**3. Discursion**

*Gastrointestinal Stomas*

**18**

**Figure 17.**

*resurfaced.*

**Figure 16.**

*A view of ileostoma creation; the ruptured ileum was encircled by two flaps.*

*A view of the abdominal wound 3 months after the surgery, showing that all abdominal wounds had* 

### **3.1 Management of complex abdominal wall wounds**

Management of the patients with infected abdominal wounds associated with bowel fistulae is complicated, and the condition may prove fatal. Kendrick et al. reviewed 21 patients with severe postoperative soft tissue necrosis of the abdominal wall with and without associated intestinal fistulae and reported an overall survival rate of only 71% [8].

Regarding the treatment of an enterocutaneous fistula resulting from invasive bowel infection, en bloc resection of the involved bowel and enterocutaneous fistula tract with a healthy tissue margin while employing direct abdominal wall closure may be an ideal surgical treatment [9]. If the intestinal fistulation cannot be closed directly and end-to-end bowel anastomosis after ruptured intestine removal is not possible, the treatment for these patients becomes complicated, because debridement of contaminated soft tissue, abdominal wall reconstruction, and stoma fashioning are required at the same time [10].

In the procedure of fashioning a stoma, patients who have undergone prior complex abdominal operations present with difficulty due to an edematous and friable bowel and intra-abdominal adhesion, which decrease bowel mobilization. In these cases, the bowel is fixed on the adhesive mass of inflammation, making it difficult to deliver a well-vascularized, tension-free segment of bowel to the normal skin area and secure it through an adequate site of the abdominal wall [3, 11]. Furthermore, the inflammatory and exposed bowel caused by the wound dehiscence tends to develop ischemia and necrosis, which can result in intestinal rupture. The drained digestive juice and stool from the fistulae spread and worsen the soft tissue infection. Ileostomy effluent, with an alkaline pH and containing active digestive enzymes, is discharged almost continuously and excoriates and digests unprotected skin if left exposed. A colostomy discharges feces, which can cause continuous contamination of wounds [12]. Many of these patients have lost substantial soft tissue to resurface the wound, due to prior enterectomy resulting in reduced compliance of the skin and abdominal wall caused by multiple operations, stomas, abscesses, and enterocutaneous fistulae [13].

The procedure for fashioning an ileostomy or colostomy is well established and straightforward in typical cases. However, problems such as intra-abdominal adhesions, bowel rupture with infection, and abdominal wall defect are difficult to manage [14]. In this context, the key point of managing these complex wounds is to create a stoma on the durable skin and separate the wound from the ileostomy effluent. To achieve this the area around the fistulae should be resurfaced with well-vascularized skin flaps.

### **3.2 Surgical reconstruction of the abdominal wall**

Regarding abdominal wall reconstruction, several surgical methods include primary closure with and without artificial instruments, tissue expanders, component separation, and the use of local, regional, or free flaps [9]. Simultaneous reconstruction of the abdominal wall with prosthetic mesh is associated with a particularly high incidence of recurrent postoperative fistulation. Repair of contaminated abdominal wall defects with non-cross-linked biologic mesh and a component separation technique led to 36 of 80 patients (45%) developing wound infection [15]. Also, artificial mesh disturbs intestinal penetration though the abdominal wall [16]. Adaptations of artificial fascia are not adequate to resurface these contaminated wounds, because these non-vascularized substances are foreign bodies, which can aggravate infection [17–19]. Tissue expanders are used with the aim of expanding the skin around the wound [20]. They can provide the skin that can be used to cover large defects. However, this technique also requires the use of a foreign body in patients, which is a risk of infection, and there are space limitations caused by enterocutaneous fistulae, scar tissue, and stomas [2].

If the abdominal wall defect has a moderate size, but direct wound closure is impossible, abdominal repair with the component separation method, which is one of rectus abdominis muscle advancement flaps, is an alternative technique. This method can be accomplished without the need for artificial mesh, so it is also recommended from an infection control perspective (**Figure 19**) [21]. Separation of the muscle components of the abdominal wall allows mobilization of the rectus abdominal muscle, which enables each unit of the muscle to be sutured directly, and the stoma can be created through the reconstructed muscle. The external oblique muscle is bluntly dissected from the underlying internal oblique muscle, which should result in approximately 5 cm of advancement in the upper third of the abdomen, 10 cm in the mid-abdomen, and 3 cm in the lower third of the abdomen (**Figures 20**–**22**). This method is easy to perform without requiring the transposition of remote myocutaneous flaps or free tissue transfers [22, 23].

