Ninković M, Kronberger P, Harpf C, Rumer A, Anderl H
Department of Plastic and Reconstructive Surgery, University of Innsbruck, Austria.
Plast Reconstr Surg. 1998 Apr;101(4):971-8. doi: 10.1097/00006534-199804040-00013.
Full-thickness abdominal wall defects continue to be a challenge for the reconstructive surgeon. The most frequently used reconstructive techniques are transfer of a pedicled, local abdominal flap or a distant flap from the thigh region. The purpose of this paper is to present a new approach to full-thickness abdominal wall reconstruction using an innervated free latissimus dorsi musculocutaneous flap. Four patients with large full-thickness abdominal wall defects underwent reconstruction with a free innervated latissimus dorsi muscle flap. In two patients, staged abdominal wall reconstruction was performed. Primary closure was first obtained with a skin graft. During the subsequent definitive reconstruction (with an innervated free latissimus dorsi muscle flap), this skin graft was not excised. Instead, deep dermabrasion of the skin graft was performed, leaving a residual dermal layer. This layer was then covered with a free innervated latissimus dorsi muscle flap. In these two cases, there was no need for the use of a prosthetic mesh. A single stage reconstruction was performed in the other two cases. After abdominal wall sarcoma resection, Prolene mesh was placed and subsequently covered with a free innervated latissimus dorsi muscle flap. There were no free flap failures. The average time of surgery was 4 hours, 50 minutes. The average hospital stay was 14 days. No significant complications occurred except for one donor site seroma. No hernias have occurred postoperatively. The mean follow-up was 21 months. Postoperatively, electromyographic testing was performed regularly in all patients to document reinnervation of the latissimus dorsi muscle flap. With reinnervation and intensive muscle training, the transplanted latissimus dorsi muscle offers enough contractile capacity and strength to adequately replace the function of the missing abdominal wall muscles. In complicated staged reconstructions, dermabrasion of the temporary skin graft allows for the use of a residual dermal layer as a fascia-like substitute to aid in the restoration of structural integrity. The combination of the dermal layer with an innervated free latissimus dorsi muscle provides a strong, vascularized fascial repair as well as an overlying vascularized soft-tissue coverage. In conclusion, adequate functional dynamic reconstruction of full-thickness abdominal wall defects is possible using an innervated free latissimus dorsi muscle flap. The reinnervated latissimus dorsi muscle is suitable for reconstitution of the missing functional and anatomic components of complex abdominal wall defects.
全层腹壁缺损仍然是重建外科医生面临的一项挑战。最常用的重建技术是带蒂局部腹部皮瓣转移或大腿区域的远位皮瓣转移。本文的目的是介绍一种使用带神经支配的背阔肌肌皮瓣进行全层腹壁重建的新方法。4例全层腹壁大缺损患者接受了带神经支配的背阔肌游离肌皮瓣重建。其中2例患者接受了分期腹壁重建。首先通过植皮实现一期闭合。在随后的确定性重建（使用带神经支配的背阔肌游离肌皮瓣）过程中，未切除该植皮。取而代之的是对植皮进行深层磨皮，保留残余的真皮层。然后用带神经支配的背阔肌游离肌皮瓣覆盖这一层。在这2例病例中，无需使用人工补片。另外2例患者进行了一期重建。在切除腹壁肉瘤后，放置普理灵补片，随后用带神经支配的背阔肌游离肌皮瓣覆盖。未发生游离皮瓣失败。平均手术时间为4小时50分钟。平均住院时间为14天。除1例供区血清肿外，未发生明显并发症。术后未发生疝。平均随访时间为21个月。术后，对所有患者定期进行肌电图检查，以记录背阔肌肌皮瓣的再神经支配情况。通过再神经支配和强化肌肉训练，移植的背阔肌具有足够的收缩能力和强度，能够充分替代缺失的腹壁肌肉的功能。在复杂的分期重建中，对临时植皮进行磨皮可利用残余的真皮层作为类似筋膜的替代物，有助于恢复结构完整性。真皮层与带神经支配的背阔肌游离肌皮瓣相结合，可提供强大的、血管化的筋膜修复以及覆盖其上的血管化软组织。总之，使用带神经支配的背阔肌游离肌皮瓣可以实现全层腹壁缺损的充分功能性动态重建。再神经支配的背阔肌适用于重建复杂腹壁缺损中缺失的功能和解剖结构。
