What Is Abdominal Wall Reconstruction?

Abdominal wall reconstruction is a surgery involving the reconstruction of the abdominal wall in order to restore anatomy and function. For example, abdominal wall reconstruction can be used to repair a hernia of the front of the abdomen.

The abdominal wall (or the belly) is made up of skin, several layers of tissue, including fat and muscle. It protects the abdominal organs, such as the stomach, the liver and others and helps maintain posture while supporting the spine. The abdominal wall also assists in important body functions such as coughing, urination, and defecation.

The indications for reconstruction of the abdominal wall can be symptomatic (for example, pain relief of certain pains or for structural defects. Large abdominal defects can lead to significant herniation (abnormal protrusion of an organ or other body structures through a defect or natural opening in the body).

Defects of the abdominal wall may be due to:

• Trauma
• Tumors
• Tumor removal surgery
• Other past abdominal surgeries
• Infection

• Poor general health and nutritional status
• Simultaneous other serious illnesses

• Maintain a healthy diet and stop smoking at least 2 weeks prior to surgery. Tobacco smoking delays healing.
• Stop taking blood thinning medication five to seven days before surgery.
• Refrain from eating or drinking (including water) six to eight hours before surgery.

The surgery is performed with general anesthesia. Depending on the extent of defect or infection, the surgery can take anywhere between two to eight hours. Abdominal wall is reconstructed using the following:

• Graft harvesting the patient’s own tissue (autograft).
  • Prostheses
  • Bioprosthesis
  • Tissue expansion
  • Flaps
  • Vacuum assisted closure

The method of reconstruction is decided by the surgeon based on experience and nature of defect.

PROSTHESIS

Various types of synthetic prosthetic meshes are available for abdominal reconstruction. Polypropylene mesh is the most used synthetic prosthetic material in abdominal reconstruction. It is ideal for clean defects with enough soft tissue coverage.

Prostheses are superior to grafts due to the following:

• Higher tensile strength
• Easy availability
• No donor site morbidity
• Low rate of recurrence and complications
• Low cost

The disadvantages of prostheses are:

• Susceptibility to infection
• Bowel erosion
• Adhesion formation
• Foreign body reaction
• Seroma (accumulation of fluid)

BIOPROSTHESIS

• Biological meshes are derived from human or animal sources.
• The advantage of biological meshes are lower infection rates.

TISSUE EXPANSION

• This procedure uses the ability of skin to stretch over time to promote healthy skin and tissues and replace damaged tissue.
• It is usually performed by placing a balloon-like expander beneath the skin near the damaged area. Over time, the expander is filled with saline causing the skin around it to stretch and grow. 
• It is commonly used in breast reconstruction, but rarely in abdominal reconstruction.

FLAPS

• Flap is a tissue lifted from a donor site and moved to a site of defect with an intact blood supply. Based on the nature of the defect.

Types of flaps:

• Cutaneous flaps: Contain full thickness of skin and underlying superficial tissue. Ideal for small defects.
• Fascio-cutaneous flaps: Contain full thickness of skin, underlying superficial and deep tissue and more blood supply with ability to fill a larger defect.
• Musculocutaneous or myocutaneous flaps: Addition of muscle layer to fascio-cutaneous flap. Provides bulk to fill deeper defects and restore function.
• Muscle flaps: Only the use of muscle to fill defects and restore function skin can be placed over it if needed.
• Bone flaps: Used to replace bone in case of bony defects

 Myocutaneous and muscle flaps are commonly used in abdominal reconstruction.

• VACUUM-ASSISTED CLOSURE THERAPY (VAC): VAC device uses a device to reduce the air pressure on the wound, hence helping wounds heal faster and reduces infection.

• Painkillers and antibiotics may be administered.
• A surgical drain may be placed during surgery which may be removed after 24 to 48 hours.
• Dressing may be removed after 24 to 72 hours.
• Based on the extent of reconstruction, the patient may be discharged between two to seven days.
• Patients can walk slowly with support typically after 2 days.
• Swelling and bruising may be present, which eventually revolves.

• Swelling, pain, and bruising after surgery, which would subside in a week or two.
• After 5 to 7 days, patients would usually be able to walk around comfortably.
• The result may take a few months following surgery in case of major reconstruction.
• Patients are generally able to resume pre-operative activities, including sexual intercourse and exercise after 4-6 weeks.
• Regular follow-up would be required to monitor healing.
• Patients are advised to eat healthy and avoid smoking to promote healing.

• Swelling and bruising
• Hematoma (blood clot)
• Seroma (accumulation of fluid)
• Bleeding
• Infection
• Recurrence of hernia
• Poor wound healing
• Itching of skin
• Scarring or keloid formation
• Temporary numbness around incision site
• Loss of umbilicus
• Failure of prosthesis
• Adhesions due to prosthesis
• Bowel obstruction
• Intra-abdominal hypertension (IAH) or abdominal compartment syndrome (ACS): increase in pressure inside the abdomen, probably due to recurrent small bowel obstruction. Patients may present with:
  • Abdominal distention
  • Increased abdominal pain
  • Difficulty in breathing
  • Loss of consciousness
  • Nausea and vomiting
  • Multi-organ failure – failure of heart, kidney, lungs, brain