If wide and contaminated abdominal wounds cannot be closed directly, even with the component separation technique, pedicled or free flap transfer is required to resurface the wound [24, 25]. Kayano et al. compared 8 free anterolateral thigh (ALT) flaps and 12 pedicled ALT flaps for abdominal wall reconstruction to investigate their associated complications and clinical and demographic data and concluded that complication rates do not differ between free and pedicled ALT flaps. They suggested that the choice of flap depends on the size and location of the defect and the length of the vascular pedicle [26].

**21**

**Figure 20.**

**Figure 19.**

*fascial closure.*

*Stoma Revision on the Flaps in Cases of Abdominal Wall Defect with Digestive Tract Rupture*

*Schematic illustration of abdominal wall repair with the component separation technique to enable primary* 

*Abdominal wall defect with a 7-cm width developed after debridement of contaminated skin and muscle.*

*DOI: http://dx.doi.org/10.5772/intechopen.82978*

*Stoma Revision on the Flaps in Cases of Abdominal Wall Defect with Digestive Tract Rupture DOI: http://dx.doi.org/10.5772/intechopen.82978*

#### **Figure 19.**

*Gastrointestinal Stomas*

The drained digestive juice and stool from the fistulae spread and worsen the soft tissue infection. Ileostomy effluent, with an alkaline pH and containing active digestive enzymes, is discharged almost continuously and excoriates and digests unprotected skin if left exposed. A colostomy discharges feces, which can cause continuous contamination of wounds [12]. Many of these patients have lost substantial soft tissue to resurface the wound, due to prior enterectomy resulting in reduced compliance of the skin and abdominal wall caused by multiple operations,

The procedure for fashioning an ileostomy or colostomy is well established and straightforward in typical cases. However, problems such as intra-abdominal adhesions, bowel rupture with infection, and abdominal wall defect are difficult to manage [14]. In this context, the key point of managing these complex wounds is to create a stoma on the durable skin and separate the wound from the ileostomy effluent. To achieve this the area around the fistulae should be resurfaced with well-vascularized skin flaps.

Regarding abdominal wall reconstruction, several surgical methods include primary closure with and without artificial instruments, tissue expanders, component separation, and the use of local, regional, or free flaps [9]. Simultaneous reconstruction of the abdominal wall with prosthetic mesh is associated with a particularly high incidence of recurrent postoperative fistulation. Repair of contaminated abdominal wall defects with non-cross-linked biologic mesh and a component separation technique led to 36 of 80 patients (45%) developing wound infection [15]. Also, artificial mesh disturbs intestinal penetration though the abdominal wall [16]. Adaptations of artificial fascia are not adequate to resurface these contaminated wounds, because these non-vascularized substances are foreign bodies, which can aggravate infection [17–19]. Tissue expanders are used with the aim of expanding the skin around the wound [20]. They can provide the skin that can be used to cover large defects. However, this technique also requires the use of a foreign body in patients, which is a risk of infection, and there are space limitations

If the abdominal wall defect has a moderate size, but direct wound closure is impossible, abdominal repair with the component separation method, which is one of rectus abdominis muscle advancement flaps, is an alternative technique. This method can be accomplished without the need for artificial mesh, so it is also recommended from an infection control perspective (**Figure 19**) [21]. Separation of the muscle components of the abdominal wall allows mobilization of the rectus abdominal muscle, which enables each unit of the muscle to be sutured directly, and the stoma can be created through the reconstructed muscle. The external oblique muscle is bluntly dissected from the underlying internal oblique muscle, which should result in approximately 5 cm of advancement in the upper third of the abdomen, 10 cm in the mid-abdomen, and 3 cm in the lower third of the abdomen (**Figures 20**–**22**). This method is easy to perform without requiring the transposi-

If wide and contaminated abdominal wounds cannot be closed directly, even with the component separation technique, pedicled or free flap transfer is required to resurface the wound [24, 25]. Kayano et al. compared 8 free anterolateral thigh (ALT) flaps and 12 pedicled ALT flaps for abdominal wall reconstruction to investigate their associated complications and clinical and demographic data and concluded that complication rates do not differ between free and pedicled ALT flaps. They suggested that the choice of flap depends on the size and location of the defect

stomas, abscesses, and enterocutaneous fistulae [13].

