Fournier''s gangrene: therapeutic impact of hyperbaric oxygen.
Hollabaugh RS Jr. Dmochowski RR. Hickerson WL. Cox CE.
Department of Urology, University of Tennessee, Memphis, USA.
Many controversial issues exist surrounding the disease pathogenesis and optimal management of Fournier's gangrene. In Fournier's original descriptions, the disease arose in healthy subjects without an obvious cause. Most contemporary studies, however, are able to identify definite urologic or colorectal etiologies in a majority of cases. To investigate disease presentation, treatment modalities, and overall mortality, a retrospective analysis of Fournier's gangrene from a single institution is presented. Since 1990, 26 cases of Fournier's gangrene have been diagnosed at the University of Tennessee. An evaluation of intercurrent disease revealed that 38 percent of the patients had diabetes mellitus, 35 percent manifested ethanol abuse, and 12 percent were systemically immunosuppressed. Fifteen patients (58 percent) presented with identifiable etiologies for their disease: 31 percent (8) urethral disease or trauma, 19 percent (5) colorectal disease, and 8 percent (2) penile prostheses. Management in all cases involved prompt surgical debridement with initiation of broad-spectrum antibiotics. Multiple debridements, orchiectomy, urinary diversion, and fecal diversion were performed as clinically indicated. Fourteen patients received hyperbaric oxygen as adjuvant therapy. Statistically significant results were noted with mortality rates of 7 percent in the group receiving hyperbaric oxygen (n = 14) versus 42 percent in the group not receiving hyperbaric oxygen (n = 12). Overall mortality was 23 percent. Controversy still surrounds disease pathogenesis in Fournier's gangrene, particularly in regard to etiology. Our study corroborates current trends in that a clear focus or origin was identified in a majority of the cases. Although a grim prognosis usually accompanies the diagnosis, this study shows significant improvement combining traditional surgical and antibiotic regimens with hyperbaric oxygen therapy.
Bipedicle muscle flaps in sternal wound repair.
Solomon MP. Granick MS.
Division of Plastic Surgery, MCP-Hahnemann School of Medicine, Allegheny University of the Health Sciences, Philadelphia, Pa, USA.
Infection following median sternotomy is a devastating and potentially life-threatening complication. The use of muscle flaps has become widely accepted as a mainstay in the treatment of these problems. We have previously described our successful use of a bipedicle muscle flap for reconstruction of sternal defects in 16 patients. In this paper, we describe follow-up in those patients as well as an evaluation of this procedure in an additional 26 patients. All records of those patients who had sternal reconstruction using the bipedicle pectoralis major-rectus abdominis flap were reviewed. Factors analyzed included the type of cardiac surgery, associated conditions, complications of surgery, and outcome. There were 42 patients in this group from 1989 to 1996. There were a variety of cardiac procedures represented. Associated conditions included diabetes, chronic hypertension, prolonged postcardiotomy hypotension, prior radiation therapy, pulmonary failure, and steroid use. There were no deaths in this series. There was one flap failure, one persistent infection, one pneumothorax, and one hernia in this series. Three patients developed hematomas after surgery. The most common complication was a skin slough, which occurred in nine patients. This technique provides a large flap that can fill the entire mediastinum. The dissection is rapid, and the complication rate compares favorably to that of other methods.
Use of synthetic mesh for the entire abdominal wall after TRAM flap transfer.
Moscona RA. Ramon Y. Toledano H. Barzilay G.
Department of Plastic and Reconstructive Surgery, Rambam Medical Center, Haifa, Israel.
Abdominal wall competence is a major concern of all plastic surgeons using the TRAM flap for breast reconstruction. Low hernia rates and adequate abdominal stability are standard expectations in abdominal wall closure. Described here is this institution's experience with the use of a large piece of synthetic mesh as a supplementary reinforcement for the entire abdominal wall in an attempt to stabilize it and achieve a superior abdominal aesthetic result. Twenty-five consecutive patients had routine reinforcement with the extended mesh technique. Mean patient follow-up was 24 months with a minimum of 1 year. No hernia or mesh-related infection were encountered and only one patient had a lower abdominal bulge. We recommend the use of a large synthetic mesh for improved strength and aesthetic quality of the abdominal wall after TRAM flap breast reconstruction.
Role of tensor fasciae latae in abdominal wall reconstruction.
Williams JK. Carlson GW. deChalain T. Howell R. Coleman JJ.
Department of Surgery (Winship Oncology Clinic) at Emory University, Atlanta, Ga., USA.
The role of the tensor fasciae latae as autogenous tissue in reconstruction of abdominal wall defects is well established. The use of various forms of the tensor fasciae latae (free graft versus pedicled flap versus free flap) is determined by the characteristics of the defect. A review of abdominal wall reconstructions using tensor fasciae latae was completed to determine efficacy and establish guidelines for its use. Abdominal wall reconstructions from 1991 to 1994 using tensor fasciae latae were reviewed. Demographics, wound characteristics, and complications were evaluated. Twenty-seven patients with a mean follow-up of 23.6 months underwent abdominal wall reconstruction with the tensor fasciae latae: free grafts, 12; pedicled flaps, 9; and free flaps, 6. An average defect size of 14.4 x 13.1 cm was seen. Fourteen (52 percent) of the reconstructions were completed in contaminated or infected wounds. One recurrent enteric fistula was seen. Twelve (44 percent) of the patients had flap complications of which 50 percent involved partial flap necrosis. Donor site complications were seen in five patients (18 percent) and included a hematoma, seroma, and two cases of skin graft dehiscence along the edge of the wound. Tensor fasciae latae free grafts are an option for repair of abdominal hernias if abdominal soft tissue is adequate. Pedicled flaps may be used for defects of soft tissue and fascia but are limited by the arc of rotation and size of the defect. Tensor fasciae latae free flaps are versatile in orientation and may be used for supraumbilical defects. Tip necrosis is significant in both types of vascularized flaps.
