Overview
Abdominal wall reconstruction is a complex surgery typically used to correct abdominal weaknesses caused by recurring hernias, or open wounds that are not easily resolved by other specialties. Normally, the first line of hernia correction is general surgery. However, if the repair breaks down after one or more tries, an alternative solution should be considered. In cases where traditional repair methods will likely fail due to scar tissue or an abdominal wall catastrophe, such as a pancreatic leak, a more involved approach may be needed from the outset. In those circumstances, plastic surgeons can be called on to perform abdominal wall reconstruction to dynamically restructure the abdomen at the time of closure.
Abdominal wall reconstruction requires moving abdominal tissues to redistribute the abdominal muscles. This creates a dynamic repair that works to reinforce the midline closure. Patients report feeling as though they are wearing a girdle afterward — everything is tucked in — as the musculature is restored as close to the midline as possible. This helps to neutralize the reasons for hernia breakdown, and makes a successful solution more likely.
Procedural Details
Abdominal wall reconstruction entails making incisions in the abdomen, mobilizing the abdominal muscles, and moving them over to reshape the abdominal wall. This results in a dynamic repair that is more similar to the natural configuration of the abdomen compared to simply patching the gap.
There are a number of layers to the abdominal wall, and in the setting of a hernia these can be scarred and held tightly in one position. Unlike the traditional hernia repair, plastic surgeons use techniques that separate each layer so that they can slide across each other — much in the way the panels of an elevator door slide past each other to close completely. The surgeon is then able to shift those abdominal tissues, spreading them out over the entire circumference of the abdomen to allow closure where it might otherwise have been impossible. Hernias that could not be closed previously become more tractable. This approach to correcting the dynamics of the wall is why reconstruction is more involved than traditional hernia repair.
In general hernia surgery, surgeons may place a synthetic or plastic mesh over the abdominal opening. However, when circumstances are severe and complex, such as in the case of a wound infection or contamination at the surgical site, a plastic surgeon may be required to reshape the abdomen and reinforce the repair with a bioprosthetic mesh. This consists of an organic support layer and over the period of a few weeks becomes an integral part of the body.
Plastic surgeons at the UW use a multidisciplinary approach, with general surgeons handling routine hernia repair and bowel issues, and plastic surgeons performing complex hernia and wound repair with abdominal wall reshaping.
UW Medicine offers a comprehensive approach to abdominal wall reconstruction, including the use of bioprosthetic materials when necessary and abdominal reshaping, using a minimally invasive technique, making abdominal wall reconstruction a solution to many problems that others may consider too challenging or too risky.
Patients who have abdominal wall reconstruction are usually in the hospital for about five days or until bowel function returns to normal.
Considerations
Abdominal wall reconstruction may be useful to a patient who has had previous unsuccessful attempts at hernia repair, or complicating circumstances such as a fistula, or a complex abdominal wound that other surgical teams cannot close.
Most traditional repairs entail the placement of a plastic mesh over the hernia, leaving the abdominal wall with an underlying defect. For many patients, this approach is sufficient. However, for people who are active, this may not be sufficient because the muscles are still malpositioned to either side of the defect. These patients would benefit from dynamic repair of the abdominal wall and restoration of the muscles to midline as they are in the normal state.
Effectiveness
In a number of reports, the success rate of abdominal wall reconstruction has proven better than in repairs placing a mesh over the opening without correcting the underlying separation of tissue.
Abdominal wall reconstruction with bioprosthetic mesh is more robust in the face of infection and other complications.
Risks
What are the risks of having this treatment/procedure?
The biggest complications of abdominal wall reconstruction are delays in wound healing and infection. Diabetic patients may have a three times higher rate of infection compared to non-diabetic patients. Plastic mesh is extremely durable and reliable, but if infection occurs, the plastic mesh is usually involved. At that point it must be removed, requiring another surgery and reversing the hernia repair. In some high risk circumstances, or in the setting of contamination, the risk of infection is too high to warrant using plastic mesh. In such cases, bioprosthetic (or organic) mesh is a good option. Infections in bioprosthetic mesh can be treated with antibiotics and usually does not require removal of the mesh. As the bioprosthetic mesh integrates into the body, however, the potential exists for softening or weakening of the mesh, which may produce laxity or bulging in some cases. The pros and cons of each type of mesh should be taken into account given the circumstances at hand. Experience using either type of mesh means the surgeon can use the best option for the case at hand
Abdominal wall reshaping is more involved than a simple hernia repair, which entails a hospital stay averaging about five days or whenever the bowels return to normal function.
What are the risks of not having this treatment/procedure?
There are some circumstances that will not improve spontaneously. If a complex hernia or abdominal wound is left alone, the problem often tends to progressively worsen, which may result in drainage, sinus formation, fistula or other problem.