**3.2 Surgical reconstruction of the abdominal wall**

caused by enterocutaneous fistulae, scar tissue, and stomas [2].

tion of remote myocutaneous flaps or free tissue transfers [22, 23].

and the length of the vascular pedicle [26].

**20**

*Schematic illustration of abdominal wall repair with the component separation technique to enable primary fascial closure.*

#### **Figure 21.**

*The external oblique muscle was dissected from the underlying internal oblique muscle, which allowed rectus abdominal muscle advancement 4 cm median-ward (arrow).*

#### **Figure 22.**

*Bilateral separation of the muscle components of the abdominal wall allows mobilization of the rectus abdominal muscle, enabling each unit of the muscle to be sutured directly.*

**23**

can be reduced.

*Stoma Revision on the Flaps in Cases of Abdominal Wall Defect with Digestive Tract Rupture*

Consequently, free flap transfer has been traditionally chosen as the only suitable method to resurface a large upper abdominal defect [30]. A free musculocutaneous flap is supplied by large blood vessels that may promote the healing process in contaminated tissue [31]. This is because massive vascularized muscle transfer can be undertaken through the removal of contaminated tissue, and muscle flaps for dead-space obliteration and neovascularization are obligatory for successful management of such infected wounds [32, 33]. However, when performing free flap transfer around the contaminated area, identifying an acceptable recipient vessel is not always easy. Chronic inflammation in recipient vessels caused by infection and fibrosis may be one of the factors leading to thrombosis of an anastomosed vessel [34]. So, it is important to select a flap with a long pedicle, as a suitable recipient vessel may be distant from the wound. Abdominal muscle defects require synthetic materials or flaps for restoration to prevent hernias. The insertion of synthetic materials has been reserved for large defects of the abdominal wall, but they have demonstrated increased complication rates, especially in contaminated wounds [5, 27]. Therefore, a myocutaneous free flap is also desirable. The close continuity of the remaining rectus abdominis muscle after debridement and thick and bulky muscle in the transferred flap will prevent

Microsurgical free flap transfer may be one of the best options to repair soft tissue defects of the abdominal wall, as it can prevent a hernia and relapse of infection and supply a well-vascularized muscle and large durable skin paddle, which enable

Recently, anatomical understanding of the perforator and angiosomes has increased, allowing regional flaps to cover skin defects, providing an alternative to free flaps [35–37]. Perforator flaps are defined as flaps consisting of the skin and/or subcutaneous fat, with a blood supply from isolated perforating vessels of a stem artery [38]. This new concept highlights again that local flaps are a good option for covering a difficult area around a contaminated wound. An ideal flap is thought to be a good vascularized skin paddle with the same thickness and width as the wound and a single-stage operation [39]. The development of perforator flaps has increased the number of potential donor sites because a flap can be supplied by any musculocutaneous perforator, and donor-site morbidity

Perforator and fasciocutaneous rotation flaps avoid the sacrificing of the under-

lying muscle and are commonly used due to their advantages. Sameem M et al.

Several case series revealed that a large flap is usually required for repair in the presence of larger defects with further complications, such as the formation of intestinal fistulae, and wound infection [5–7]. Reconstruction of a lower abdominal defect (below the umbilicus) can be achieved using pedicled ATL and tensor fascia lata fasciocutaneous (TFL) flaps. A retrospective study that analyzed 27 patients with abdominal wall defects concluded that both pedicled ATL and TFL fasciocutaneous flaps may be good options for the reconstruction of lower abdominal wall defects. A pedicled TFL fasciocutaneous flap has usually been utilized for lower abdominal defects (**Figures 23**–**26**) [27]. A pedicled ALT flap may be a better option for the reconstruction of a lower abdominal wall defect, and it is also available for whole abdominal wall defect restoration (**Figures 27**–**29**). This flap has the following advantages: it can be harvested as a musculocutaneous flap with the vastus lateralis muscle to fill a tissue defect, and the lack of a need for position change enables flap harvest [28, 29]. Regrettably, several case series showed that these useful flaps, which are harvested from the thigh, cannot reach the upper umbilical area, and the distal third of the TFL flap is at risk of necrosis unless a

*DOI: http://dx.doi.org/10.5772/intechopen.82978*

delaying procedure is used [5–7].

hernia formation [6].

stoma fashioning on it [30].

