Shestak K C, Edington H J, Johnson R R
Magee-Women's Hospital, Department of Surgery, University of Pittsburgh School of Medicine, PA 15213, USA.
Plast Reconstr Surg. 2000 Feb;105(2):731-8; quiz 739. doi: 10.1097/00006534-200002000-00041.
Reconstruction of massive abdominal wall defects has long been a vexing clinical problem. A landmark development for the autogenous tissue reconstruction of these difficult wounds was the introduction of "components of anatomic separation" technique by Ramirez et al. This method uses bilateral, innervated, bipedicle, rectus abdominis-transversus abdominis-internal oblique muscle flap complexes transposed medially to reconstruct the central abdominal wall. Enamored with this concept, this institution sought to define the limitations and complications and to quantify functional outcome with the use of this technique. During a 4-year period (July of 1991 to 1995), 22 patients underwent reconstruction of massive midline abdominal wounds. The defects varied in size from 6 to 14 cm in width and from 10 to 24 cm in height. Causes included removal of infected synthetic mesh material (n = 7), recurrent hernia (n = 4), removal of split-thickness skin graft and dense abdominal wall cicatrix (n = 4), parastomal hernia (n = 2), primary incisional hernia (n = 2), trauma/enteric sepsis (n = 2), and tumor resection (abdominal wall desmoid tumor involving the right rectus abdominis muscle) (n = 1). Twenty patients were treated with mobilization of both rectus abdominis muscles, and in two patients one muscle complex was used. The plane of "separation" was the interface between the external and internal oblique muscles. A quantitative dynamic assessment of the abdominal wall was performed in two patients by using a Cybex TEF machine, with analysis of truncal flexion strength being undertaken preoperatively and at 6 months after surgery. Patients achieved wound healing in all cases with one operation. Minor complications included superficial infection in two patients and a wound seroma in one. One patient developed a recurrent incisional hernia 8 months postoperatively. There was one postoperative death caused by multisystem organ failure. One patient required the addition of synthetic mesh to achieve abdominal closure. This case involved a thin patient whose defect exceeded 16 cm in width. There has been no clinically apparent muscle weakness in the abdomen over that present preoperatively. Analysis of preoperative and postoperative truncal force generation revealed a 40 percent increase in strength in the two patients tested on a Cybex machine. Reoperation was possible through the reconstructed abdominal wall in two patients without untoward sequela. This operation is an effective method for autogenous reconstruction of massive midline abdominal wall defects. It can be used either as a primary mode of defect closure or to treat the complications of trauma, surgery, or various diseases.
巨大腹壁缺损的修复长期以来一直是一个棘手的临床问题。Ramirez等人引入的“解剖分离组件”技术是这些难治性伤口自体组织修复的一个里程碑式进展。该方法使用双侧带神经支配的双蒂腹直肌-腹横肌-腹内斜肌皮瓣复合体向内侧移位，以修复腹壁中央。受此概念的吸引，本机构试图明确该技术的局限性和并发症，并对其功能结果进行量化。在4年期间（1991年7月至1995年），22例患者接受了巨大中线腹壁伤口的修复。缺损宽度为6至14厘米，高度为10至24厘米。病因包括取出感染的合成网片材料（7例）、复发性疝（4例）、去除中厚皮片和致密的腹壁瘢痕（4例）、造口旁疝（2例）、原发性切口疝（2例）、创伤/肠源性败血症（2例）以及肿瘤切除（累及右侧腹直肌的腹壁硬纤维瘤）（1例）。20例患者采用双侧腹直肌游离术治疗，2例患者使用了一组肌皮瓣复合体。“分离”平面是腹外斜肌和腹内斜肌之间的界面。使用Cybex TEF机器对2例患者进行了腹壁的定量动态评估，术前和术后6个月对躯干屈曲力量进行了分析。所有患者均通过一次手术实现伤口愈合。轻微并发症包括2例浅表感染和1例伤口血清肿。1例患者术后8个月出现复发性切口疝。1例患者因多系统器官衰竭术后死亡。1例患者需要加用合成网片以实现腹壁闭合。该病例涉及一名体型消瘦的患者，其缺损宽度超过16厘米。术后腹部未出现临床上明显的肌无力，与术前相比无差异。对术前和术后躯干力量产生的分析显示，在Cybex机器上测试的2例患者力量增加了40%。2例患者可通过重建的腹壁再次手术，且无不良后果。该手术是自体修复巨大中线腹壁缺损的有效方法。它既可以作为缺损闭合的主要方式，也可以用于治疗创伤、手术或各种疾病的并发症。