Considerations on stimulated anal neosphincter formation: an anatomic investigation in search of alternatives to the gracilis muscle.
Girsch W. Rab M. Mader N. Kamolz LP. Hausner T. Schima W. Gruber H.
Department of Plastic and Reconstructive Surgery, the Institute of Anatomy, Medical School at the University of Vienna, Austria.
Electrically stimulated anal neosphincter formation with transposed gracilis is performed clinically in an increasing number of patients. The use of a stimulated gluteus maximus in this application has been reported also. The question arises whether or not an optimal design for such a procedure has already been ascertained. An anatomic study was performed on 30 human cadavers to evaluate the semitendinosus muscle and its suitability for construction of a stimulated anal neosphincter. Semitendinosus fulfilled requirements for transposition around the anal canal in all cases. The muscle length was found adequate for transposition; nerve and vascular supply provided a suitable arc of rotation. The pattern of innervation might allow selective stimulation of that particular part of the muscle, which is intended to restore sphincter function. For clinical application, a vascular delay procedure is strongly recommended.
Restoring abdominal wall integrity in contaminated tissue-deficient wounds using autologous fascia grafts.
Disa JJ. Goldberg NH. Carlton JM. Robertson BC. Slezak S.
Division of Plastic and Reconstructive Surgery at the University of Maryland Medical System, Baltimore 21201, USA.
Necrotizing abdominal wall infections, enteric fistulae, or exposed prosthetic material after ventral hernia repair often results in a loss of abdominal wall integrity. Further surgical reconstruction with prosthetic material is usually contraindicated in the contaminated wound because of the high infection rate necessitating prosthetic removal and further abdominal wall debridement. Consequently, for the past 9 years, we have been using free grafts of autologous fascia lata to replace deficient abdominal wall fascia and muscle in situations where prosthetic material is contraindicated and local tissue rearrangement (i.e., component separation) would be inadequate. Thirty-two patients (mean age 59 years) underwent abdominal wall reconstruction with autologous fascia lata grafts. Indications included exposed mesh (31 percent), enteric fistulae (28 percent), enteric contamination (22 percent), wound infection (13 percent), and immunosuppression alone (6 percent); 31 percent of all patients were immunosuppressed secondary to either a solid organ transplant or a systemic inflammatory disorder. Fascia grafts (mean size 10 x 17 cm) were sutured to the surrounding abdominal wall and covered by local skin flap advancement and/or myocutaneous flap rotation. All abdominal reconstructions were initially successful. Subsequent local abdominal wall complications included cellulitis (n = 3), seroma (n = 2), and skin dehiscence with exposed fascia grafts (n = 7). Five of seven patients with skin dehiscence healed by secondary intention, whereas two had split-thickness skin grafts successfully applied to the granulating fascia. Thigh donor site complications included hematoma (n = 1), skin dehiscence (n = 1), and seroma (n = 2). There have been no cases of lateral knee instability. The average follow-up period is 27 months (range 3 to 106 months). Recurrent hernia has been seen in three patients (9 percent). Interestingly, laparotomy has been performed through an intact fascia lata patch in three patients for unrelated intra-abdominal conditions. In each case, the graft was intact and revascularized, confirming experimental animal data performed in our laboratory. Recurrent hernia has not been observed through the laparotomy site. Our 9-year experience has demonstrated that in the face of large, contaminated abdominal wounds where prosthetic material is contraindicated and local tissue rearrangement would be inadequate, fascia lata autografts are a reliable adjuvant to abdominal wall reconstruction.
Sliding door technique for the repair of midline incisional hernias.
Kuzbari R. Worseg AP. Tairych G. Deutinger M. Kuderna C. Metz V. Zauner-Dungl A. Holle J.
Department of Plastic Surgery at the Wilhelminen Hospital, University of Vienna Medical School, Austria.
We describe a technique that enables the autologous repair of large midline incisional hernias by restoring the functional musculoaponeurotic support of the abdominal wall. Unlike other methods of hernia repair, the essential step of the sliding door technique is the complete release of the rectus abdominis muscles from the anterior and posterior layers of their sheaths. The released muscles are thus overlapped and sutured together without tension. Another step of the technique is the release of both rectus sheaths by incising the aponeuroses of the external oblique muscles. We report on the use of this technique in 10 patients with midline incisional hernias (mean size of the abdominal musculofascial defect 14 x 11 cm). The patients were examined 14 months to 5.5 years after hernia repair. Two postoperative complications occurred: one marginal skin necrosis and one subcutaneous seroma. Recurrences were not observed. Ultrasound examination showed that the rectus muscles maintained their overlapped position postoperatively. Clinical muscle testing indicated that the strength of the released rectus muscles provides functional support to the reconstructed anterior abdominal wall.