Abdominal Wall Reconstruction

Excerpt

Abdominal wall reconstruction has become a frequently used term to describe hernia repairs that try to recreate the abdominal wall and restore function and structure. Although there has been no universally agreed-upon definition of a functional abdominal wall, many surgeons believe this involves the closure of the fascia at the midline, often with reinforcement using mesh prosthetics.

The integrity of the abdominal wall is vital as it serves to protect the internal organs, supports the spine and helps maintain an upright posture. Also, the abdominal wall aids in the performance of several bodily functions requiring the generation of Valsalva such as urination, coughing, and defecation. There are also data suggesting an absence of an intact abdominal wall can lead to a sensation of insatiety, possibly contributing to weight gain.

Hernia Risks

Incisional hernia following exploratory laparotomy occurs in 5 - 20% of patients. Risk factors for incisional hernia formation include (1) immunosuppression, (2) wound infection, (3) extreme obesity, (4) malnutrition, (5) patient age, (6) prior abdominal surgery, (7) and any medical condition that is associated with an increase in intra-abdominal pressure in the postoperative period. Other biological factors that may increase risk include have a connective tissue disorder like Ehlers-Danlos syndrome, history of the aneurysmal disease, a diet high in chickpeas, or lathyrism.

Several tumors can occur on the abdominal wall, though these are rare. The most common are desmoid tumors, which often are very locally invasive though histologically benign. Treatment of desmoids often requires full-thickness abdominal wall excision. Despite this, local recurrence rates are 40 to 50%. Most recurrences occur within the first 24 months after surgery. In some cases, adjuvant radiation therapy is recommended especially when the surgical margins are not cleared.

Management of malignant lesions of the abdominal wall requires aggressive resection of the subcutaneous tissues and skin, as well as any involved muscle. Sarcomas are the most common malignant tumors of the abdominal wall and require aggressive resection followed by radiotherapy. Metastatic abdominal wall tumors also exist and may require surgical resection; proposed mechanisms are either via hematogenous or contiguous spread. Reconstruction of the abdominal wall in these cases is usually dictated by the extent of resection and the possible need for further oncologic surgical intervention.