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Partition Technique in Management of Difficult Abdominal Fascia Closure

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Partition Technique in Management of Difficult Abdominal Fascia Closure View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Formosan Journal of Surgery (2013) 46, 149e156 Available online at www.sciencedirect.com journal homepage: www.e-fjs.com ORIGINAL ARTICLE Partition technique in management of difficult abdominal fascia closure Pin-Keng Shih a,b,*, Hsu-Tang Cheng a,b, Ka-Wai Liu a,b, Hsin-Han Chen a,c,* a Division of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan b China Medical University, Taichung, Taiwan c Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan Received 11 March 2013; received in revised form 8 May 2013; accepted 4 June 2013 Available online 4 October 2013 KEYWORDS Summary Background: The partition technique is a type of method to repair abdominal fas- abdominal wall cia defects with autologous tissue. repair; Aim: We present hereby our experience in 11 cases and report the relationship between some partition technique; parameters and complication rates. receiver operating Materials and methods: From January 2006 to March 2010, 11 patients with complex abdom- characteristic inal fascia defects underwent reconstruction using the partition technique. The related data (ROC) curve including sex, age, size of defect, duration of follow-up, comorbidities, mean fascia defect width/abdominal circumference ratio, body weight, body mass index (BMI), serum albumin level, and complications were collected. With regard to immediate postoperative outcome, patients were divided into two groups: patients with and without complications. The nonpara- metric Mann-Whitney U test was used to evaluate the differences between the groups; the receiver operating characteristic curve was used to assess the area under the curve (AUC), cut- off value, sensitivity, and specificity of each parameter. The relationships between comorbid- ities and postoperative complications were analyzed by Chi-square analysis. Results: The mean fascia defect size was 11.85 cm, the mean follow-up was 18.64 months, and the mean fascia defect width/abdominal circumference ratio was 13.98%. Postoperative complications occurred in four patients. Compared with patients without complications, the group of patients with complications had a significantly larger fascia defect and greater fascia defect size/abdominal circumference ratio. The AUC for fascia defect size/abdominal circumference ratio (1.00) and fascia defect size (0.928) indicated that these two factors were good predictors. At 1-year follow-up, no patients developed any abdominal wall compli- cations. * Corresponding authors. Division of Plastic and Reconstructive Surgery, China Medical University Hospital, 2 Yuh-Der Road, Taichung City 40447, Taiwan. E-mail addresses: [email protected] (P.-K. Shih), [email protected] (H.-H. Chen). 1682-606X/$ - see front matter Copyright ª 2013, Taiwan Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved. http://dx.doi.org/10.1016/j.fjs.2013.06.001 150 P.-K. Shih et al. Conclusion: The partition technique may be a single-stage solution to complex abdominal fas- cia defects, and the fascia defect width/abdominal circumference ratio is the most reliable parameter to predict the probability of complications. Copyright ª 2013, Taiwan Surgical Association. Published by Elsevier Taiwan LLC. All rights reserved. 1. Introduction found. In this study, we present our experience in a difficult abdominal fascia closure with the partition Difficult abdominal wall closure is a great challenge, technique and reliable parameters to predict the especially in patients with abdominal compartment syn- complications. drome or repetitive abdominal surgery. Delayed abdom- inal wall closure may cause wound infection, bowel ischemia, ventral herniation, and cosmetic dysfunction. 2. Materials and methods Several methods, including split-thickness skin graft,1 e local or free flap transfer,2 4 and silicon mesh,5,6 have This study analyzed the results of the partition technique been reported with different benefits. The component for a difficult abdominal fascia closure performed in 11 separation technique was suggested to be a natural patients (nine males and two females; age range: 20e71 method of fascia-fascia closure without complications of years; mean age: 45.6 years) between January 2006 and artificial implants because of the creation of the linea March 2010. All patients enrolled in this study had alba, successfully providing a midline anchor.7 However, abdominal fascia defects. The fascia defect was defined as separation of components is indicated only when the the maximum distance between both rectus abdominis defect does not exceed 6 cm in the subxiphoid area, 10 cm sheaths on the computed tomography (CT) of the abdomen at the waist, and 5 cm in the suprapubic region, respec- prior to the operation, and