#### *Stoma Revision on the Flaps in Cases of Abdominal Wall Defect with Digestive Tract Rupture DOI: http://dx.doi.org/10.5772/intechopen.82978*

Several case series revealed that a large flap is usually required for repair in the presence of larger defects with further complications, such as the formation of intestinal fistulae, and wound infection [5–7]. Reconstruction of a lower abdominal defect (below the umbilicus) can be achieved using pedicled ATL and tensor fascia lata fasciocutaneous (TFL) flaps. A retrospective study that analyzed 27 patients with abdominal wall defects concluded that both pedicled ATL and TFL fasciocutaneous flaps may be good options for the reconstruction of lower abdominal wall defects. A pedicled TFL fasciocutaneous flap has usually been utilized for lower abdominal defects (**Figures 23**–**26**) [27]. A pedicled ALT flap may be a better option for the reconstruction of a lower abdominal wall defect, and it is also available for whole abdominal wall defect restoration (**Figures 27**–**29**). This flap has the following advantages: it can be harvested as a musculocutaneous flap with the vastus lateralis muscle to fill a tissue defect, and the lack of a need for position change enables flap harvest [28, 29]. Regrettably, several case series showed that these useful flaps, which are harvested from the thigh, cannot reach the upper umbilical area, and the distal third of the TFL flap is at risk of necrosis unless a delaying procedure is used [5–7].

Consequently, free flap transfer has been traditionally chosen as the only suitable method to resurface a large upper abdominal defect [30]. A free musculocutaneous flap is supplied by large blood vessels that may promote the healing process in contaminated tissue [31]. This is because massive vascularized muscle transfer can be undertaken through the removal of contaminated tissue, and muscle flaps for dead-space obliteration and neovascularization are obligatory for successful management of such infected wounds [32, 33]. However, when performing free flap transfer around the contaminated area, identifying an acceptable recipient vessel is not always easy. Chronic inflammation in recipient vessels caused by infection and fibrosis may be one of the factors leading to thrombosis of an anastomosed vessel [34]. So, it is important to select a flap with a long pedicle, as a suitable recipient vessel may be distant from the wound. Abdominal muscle defects require synthetic materials or flaps for restoration to prevent hernias. The insertion of synthetic materials has been reserved for large defects of the abdominal wall, but they have demonstrated increased complication rates, especially in contaminated wounds [5, 27]. Therefore, a myocutaneous free flap is also desirable. The close continuity of the remaining rectus abdominis muscle after debridement and thick and bulky muscle in the transferred flap will prevent hernia formation [6].

Microsurgical free flap transfer may be one of the best options to repair soft tissue defects of the abdominal wall, as it can prevent a hernia and relapse of infection and supply a well-vascularized muscle and large durable skin paddle, which enable stoma fashioning on it [30].

Recently, anatomical understanding of the perforator and angiosomes has increased, allowing regional flaps to cover skin defects, providing an alternative to free flaps [35–37]. Perforator flaps are defined as flaps consisting of the skin and/or subcutaneous fat, with a blood supply from isolated perforating vessels of a stem artery [38]. This new concept highlights again that local flaps are a good option for covering a difficult area around a contaminated wound. An ideal flap is thought to be a good vascularized skin paddle with the same thickness and width as the wound and a single-stage operation [39]. The development of perforator flaps has increased the number of potential donor sites because a flap can be supplied by any musculocutaneous perforator, and donor-site morbidity can be reduced.

Perforator and fasciocutaneous rotation flaps avoid the sacrificing of the underlying muscle and are commonly used due to their advantages. Sameem M et al.

