Reconstruction of severely infected abdominal walls using latissimus dorsi free flaps

Abstract

Exposure of vital organs of the abdomen due to defects in the abdominal wall results in massive fluid loss, sepsis due to spreading of uncontrolled infection, and nutrient and electrolyte imbalance. Hence timely reconstruction of the abdominal wall is regarded as life saving, especially in severe infections of various kinds. Since the abdominal wall has redundant skin and multiple layers of musculature, small defects can be closed by local recruitment of these structures. However, when the wound is severely infected, radical debridement is required to stabilize it and the defect cannot be closed immediately. Moreover, wide spread infection involving the entire abdomen prevents the use of local tissues and component separation techniques. Even though closure is possible, the infected local tissue decreases the blood supply and this cannot be controlled in severe infections. In this situation, free tissue transfer should be considered. For ideal reconstruction of abdominal defects, the basic requirements include maintaining the functional and aesthetic integrity of the abdominal wall. In this respect, the anterolateral thigh flap and latissimus dorsi flap are suitable for reconstruction of extensive defects of the entire abdominal wall due to infection. The anterolateral thigh flap can include the thick fascial system, which replaces the abdominal fascia and can prevent postoperative hernia because artificial materials are not used. However the inclusion of large fascia and muscle to control the infection give rise to knee extension problems during walking. On the other hand, the latissimus dorsi myocutaneous flap can include large muscle structures that are able to control severe infection. Moreover, the flap also has a fascial system that can prevent hernia when the fascia is fixed into Scarpa's fascia of the abdomen. The latissimus dorsi flap with its large muscle paddle also has less effect on walking and upper extremity function. Hence it is suitable for reconstruction of severely infected abdominal wall defects. In this chapter we describe our novel methods of flap harvesting and insetting, and their application to infected abdominal wall defects.