recorded as fascia defect width. tively, on either side.8 The abdominal circumference was defined as the distance The partition technique is another method considered of outer muscle layer plus fascia defect width on the to close an abdominal fascia defect naturally. Although abdominal CT. The disorders causing difficult abdominal the partition technique was recommended in abdominal wall closure included wound dehiscence after repetitive fascia closure, some unrelated complications, such as operations, acute abdomen, or blunt abdominal trauma. partial skin loss or small ventral herniation, have been The average weight of the patients was 65.82 kg (range: Figure 1 Diagram of the surgical procedure. (A) The bowel was released initially from the abdominal wall and then (B) the subcutaneous layer was dissected from the margin of fascia defect to the anterior axillary lines bilaterally. (C) Parallel, para- sagittal, staggered releases were achieved of the transversalis fascia, transversalis muscle, external oblique fascia, external oblique muscle, and rectus fascia from the costal margin to the pelvic inlet. (D) Fascia-to-fascia closure in the midline by vicryl 1- 0 suture. Partition technique for difficult abdominal fascia closure 151 53e78.5 kg). Five of eleven patients were smokers, one had 2.3. Statistical analysis diabetes mellitus, and two had hypertension. The parameters were not normally distributed. Because the sample sizes of the two groups were also different, the 2.1. Surgical technique nonparametric Mann-Whitney U test was used to determine the magnitudes of between-group differences. A p value 9 The technique was described in detail in Lindsey’s study. <0.05 was considered statistically significant. The diag- In brief, the bowel was released initially from the abdom- nostic accuracy of parameters significantly different among inal wall (Fig. 1A) and then the subcutaneous layer was the two groups was analyzed by the receiver operating dissected from the margin of the fascia defect to the characteristic (ROC) curve. Chi-square analysis was used for anterior axillary lines bilaterally (Fig. 1B). Parallel, para- the differences of comorbidities (hypertension, diabetes sagittal, and staggered releases are thus achieved of the mellitus, and smoking). All the data for statistical analysis transversalis fascia, transversalis muscle, external oblique were processed with GraphPad Prism 5.0 for Windows. fascia, external oblique muscle, and rectus fascia from the costal margin to the pelvic inlet (Fig. 1C). Fascia-to-fascia closure is made in the midline by vicryl 1-0 suture 3. Results (Fig. 1D). Two Jackson-Pratt drains are routinely placed underneath the subcutaneous skin flaps and allowed to Table 1 provides a summary of the patients and reconstruc- remain in that location until drainage is less than 20 cc in a tive outcomes. The mean defect width was 11.85 cm (range, 24-hour period, at which time the drains are removed. 8e18.9 cm). The mean follow-up was 18.64 months (range, 12e38 months). The mean defect width/abdominal circum- ference ratio was 13.99% (range, 11.4e23.04%). Post- 2.2. Data collection operative complications occurred in four of the 11 patients, but healed spontaneously without surgery in two of the The sex, age, body weight, body mass index (BMI), width of four patients. The other two patients required additional defect, fascia defect width/abdominal circumference de´bridement and closure. At 6-month follow-up, CT showed ratio, serum albumin level, and comorbidities (hyperten- no herniation in any of the patients. At 1-year follow-up, sion, diabetes mellitus, and smoking) of each patient were none of the patients developed abdominal wall collected for statistical analysis. complications. Table 1 Summary of the cases. Case Age/ Causes Width of Body BMI Defect width/ Albumin Follow- Comorbidities Complicationa no. sex defect weight (kg/m2) abdominal (g/dL) up (mo) (cm) (kg) circumference ratio (%) 1 71/M Bowel obstruction 11.7 63 26.22 14.43 4 32 H/T, smoking Minor (B) 2 47/M Traumatic liver 10.2 70 25.03 11.57 1.8 12 dd laceration 3 49/M Ischemic bowel 12.1 64 22.4 14.34 2.5 13 Smoking Minor (A) with perforation 4 57/M Traumatic bowel 15 55 17.75 12.33 3 12 DM, smoking d perforation 5 63/M Traumatic internal 9.3 78.5 27.81 11.4 2.3 38 H/T, smoking d bleeding 6 25/M Traumatic internal 11 71.3 22 13.63 2.3 28 dd bleeding 7 20/M Traumatic internal 9.1 72 24.33 11.99 3.1 14 Smoking d bleeding 8 33/M Traumatic internal 15.1 75 26.57 16.86 2.3 12 d Major (A) bleeding 9 70/M Bowel obstruction 18.9 57 20.94 23.04 2.6 15 Major (B) 10 42/F Bowel perforation 8 53.2 22.14 12.43 4.3 13 dd with fascia dehiscence 11 49/F Cervical cancer 10 65 25.39 11.76 3.6 16 dd with fascia dehiscence DM Z diabetes mellitus; H/T Z hypertension. a Minor (A) Z umbilical area wound dehiscence; Minor (B) Z minimal ventral hernia (1 cm); Major (A) Z partial skin loss; Major (B) Z partial skin loss.
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