Long Term Follow Up Results of Dynamic Functional Abdominal Wall + Perineal and Peri Anal Reconstruction + Fecal / Urinary Incontinence

Introduction: Managing complex abdominal wall / perineal + peri anal injuries acutely or at the time of reconstruction is challenging. Contaminated surgical fields, life threatening sepsis, devitalized tissue, intestinal / urinary fistula and tissues under tension contribute to clinical scenarios where closure is not possible or morbidity is unacceptable. Successful functional rehabilitation following high velocity, extensive post-traumatic, complex life threatening injuries including loss of the anterior abdominal wall, anterior wall of the urinary bladder, pubic symphysis and pubic ramus and / or phallus, scrotum, testes using vascularized fibula graft + innervated Latissimus dorsi to achieve the pelvic area stability and strength + gracillis muscle flaps to achieve the anal / urinary sphincter control.

Methodology and Material: From 1984 to 2012, sixteen patients with complex abdominal wall defects underwent reconstruction using free flaps. All patients had multiple co-morbidities. Flaps used included a free radial forearm flap in one patient, a tensor fasciae latae myocutaneous flap in two patients, a free anterolateral thigh myocutaneous flap in one patient, and free conjoined tensor fasciae latae and anterolateral thigh myocutaneous flaps in the last patient.

Author presents his experience of 16 cases of the use of abdominal wall / perineal reconstruction using different combinations of microsurgical techniques with long term follow up to 18 years. All cases had

• # Pelvis with loss of pubic symphysis and pubic rami.

• Extensive loss of soft tissue / muscles of the abdominal wall / perineum.

• Loss of the anterior wall of the urinary bladder / sphincter control.

• Destruction of vagina / penis and scrotum with both testes.

• Disruption of the perineal musculature / anal sphincter control

Results: Dynamic innervated gracilis flap for neo-sphincter was been used for urinary / anal incontinence. Most patients showed an average increase in mean squeeze pressure: from 43.0 mm Hg prior to surgery to 151.0 mm Hg. The muscle along its entire length from its neuro-vascular pedicle to its insertion on the tibial plateau is harvested using magnifying loupe. Uro dynamic pressure studies, ultra-sonography electromyography and Manometry studies helped analysis of patients with incontinence to urine / stool. All patients reported improvement in urinary / fecal incontinence, social interactions, and the quality of their life.

Due to regional advantage, these flaps either alone or in combination were performed under regional anesthesia like Brachial block + Continuous Epidural block. Lat. Dorsi muscle flap could also be dissected under thoracic epidural block along with infiltration in axilla for dissection of the pedicle.

Conclusions: The reconstructive ladder for large, complex abdominal hernias is poorly defined. The proposed algorithm provides a systematic staged approach that incorporates available techniques used for delayed reconstruction of the abdominal wall