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Autologous Reconstruction of the Inguinal Ligament Using Pedicled Fascia Lata Flap

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Autologous Reconstruction of the Inguinal Ligament Using Pedicled Fascia Lata Flap CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 4 (2013) 785–788 View metadata, citation and similar papers at core.ac.uk brought to you by CORE Contents lists available at SciVerse ScienceDirect provided by Elsevier - Publisher Connector International Journal of Surgery Case Reports journa l homepage: www.elsevier.com/locate/ijscr Autologous reconstruction of the inguinal ligament using pedicled ଝ fascia lata flap: A new technique a,∗ a a,c b Alasdair R. Bott , Shaheel Chummun , Rory F. Rickard , Andrew N. Kingsnorth a Department of Plastic Surgery, Derriford Hospital, Plymouth, UK b Department of General Surgery, Derriford Hospital, Plymouth, UK c Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK a r a t b i c l e i n f o s t r a c t Article history: INTRODUCTION: A technique of reconstructing the inguinal ligament using a pedicled fascia lata flap is Received 22 October 2012 described. Received in revised form 5 March 2013 PRESENTATION OF CASE: A 62-year-old man was referred with massive bilateral abdominal wall hernias, Accepted 9 April 2013 following numerous attempts at repair and subsequent recurrences. There was complete absence of the Available online 30 May 2013 right inguinal ligament. The inguinal ligament was reconstructed using a strip of fascia lata, pedicled on the anterior superior Keywords: iliac spine. This was transposed to cover the external iliac vessels, and sutured to the pubic tubercle. The Inguinal ligament × Reconstruction musculoaponeurotic abdominal wall was reconstructed with two 20 cm 20 cm sheets of porcine acel- lular dermal matrix and an overlying sheet of polypropylene mesh, sutured to the remaining abdominal Autologous tissue Fascia lata wall muscles laterally, and to both inguinal ligaments. The cutaneous abdominal wall was closed with an Hernia abdominoplasty technique. The reconstruction has remained intact nine months following surgery. DISCUSSION: Complete destruction of the inguinal ligament is rare but can occur following multiple operative procedures or trauma. To date, the only published reports of inguinal ligament reconstruction have been performed using synthetic mesh. The use of autologous tissue should reduce the risk of erosion into the neurovascular bundle, seroma formation, and enhance integration into surrounding tissues. CONCLUSION: This new technique for autologous reconstruction of the inguinal ligament provides a safe alternative to the use of synthetic mesh in the operative armamentarium of plastic and hernia surgeons. © 2013 Surgical Associates Ltd. Published by Elsevier Ltd. Open access under CC BY-NC-ND license. 1. Introduction Reconstruction of complex abdominal wall and inguinal her- nia are challenging and technically demanding. They often require Inguinal hernia repair is probably the most commonly per- an individualised operative strategy with specialist skills of both 1 5 formed general surgical operation in the United Kingdom. Despite hernia repair and reconstructive plastic surgery. developments in surgical technique and mesh technology, the rate Complete destruction of the inguinal ligament following of recurrence following primary repair remains at approximately repeated hernia repair and recurrence is a problem rarely encoun- 1,2 10%. It is estimated the rate of re-recurrence increases to 25% tered. A literature search revealed only one technique described 1,2 following revision procedures. by Scuderi et al. in 2007 for reconstruction of the inguinal liga- Several factors are associated with an increased risk of recurrent ment. This technique involves reconstruction with three sheets of 6 herniation: poor operative technique and post-operative compli- synthetic mesh. cations, aberrations of local anatomy and repetitive elevation of Synthetic Mesh has been shown to result in a higher complica- 1–4 intra-abdominal pressure. More recently it has been recognised tion rate than biological matrices or autologous tissues of erosion 5,7,8 that underlying abnormalities in collagen matrix formation may into structures, fistula formation, and seroma formation. 