Overview of Abdominal Wall Reconstruction
Abdominal wall reconstruction is a type of surgery often used to repair hernias and bring back the normal function and structure of the abdominal wall. Your abdominal wall is like the body’s shield, safeguarding your internal organs. It also helps you stand upright by supporting your spine. Plus, it aids in various bodily functions, such as going to the bathroom or coughing, by generating force.
Although there’s no absolute definition of what makes an abdominal wall functional, most surgeons agree that it involves closing the midlayer of the wall (called the fascia) along the center line of your body, and reinforcing it with a special type of mesh.
Incidentally, not having a properly functioning abdominal wall could result in feeling hungry all the time and could potentially contribute to gaining weight.
Some people run a risk of developing hernias in the abdominal wall as a result of surgery. This typically happens in 5-20% of patients who have had a laparotomy, a surgical procedure that involves a large incision through the abdominal wall. Things that increase the risk of a hernia include having a weak immune system, surgical wound infections, being extremely overweight, malnutrition, being older in age, previous abdominal surgery, or any medical conditions that increase pressure inside the abdomen after surgery. Certain biological factors, such as having a connective tissue disorder like Ehlers-Danlos syndrome, a history of aneurysms, a chickpea-rich diet, or lathyrism can also increase risk.
Although rare, some tumors can develop in the abdominal wall. The most common type is called a desmoid tumor. Even though these tumors are not cancerous, they can grow and affect the tissues around them. Treating desmoid tumors usually requires removing a full layer of the abdominal wall, but even then, there is a 40-50% chance that the tumor may come back within 24 months. In these cases, radiation therapy might be necessary, particularly if the tumor wasn’t fully removed during surgery.
Management of cancerous tumors in the abdominal wall usually requires an aggressive removal of the subcutaneous tissues and skin, as well as any affected muscle. The most common type of malignant tumor in the abdominal wall is sarcomas, which require aggressive removal followed by radiation therapy. There also exist metastatic abdominal wall tumors, which are tumors that have spread from another part of the body. These might also require surgical removal. Reconstruction of the abdominal wall in these cases depends on how much was removed during the surgery and whether further surgery is needed in the future.
Anatomy and Physiology of Abdominal Wall Reconstruction
The belly or abdominal wall is made up of several layers. These layers include the skin, fat tissue underneath the skin, a tough, connective layer known as the fascia, muscle, and a thin tissue known as the peritoneum that lines the inside of the abdomen. Understanding the anatomy of these layers, especially the network of nerves and blood vessels within the abdominal wall, is crucial for successfully rebuilding the abdominal or belly wall if needed.
Why do People Need Abdominal Wall Reconstruction
Reconstructing the stomach wall is sometimes needed for a few different reasons. This is usually necessary due to issues with the structure of the wall or related symptoms. The goal of this reconstruction can vary; it might aim to provide pain relief or prevent severe situations like the trapping or constricting of tissues which can cause damage.
However, it’s crucial to note that although a large hole in the stomach wall can cause the stomach’s contents to squeeze through, the danger of these contents becoming trapped is actually greater when the hole is smaller. For example, if the defect is small, a person might not feel any discomfort, but there’s a higher risk of something getting stuck in the hole. In contrast, larger holes can be more noticeable and may cause issues, but the risk of contents getting trapped is lower.
Some stomach wall issues that might eventually need reconstructing include those that develop from removing cancer, managing serious infections, or fixing previous wounds to the stomach area.
When a Person Should Avoid Abdominal Wall Reconstruction
There are a few reasons why someone might not be able to have abdominal wall reconstruction, a major surgery that rebuilds the structure of the abdomen. People who are unable to handle general anesthesia, used to keep them unconscious during surgery, often cannot have this procedure.
A few issues can also discourage doctors from recommending this operation. One such concern is surgical site infection. Although these infections are rare, if one happened after abdominal wall reconstruction, it would raise the chances of a hernia recurring.
Current smokers might be asked to hold off on the surgery, too. That’s because smoking increases the likelihood of both surgical site infections and wounds not healing properly. Many surgeons ask patients to quit smoking for at least 30 days before they’ll attempt the surgery.
Doctors also tend to be cautious about doing this surgery on extremely obese patients and those with uncontrolled diabetes. These conditions can make surgery riskier, so it’s often best for these patients to lose weight or manage their diabetes before considering major surgery like abdominal wall reconstruction.