*Gastrointestinal Stomas*

**22**

**Figure 22.**

**Figure 21.**

*The external oblique muscle was dissected from the underlying internal oblique muscle, which allowed rectus* 

*Bilateral separation of the muscle components of the abdominal wall allows mobilization of the rectus* 

*abdominal muscle, enabling each unit of the muscle to be sutured directly.*

*abdominal muscle advancement 4 cm median-ward (arrow).*

#### **Figure 23.**

*Schematic illustration of lower abdominal wall repair using anterolateral thigh and tensor fascia lata flaps.*

reviewed complications of musculocutaneous, fasciocutaneous, and perforator flaps for the treatment of pressure ulcers and revealed that there was no significant difference with regard to complication rates among these flaps [40]. However, comparing perforator and fasciocutaneous rotation flaps, application of the perforator

**25**

**Figure 25.**

**Figure 24.**

*15 min, which was used for boiling sweet beans.*

*Stoma Revision on the Flaps in Cases of Abdominal Wall Defect with Digestive Tract Rupture*

*A man sustained severe full-thickness abdominal burns due to contact with a large iron bowl (about 200°C) for* 

*The abdominal wall ruptured and the intestines were exposed due to the abdominal akin and muscle necrosis.*

*DOI: http://dx.doi.org/10.5772/intechopen.82978*

*Stoma Revision on the Flaps in Cases of Abdominal Wall Defect with Digestive Tract Rupture DOI: http://dx.doi.org/10.5772/intechopen.82978*

#### **Figure 24.**

*Gastrointestinal Stomas*

**24**

**Figure 23.**

reviewed complications of musculocutaneous, fasciocutaneous, and perforator flaps for the treatment of pressure ulcers and revealed that there was no significant difference with regard to complication rates among these flaps [40]. However, comparing perforator and fasciocutaneous rotation flaps, application of the perforator

*Schematic illustration of lower abdominal wall repair using anterolateral thigh and tensor fascia lata flaps.*

*A man sustained severe full-thickness abdominal burns due to contact with a large iron bowl (about 200°C) for 15 min, which was used for boiling sweet beans.*

#### **Figure 26.**

*View of the abdominal wall 9 months after reconstruction, using two pedicled TFL fasciocutaneous (1) and a free latissimus dorsi musclocutaneous (2) flaps.*

**Figure 27.** *Rectus abdominal muscle defect with a 9-cm width developed after debridement of contaminated muscle.*

**27**

**Figure 29.**

**Figure 28.**

*abdominal wall defect.*

*Stoma Revision on the Flaps in Cases of Abdominal Wall Defect with Digestive Tract Rupture*

*A pedicled vastus lateralis-anterolateral thigh flap was elevated from the left thigh and transferred to the* 

*The muscle flap was tunneled under the rectus femoris muscle and transferred to the muscle defect.*

*DOI: http://dx.doi.org/10.5772/intechopen.82978*

*Stoma Revision on the Flaps in Cases of Abdominal Wall Defect with Digestive Tract Rupture DOI: http://dx.doi.org/10.5772/intechopen.82978*

#### **Figure 28.**

*Gastrointestinal Stomas*

**Figure 26.**

*free latissimus dorsi musclocutaneous (2) flaps.*

*View of the abdominal wall 9 months after reconstruction, using two pedicled TFL fasciocutaneous (1) and a* 

*Rectus abdominal muscle defect with a 9-cm width developed after debridement of contaminated muscle.*

**26**

**Figure 27.**

*A pedicled vastus lateralis-anterolateral thigh flap was elevated from the left thigh and transferred to the abdominal wall defect.*

flap concept has many advantages. Parrett et al. revealed in a retrospective study that analyzed 290 flaps that blood circulation of the perforator flaps is supplied from isolated perforating vessels of a stem artery [38]. So, the most significant advantage of the perforator flap is that there is no need to sacrifice any main arteries, which means that there is minimal morbidity at the donor site [41, 42]. Also, microvascular anastomoses have the potential disadvantages that they require high-level surgical skill and prolong the operative period.

This new concept highlights again that local flaps could be a good option for the coverage of a difficult area of the upper abdomen, whose optimal reconstruction was previously thought to be possible with only free flap transfer.

Bilateral lower abdominal artery perforator flaps provide a well-vascularized skin paddle with an easy procedure, which does not require complicated microsurgical techniques. I believe that the use of this perforator flap is a good option to reconstruct large abdominal wall defects associated with many complications.
