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Total Abdominal Wall Composite Tissue Allotransplantation: An anatomical study and Classification System
David Light MD, Neil Kundu MD, Risal Djohan MD, Brian Gastman MD, Namita Gandhi MD, Maria Siemionow MD
Cleveland Clinic
2012-02-10
Presenter: David Light, MD
Affidavit:
The resident was involved in the project design, dissections, and authored the presentation and manuscript.
Director Name: Steven Bernard, MD
Author Category: Chief Resident Plastic Surgery
Presentation Category: Clinical
Abstract Category: General Reconstruction
How does this presentation meet the established conference educational objectives?
The meetings objectives include demonstrating knowledge of current concepts, managing patient complications, improving patient care and addressing techniques and procedures relevant to plastic surgery. This presentation will meet all of the above criteria.
Composite tissue allotransplantation is at the forefront of transplant surgery, and plastic surgeons are leading that charge. This presentation will discuss how to manage the severely injured abdominal walls of multi-visceral transplant patients utilizing partial and total abdominal wall transplants. A novel classification system was developed to establish a nomenclature and adequately describe the abdominal wall defects. Included in the classification system are descriptions of myocutaneous grafts that could be employed to cover each type of defect
How will your presentation be used by practicing physicians in the audience?
Bowel and multi-visceral transplant patients often have hostile abdomens that suffer from poor perfusion and a loss of domain. Plastic surgeons have been called on in the past to aid in closure of such abdomens. Unfortunately, closure via traditional methods such as tissue expansion and component separation may not be sufficient. Two transplant teams have already utilized partial abdominal wall transplants for closure following visceral transplantation. This presentation will provide plastic surgeons in the audience a means to adequately describe abdominal wall defects, as well as outline the dissection of partial and total abdominal wall myocutaneous grafts that could be utilized for the abdominal closure of transplant patients in their own institutions.
Objectives
To develop a dissection technique for a total abdominal wall transplant, determine which vessels are needed to perfuse the graft, and outline a classification system to describe the defects and aid in selecting a reconstructive option.
Methods
Between August 2009 and September 2011, twenty total abdominal wall cadaveric dissections where performed. During each dissection anatomic variants were noted and measurements from the inguinal ligament to the origins of the DCIA, SCIA, DIEA and SIEA were taken.
Results
The cranial to caudal dissection allows for a rapid and safe entrance into the peritoneal cavity, giving transplant teams the opportunity to simultaneously procure the visceral organs.
Results of the dissections demonstrated that the DCIA, SCIA, DIEA and SIEA all branch off of the iliofemoral system within a 4.5 cm cuff at the level of the inguinal ligament, allowing for a focused and efficient dissection of the pedicle. We also noted that there is frequently a valve found in the common femoral vein (75%). This is clinically significant for the venous anastomosis to avoid valvular obstruction of venous drainage.
Partial abdominal wall transplants have already been performed utilizing bilateral V.R.A.M. flaps harvested as a single unit. This is an excellent option; however, many multi-visceral transplant candidates have extensive defects which require larger tissue transfers. To date, larger abdominal wall transplants have not been reported in the literature. Our classification system describes a spectrum of partial to total abdominal wall transplants, including a description of the myocutaneous graft that could treat each type of defect.
