Br. J. Surg. Vol. 68 (1981) 840-841 Printed in Great Britain

A one-stage reconstruction of the anterior abdominal with a musculocutaneous flap B R Y A N J . M A Y O U , R A L P H C. B E A R D A N D E D W A R D E. A B D U L N O U R *

LARGE full-thickness defects in the lower half of the abdominal wall present an uncommon but difficult reconstructive problem. Most result from war wounds, synergistic infection or the radical surgery of tumours. These may be primary tumours of the abdominal wall, such as fibrosarcomas and desmoids, or direct extension or implantation from intra-abdominal tumours. Since abdominal reconstruction has been so difficult, patients with abdominal wall tumours may have been denied curative or worth-while palliative surgery.

Case report 4 patient with a recurrent adenocarcinoma of a urachal remnant. treated elsewhere by partial cystectomy and radio- therapy. was found to be in constant pain from a tumour of the bladder, extending into the anterior abdominal wall. There was a hyperpigmented area of skin, 12 x l2cm above the symphysis pubis. corresponding to the presumed area of radiotherapy. On cystoscopy, the tumour was seen to be confined to the anterior bladder wall and not involving the bladder base.

A supratrigonal cystectomy was performed with an en bloc resection of the anterior abdominal wall below the umbilicus, the left inguinal ligament and the left iliac lymph nodes. The bladder was reconstructed with a caecocystoplasty and the anterior abdominal wall with a flap taken from the left thigh. However, this flap became congested due to a partial obstruction of the common iliac vein at the site of the block dissection. The flap was therefore resected, retaining its base to cover the femoral vessels. The abdominal wall defect was reconstructed with an island flap taken from the outer aspect of the opposite thigh. It consisted of the fascia lata, the tensor fascia muscle and the subcutaneous tissue and skin, measuring 18 x 25cm. It had an 8-cm pedicle, consisting of the lateral circumflex femoral muscles. The flap was sewn into the anterior abdominal wall overlapping the remaining external oblique muscle by 3cm. using two rows of interrupted 3/0 nylon sutures. An extra 4cm of fascia lata was folded on itself to reconstruct the left inguinal ligament. Theskin edges of the thigh defects were advanced and the remaining defects grafted with split skin.

The patient made an uneventful recovery apart from mild obstructive symptoms which settled on conservative management and a lym hatic fistula in the left groin which persisted for 6 weeks. !he flap healed primarily to give a strong abdominal wall without herniation (Figs. I and 2). Micturition was achieved satisfactorily by abdominal straining.

Discussion Traditional techniques of repair of large defects of the lower half of the anterior abdominal wall have been closure of the ritoneum where possible, suture of a free fascia1 gra p" t or Marlex mesh to the aponeurotic or muscular margins of the wound, and skin cover by large local flaps or delayed skin grafting of granula- tions appearing through the mesh (I) . The abdominal flaps are, however, unreliable and skin grafting alone is unstable. Wan ensteen in 1934 (2) used the fascia lata alone on a peticle of the tensor fascia lata muscle to repair large abdominal hernias and to reconstruct the abdominal wall where sufficient abdominal skin could

wall

Fig. 1. The reconstructed anterior abdominal wall (front view).

Fig. 2. The reconstructed anterior abdominal wall (side view), showing a sound repair with the patient standing and the skin grafted donor defect of the thigh.

Department of Plastic Surgery, St Thomas's Hospital, London SEI 7EH.

Anterior abdominal wall reconstruction 841

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Fig. 3. The tensor fascia lata Rap. The dotted line represents the largest area of skin which may be included. Branches of the lateral circumflex femoral vessels are seen entering the tensor fascia lata muscle, 6cm below the anterior superior iliac spine. Sensory nerves enter from above.

be saved to allow closure. More recently, Nahai et al. (3) have included the overlying skin with the tensor fascia lata and refined the pedicle to just the lateral circumflex femoral vessels (Fig. 3). This flap has been used to close pressure sores and defects of the groin. We suggest that the musculocutaneous flap provides a reliable method of replacing the lower half of the anterior abdominal wall extending to the umbilicus and the opposite inguinal ligament. The fascia lata provides an aponeurotic replacement of muscle, strong and inelastic enough to allow the remaining musculature to maintain intra-abdominal pressure. This is of particular importance after caecocystoplasty where micturition cannot be maintained by detrusor action alone. Its glistening undersurface obviates the necessity of peritoneal closure at the time of reconstruction (4).

References I . ASTON s. J . and PICKRELL K. L.: In: CONVERSE J. M. (ed):

Reconstructive Plastic Surgery, 2nd ed. New York Saunders 1977; 7 373 1-6.

2. WANGENSTEEN 0. H.: Repair of recurrent and difficult herniae and other large defects of the abdominal wall employing the ilio-tibia1 tract of fascia lata as a pedicled flap. Surg. Gynecol. Obsret. 1934; 59 766-80.

3. NAHAI F., SILVERTON I. s., HILL H. et al.: Tensor fascia lata musculocutaneous flan Ann. Plust. Surp. 1978: 1: 372-9.

4. MCPEAK c. J . and MILLER T. R.: AbdoAnal replacement. Surgery 1960; 4 7 944-52.

Paper accepted 8 May 1981.

Seventh International Oculoplastic Society Congress The Seventh International Oculoplastic Society Congress will be held from 20 to 27 February 1982 at the Mullet Bay Beach Hotel, St Maarten, Netherlands Antilles. Further details can be obtained from: Ms P. Tamkin, c/o Dr P. Guibor, 630 Park Avenue, New York, NY 10021. USA; telephone (212) 734-1010.