Equipment used for Abdominal Wall Reconstruction
For major tummy surgeries, a set of standard equipment is necessary. There is also typically a need for something called mesh prosthetics. These are like special supports used to repair the wall of the abdomen. The decision to use them is usually at the discretion of the surgeon, meaning the surgeon gets to decide if they’re needed or not.
However, it’s important that surgeons are informed about the different types of mesh prosthetics available and their characteristics. This includes knowing the pros and cons of each type. This helps them make the best decision for each unique patient and their specific needs.
Who is needed to perform Abdominal Wall Reconstruction?
These types of operations involve the belly area and are quite significant. Therefore, they often require additional help for the main surgeon. This help could come from a student learning surgery, a physician assistant (a medical professional who helps doctors), or a scrub technician (someone skilled in handling surgical tools). These team members provide needed support during the operation, like help in pulling back the skin and tissue, to provide a clear view of the surgical area.
Preparing for Abdominal Wall Reconstruction
Like any other standard abdominal surgery, the patient needs to be ready for the procedure. This preparation includes managing their weight and nutrition, addressing any other health conditions they may have, and quitting smoking. During the operation, the patient will be laid flat on their back with their arms in a comfortable position at their sides. This is done to ensure the patient’s safety and comfort during the surgery. Padding is also used as part of the preparation for surgery, just like it is with all major abdominal surgeries.
How is Abdominal Wall Reconstruction performed
Doctors use various methods to repair larger hernias where they need to stitch together the supporting structure down the middle of your stomach, which they call “midline fascial closure”. These specialized techniques allow for a smoother, tighter repair without any unnecessary strain.
One common method involves separating and sometimes releasing different layers of muscles and supporting tissues on the belly. In a technique made popular by Ramirez, surgeons make a cut in the back sheath of the straight belly muscle, peel soft tissue from the outer layer of the belly muscle, and then make another cut in the outer muscle layer around the side of your abdomen. This method is widely used because it is effective, but doctors may sometimes modify it for better results.
Different methods of hernia repair use component separation. One well-known technique is the Rives-Stoppa, or retro rectus, repair. In this method, surgeons cut the back sheath of the straight muscle on both sides, stitch together these pieces, and put a mesh patch in the space behind the straight stomach muscle. Then they close the front layer.
Some newer methods also involve making a cut in the back layer of the straight belly muscle. Another technique called transversus abdominis release was introduced by Novitsky. This technique involves performing a Rives-Stoppa repair, but it goes a step further by cutting the muscle that runs across your stomach, close to the nerve and blood supply. By doing this, the surgeon can fit a large mesh patch into the space just under the belly wall, which reduces the risk of infection as it doesn’t require making large incisions in the skin or the fatty layer just under it.
Possible Complications of Abdominal Wall Reconstruction
When doctors do surgery to rebuild the wall of the abdomen, it can lead to some complications. For those who are not familiar, an abdominal wall reconstruction is a difficult surgical procedure to fix deformities of the abdominal wall. These complications can be the same as any major stomach surgery. For instance, the doctor could accidentally damage the intestines because they typically have to separate tissues that have stuck together in the abdomen during the surgery. This risk, although quite rare, should be discussed with you as a patient, as it might give rise to the need to create an ostomy – a hole made to divert waste away from the bowels.
Since this operation often needs a lot of cutting and separating of the skin and underlying layers, wound problems can happen. These could range from simple surgical site infections to deeper infections or significant tissue death in the skin or layers beneath it.
Something else doctors worry about when reconstructing the abdominal wall is infections linked with the use of an artificial mesh. This is a common tool they use in these surgeries to provide additional support. But usually, proper preparation before the operation, using good surgical techniques, and the right use of mesh and antibiotics around the time of surgery, can reduce the risk of these kinds of infections.
What Else Should I Know About Abdominal Wall Reconstruction?
Abdominal wall defects, which are issues with the structure of the abdomen, are fairly common and can sometimes be very intricate. It’s important that the doctor knows all about the precise layout of a person’s abdomen, how to prepare a patient for surgery, the different ways to repair these defects, how and when to use medical mesh, and the potential problems that could come up. This knowledge will enable the doctor to effectively manage these challenging medical conditions.
