Abdominal Wall Reconstruction

Abdominal wall reconstruction procedures are common. Quite often after abdominal surgery, a patient may develop a hernia. One of the keys points to hernia surgery is to develop adequate exposure so that the hernia can be repaired.The lower abdominal incision affords ample exposure to place underlay mesh as well as close the lower abdomen. This can restore the abdominal muscles back to their original position.

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Abdominal Wall Reconstruction

Abdominal wall reconstruction can be a common procedure after many different types of abdominal surgery.

One of the more important components of abdominal wall reconstruction is to recreate a dynamic abdominal wall so that the musculoaponeurotic system of the trunk can serve its purpose. 

By bringing the rectus muscles back toward the midline of the abdomen, the intraabdominal pressure can equilibrate. That is, when one coughs or strains, the intra-abdominal pressure can be transmitted from the bowel to the abdominal wall and vice versa. 

Often, large defects of the abdominal wall need to be closed with components separation to appropriately bring the rectus muscles back toward the midline of the abdomen.

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Hernia Repair and Abdominal Wall Reconstruction

Abdominal hernias are often uncomfortable for patients. Abdominal or ventral hernias can be repaired in many different fashions. When ventral hernias or incisional hernias have been previously repaired and recur, it is often best to undergo abdominal wall reconstruction with mobilization and medialization of the abdominal muscles and component separation.

The medialization of the abdominal muscles allows for the creation of a dynamic abdominal wall which can now exert an equivalent back pressure on the intra-abdominal contents that tend to move outward with coughing, sneezing, straining, etc. The abdominal wall reconstruction is often a much larger procedure than laparoscopic repair, but allows for the abdominal wall musculature to dynamically contract and prevent hernia repair.

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Repair of Abdominal Wall Hernias with Component Separation

Abdominal wall hernias are best reconstructed by recreating a functional abdominal wall. That is, return all the abdominal wall musculature back to its original position. When patients cough, sneeze, or bear down to have a bowel movement, this increases the intra-abdominal pressure. As the intraabdominal pressure increases, the abdominal wall musculature exerts a back pressure on the viscera. If there is a segment of abdominal wall that is devoid of functional (i.e. contracting muscle) then hernias tend to occur, or can occur in areas of weakness.

Often the hernias can be repaired with an underlay of structure with transfascial sutures and with restoring the abdominal wall musculature over the structure. That is when the abdominal domain is composed of functional muscle, there is a decreased chance of the hernia recurring.

Large hernia surgery typically requires an inpatient stay of three to seven days. During that time we are waiting for bowel function to resume, ambulation to occur, and pain to be controlled on oral pain medications.

An abdominal binder is worn in placed for 8 weeks. after eight weeks patients begin physical therapy to increase core musculature without large ranges of motion (i.e. no crunches or abdominal extension). Once the ore muscle strength is restablished, then patients begin to resume normal activity.

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Incisional Hernia Repair & Abdominal Wall Reconstruction

Incisional hernias can occur after surgery on the abdominal wall. Often a recurrent hernia needs to be repaired differently to prevent the recurrence of the hernia again. Just as important are patient factors that need to be controlled such as weight, protein intake, and cessation of smoking if the patient is a smoker.

If there are multiple hernias of the abdominal wall, it is often advantageous to the surgeons, both general surgeon and plastic and reconstructive surgeon to create adequate and wide exposure of all hernias to allow appropriate reconstruction. The wide exposure can also allow component separation to be performed to facilitate reconstruction of the abdominal wall musculature to create a dynamic abdominal wall.

The wide exposure creates a potential space that must be drained adequately post-operatively with drains. These drains can stay in for approximately 7 days to up to three weeks post-operatively.

Proper protein intake in the post-operative period is important to optimize wound healing.

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Hernia Reconstruction with Component Separation and Tensor Fascia Lata Flap

In order to repair multiple hernias of the abdominal wall, for example midline hernias and hernias related to colostomy or ileostomy procedures a large exposure is needed to properly perform a repair. Often the previous multiple incisions can be incorporated and included into one wound to obviate or prevent complications from wound breakdown.

Further, massive hernias of the abdominal wall may require multiple stages to repair. When repairing hernias, stable soft tissue coverage is important. In patients who have developed a loss of domain because of prior open wounds, a component separation may be employed to recruit more tissue to facilitate closure. Occasionally, in large tumors of the abdominal wall, the plastic and reconstructive surgeon will use the tensor fascia lata muscle from the thigh to close the wound.

The tensor fascia lata is harvested and exposed and then rotated towards the abdomen. The upper border of the abdominal fascia can be closed and the inferior portion can be closed as an underlay with the tensor fascia lata.

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Hernia Repair & Abdominal Wall Reconstruction

Abdominal Wall Reconstruction and Hernia Repair:

It is quite common for patients to have undergone a previous umbilical hernia repair and have a recurrence of their hernia. Also, patients can have a history of a previous surgical operation that results in an abdominal or “incisional” hernia.

Typically, when patients have a hernia that recurs, it is often required to restore the abdominal musculature back to its original anatomic location.

Often when repairing incisional, umbilical or large recurrent hernias, the Plastic & Reconstructive Surgeons work in conjunction with General Surgeons.

The plastic surgeon creates the exposure to allow large exposure to the defect and help prevent and correct any wound problem that may occur secondary to the large exposure. The muscles can then be released, relocated, or repositioned to create a dynamic abdominal wall.

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