1 also play a role. The proximity of the femoral neurovascular bundle to the inguinal reconstruction and concerns about erosion led the senior authors to devise a novel technique for the reconstruction of the inguinal ligament as part of the treatment of this complex subtotal ଝ This work has been presented at the Association of Surgeons in Training Annual abdominal wall reconstruction using autologous fascia lata. Conference, Sheffield, UK, May 2011. ∗ We describe a case of massive abdominal wall hernia, where the Corresponding author at: Department of Plastic Surgery, Derriford Hospital, Ply- right inguinal ligament was reconstructed using a strip of pedicled mouth PL6 8DH, United Kingdom. Tel.: +44 01752 431519; fax: +44 01752 763042. E-mail addresses: [email protected], [email protected] (A.R. Bott). fascia lata. 2210-2612 © 2013 Surgical Associ ates L td. Publi shed by Els evie r Ltd. Open access under CC BY-NC-ND license . http://dx.doi.org/10.1016/j.ijscr.2013.04.003 CASE REPORT – OPEN ACCESS 786 A.R. Bott et al. / International Journal of Surgery Case Reports 4 (2013) 785–788 Fig. 1. The patient was referred with massive attenuation of the anterior abdominal wall, worse on the right side, where hernia contents extended to mid thigh level. The right inguinal ligament was missing. (b) Axial slice MRI image showing preoperative appearance of herniation into right groin at level of pubic symphisis. 2. Presentation of case cutaneous component of the wound was closed using an abdomino- plasty technique. Post-operative recovery was uneventful. A 62-year-old male was referred with massive bilateral anterior At nine months following surgery there was no evidence of abdominal wall hernias, six years after initially undergoing bilat- recurrence (Fig. 5a), and MRI at this point showed the new inguinal eral inguinal hernia repairs. During this time, he had undergone ligament to be intact (Fig. 5b). a further five operations, both open and laparoscopic, for recur- rent herniation. He complained of abdominal pain and difficulty walking. Clinical examination revealed two large hernial sacs bilat- erally. That on the right side was more prominent, and here the sac extended to the level of the mid thigh, lifting anterior thigh skin and fat (Fig. 1). Mesh from previous repairs was palpable subcu- taneously. An abdominal MRI scan revealed a completely absent right inguinal ligament. The anterior abdominal wall musculature was absent to the mid-axillary lines bilaterally, although severely attenuated rectus abdominis muscles remained (Fig. 1b). Surgical treatment was planned as a joint case combining the skills of an international expert in hernia repair and a consul- tant plastic and reconstructive surgeon. Jointly the technique for restoring inguinal ligament was chosen to define and contain the boundary of the inferior aspect of the abdominal wall in a fash- ion that would enhance integration between mesh and host tissue whilst protecting the neurovascular structures of the leg and sper- Fig. 2. The right groin. Distal thigh is to the right of the image. A 15 cm × 5 cm strip matic cord from erosion. of fascia lata anterior to the Rectus Femoris muscle was raised as a flap, pedicled on the anterior superior iliac spine. At operation, two large ellipses of atrophic skin covering the her- nia sacs were excised. An extensive adhesiolysis was performed, and five pieces of synthetic mesh of varying sizes and materi- als were retrieved. The right inguinal ligament was reconstructed using a pedicled fascia lata flap thus: The subcutaneous tissues of the right thigh were undermined further to expose fascia lata over- lying sartorius and rectus femoris (Fig. 4A). A 15 cm by 3 cm strip of fascia was raised, pedicled at its proximal attachment to the anterior superior iliac spine (ASIS) (Figs. 2 and 4B). This was trans- posed, and secured to the fascia iliaca laterally, and to the pectineal ligament and the periosteum of the right pubic tubercle medially with interrupted taken not to compress the neurovascular bundle (Figs. 3 and 4C). The anterior abdominal wall was reconstructed using two 20 cm × 20 cm sheets of porcine acellular dermal matrix. These were secured to each other in the midline, to the lateral mus- Fig. 3. The fascial flap was transposed to cover the iliofemoral bundle and sewn to culature, and to the native and the newly reconstructed inguinal the pectineal ligament and pubic tubercle. Filled circle = anterior superior iliac spine. ligaments using polypropylene sutures. This construct was fur- Asterisk = pubic tubercle. The triangle of contrast material is resting on the femoral ther reinforced with an on-lay polypropylene mesh (Fig. 4D). The artery and points to the newly constructed inguinal ligament. CASE REPORT – OPEN ACCESS A.R. Bott et al. / International Journal of Surgery Case Reports 4 (2013) 785–788 787 Fig. 4. (A–D) Schematic depicting surgical technique. 3. Discussion options. Scuderi et al. reported a series of 11 successful inguinal ligament reconstructions using a three-layer polypropylene mesh 6 The accumulated effect of multiple operations and recurrences technique. The use of synthetic mesh, however, is associated in in this patient was the almost complete absence of the anterior 10–15% of hernia repairs with complications such as infection, abdominal wall musculature and complete obliteration of the right erosion into
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