Functional Abdominal Wall Reconstruction Using an Innervated Abdominal Wall Vascularized Composite Tissue Allograft: A Cadaveric Study and Review of the Literature

Abstract

Background Large, composite abdominal wall defects represent complex problems requiring a multidisciplinary approach for reconstruction. Abdominal wall vascularized composite allotransplantation (AW-VCA) has been successfully performed in 21 patients, already receiving solid organ transplants, to provide immediate abdominal closure. The current study aims to establish a novel anatomic model for AW-VCA that retains motor and sensory function in an effort to preserve form and function while preventing complications.

Methods Three fresh cadaver torsos were obtained. Dissection was started in the midaxillary line bilaterally through the skin and subcutaneous fascia until the external oblique was encountered. The thoracolumbar nerves were identified and measurements were obtained. A peritoneal dissection from the costal margin to pubic symphysis was performed and the vascular pedicle was identified for subsequent microsurgical anastomosis.

Results The mean size of the abdominal wall graft harvested was 615 ± 120 cm². The mean time of abdominal wall procurement was ∼150 ± 12 minutes. The mean number of thoracolumbar nerves identified was 5 ± 1.4 on each side. The mean length of the skeletonized thoracolumbar nerves was 7.8 ± 1.7 cm. The cross-sectional diameter of all nerves as they entered the rectus abdominis was greater than 2 mm.

Conclusions Motor function and sensory recovery is expected in other forms of vascularized composite allotransplantation, such as the hand or face; however, this has never been tested in AW-VCA. This study demonstrates feasibility for the transplantation of large, composite abdominal wall constructs that potentially retains movement, strength, and sensation through neurotization of both sensory and motor nerves.

Keywords

vascularized composite allotransplant - abdominal wall transplant - abdominal wall reconstruction - innervation of abdominal wall

• References

• 1 Butler CE. The role of bioprosthetics in abdominal wall reconstruction. Clin Plast Surg 2006; 33 (2) 199-211 , v–vi
• 2 Grevious MA, Cohen M, Jean-Pierre F, Herrmann GE. The use of prosthetics in abdominal wall reconstruction. Clin Plast Surg 2006; 33 (2) 181-197 , v
• 3 Lowe III JB. Updated algorithm for abdominal wall reconstruction. Clin Plast Surg 2006; 33 (2) 225-240 , vi
• 4 Burger JW, Luijendijk RW, Hop WC, Halm JA, Verdaasdonk EG, Jeekel J. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 2004; 240 (4) 578-583 , discussion 583–585
• 5 Itani KM, Rosen M, Vargo D, Awad SS, Denoto 3rd G, Butler CE , RICH Study Group. Prospective study of single-stage repair of contaminated hernias using a biologic porcine tissue matrix: the RICH Study. Surgery 2012; 152 (3) 498-505
• 6 Jin J, Rosen MJ, Blatnik J , et al. Use of acellular dermal matrix for complicated ventral hernia repair: does technique affect outcomes?. J Am Coll Surg 2007; 205 (5) 654-660
• 7 Sacks JM, Broyles JM, Baumann DP. Flap coverage of anterior abdominal wall defects. Semin Plast Surg 2012; 26 (1) 36-39
• 8 Sacks JM, Broyles JM, Baumann DP. Considerations in abdominal wall reconstruction. Semin Plast Surg 2012; 26 (1) 5-7
• 9 Cipriani R, Contedini F, Santoli M , et al. Abdominal wall transplantation with microsurgical technique. Am J Transplant 2007; 7 (5) 1304-1307
• 10 Levi DM, Tzakis AG, Kato T , et al. Transplantation of the abdominal wall. Lancet 2003; 361 (9376) 2173-2176
• 11 Selvaggi G, Levi DM, Cipriani R, Sgarzani R, Pinna AD, Tzakis AG. Abdominal wall transplantation: surgical and immunologic aspects. Transplant Proc 2009; 41 (2) 521-522
• 12 Selvaggi G, Levi DM, Kato T , et al. Expanded use of transplantation techniques: abdominal wall transplantation and intestinal autotransplantation. Transplant Proc 2004; 36 (5) 1561-1563
• 13 Zanfi C, Cescon M, Lauro A , et al. Incidence and management of abdominal closure-related complications in adult intestinal transplantation. Transplantation 2008; 85 (11) 1607-1609
• 14 Allin BS, Ceresa CD, Issa F , et al. A single center experience of abdominal wall graft rejection after combined intestinal and abdominal wall transplantation. Am J Transplant 2013; 13 (8) 2211-2215
• 15 Berli JU, Broyles JM, Lough D , et al. Current concepts and systematic review of vascularized composite allotransplantation of the abdominal wall. Clin Transplant 2013; 27 (6) 781-789
• 16 Schneeberger S, Landin L, Jableki J , et al; ESOT CTA Working Group. Achievements and challenges in composite tissue allotransplantation. Transpl Int 2011; 24 (8) 760-769
• 17 Nasir S, Bozkurt M, Klimczak A, Siemionow M. Large antigenic skin load in total abdominal wall transplants permits chimerism induction. Ann Plast Surg 2008; 61 (5) 572-579
• 18 Yang J, Erdmann D, Chang JC , et al. A model of sequential heart and composite tissue allotransplant in rats. Plast Reconstr Surg 2010; 126 (1) 80-86
• 19 Quigley MA, Fletcher DR, Zhang W, Nguyen VT. Development of a reliable model of total abdominal wall transplantation. Plast Reconstr Surg 2013; 132 (4) 988-994
• 20 Jin J, Williams CP, Soltanian H , et al. Use of abdominal wall allotransplantation as an alternative for the management of end stage abdominal wall failure in a porcine model. J Surg Res 2010; 162 (2) 314-320