent objective results and patient satisfaction, this study does have shortcomings, both, in technique and methods. First, the defects are scanned before VAC therapy. After this first step, it is known that these defects were smaller in size. We can easily imagine that in case of larger defects, an alternative technique of reconstruction would have been necessary. Second, patients found in our study are for the most part non-smokers with a BMI lower than 30 kg/m 2. Results with patients with higher BMI would have probably not have been so satisfactory. Finally, this study has no control group. However, as stated by Rausei et al. (28), because of the difficulty of recruitment and the multifaceted nature of the patients subjected to open abdomen, proper randomised controlled trials comparing our technique with conventional surgery are probably impossible to perform. Conclusion Reconstruction of abdominal wall defect with the TST is a reliable and reproducible technique. This technique provides excellent outcomes, and we anticipate that it will become widespread in the near future. Acknowledgement The authors have declared no conflict of interest. References 1. Demetriades D. Total management of the open abdomen. Int Wound J 2012;9: Caro A, Olona C, Jiménez A, Vadillo J, Feliu F, Vicente V. Treatment of the open abdomen with topical negative pressure therapy: a retrospective study of 46 cases. Int Wound J 2011;8: Kakisaka T, Yoneyama S, Katayama T, Kikuchi T, Uemura K, Ito Y, Une Y. Local skin flap reconstruction for abdominal wound dehiscence after abdominal surgery with a stoma: report of two cases. 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