**2.2 Case 2. Abdominal reconstruction with pedicled perforator flaps for the patient without previous stoma**

A 66-year-old male originally had squamous cell carcinoma of the lower esophagus (Stage III) and had undergone radical resection of the esophageal cancer followed by reconstruction using free jejunum flap transfer. However, his postoperative course was complicated by peritonitis due to a perforation of the duodenum on the next day, which required another emergency laparotomy to cleanse and close the duodenal fistula. The mid-abdominal wound, which extended from the pubic symphysis to the processus xiphoideus, measuring 25 × 6 cm, developed infection and dehiscence 4 days after the primary surgery (**Figure 13**). Thus, the patient underwent debridement, and the wound was packed with saline-soaked gauze dressing every day. Furthermore, the exposed small intestine, which was adherent and fixed at the center of the abdominal wound, developed necrosis and drained digestive juice into the wound, resulting in a contaminated chronic ulcer 10 days after the primary surgery (**Figure 14**).

Reconstruction surgery was performed 20 days after the primary surgery, so that the open wound could be resurfaced with a large vascularized flap to prevent chronic contamination and create a new ileostoma for the ruptured ileum to separate the wound from drained digestive juice. The abdominal full-thickness defect was curetted carefully, and two triangular fasciocutaneous flaps of 25 × 7 cm, both of which were based on the perforator vessels of the lower abdominal artery, were harvested bilaterally (**Figure 15**).

Following primary closure of the donor sites, these perforator flaps were transferred medially to resurface the exposed small intestine. The ruptured ileum was encircled by these two flaps, and the mucosa of the small intestine was sutured to the skin of the flaps; consequently, an ileostoma was fashioned between the skin flaps (**Figure 16**). The remaining upper and lower abdominal wounds were resurfaced using free skin grafting.

**17**

**Figure 15.**

*abdominal artery.*

**Figure 14.**

*and developed a fistula (arrow).*

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

Three months later, all abdominal wounds had resurfaced, and the draining digestive juice could be controlled using a stoma bag. The patient could walk in the absence

*A view of flap elevation, involving a triangular fasciocutaneous flap, fed by the perforator vessels of the lower* 

*A view of the abdominal wound after debridement, demonstrating the exposed small intestine, which ruptured* 

of abdominal hernia formation and relapse of infection (**Figures 17** and **18**).

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

**Figure 13.** *A view of the abdominal wound, demonstrating infection and dehiscence.*

*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 14.**

*Gastrointestinal Stomas*

and relapse of infection (**Figure 12**).

faced using free skin grafting.

*A view of the abdominal wound, demonstrating infection and dehiscence.*

**patient without previous stoma**

A CT scan taken after 2 weeks showed that the pelvic cavity had been filled with the transported muscles (**Figure 11**). She underwent excess free skin grafting due to partial necrosis developing at the distal end of the skin flap 3 weeks later. Three months later, the patient could walk in the absence of abdominal hernia formation

A 66-year-old male originally had squamous cell carcinoma of the lower esophagus (Stage III) and had undergone radical resection of the esophageal cancer followed by reconstruction using free jejunum flap transfer. However, his postoperative course was complicated by peritonitis due to a perforation of the duodenum on the next day, which required another emergency laparotomy to cleanse and close the duodenal fistula. The mid-abdominal wound, which extended from the pubic symphysis to the processus xiphoideus, measuring 25 × 6 cm, developed infection and dehiscence 4 days after the primary surgery (**Figure 13**). Thus, the patient underwent debridement, and the wound was packed with saline-soaked gauze dressing every day. Furthermore, the exposed small intestine, which was adherent and fixed at the center of the abdominal wound, developed necrosis and drained digestive juice into the wound, resulting in a

**2.2 Case 2. Abdominal reconstruction with pedicled perforator flaps for the** 

contaminated chronic ulcer 10 days after the primary surgery (**Figure 14**).

Reconstruction surgery was performed 20 days after the primary surgery, so that the open wound could be resurfaced with a large vascularized flap to prevent chronic contamination and create a new ileostoma for the ruptured ileum to separate the wound from drained digestive juice. The abdominal full-thickness defect was curetted carefully, and two triangular fasciocutaneous flaps of 25 × 7 cm, both of which were based on the perforator vessels of the lower abdominal artery, were harvested bilaterally (**Figure 15**). Following primary closure of the donor sites, these perforator flaps were transferred medially to resurface the exposed small intestine. The ruptured ileum was encircled by these two flaps, and the mucosa of the small intestine was sutured to the skin of the flaps; consequently, an ileostoma was fashioned between the skin flaps (**Figure 16**). The remaining upper and lower abdominal wounds were resur-

**16**

**Figure 13.**

*A view of the abdominal wound after debridement, demonstrating the exposed small intestine, which ruptured and developed a fistula (arrow).*

Three months later, all abdominal wounds had resurfaced, and the draining digestive juice could be controlled using a stoma bag. The patient could walk in the absence of abdominal hernia formation and relapse of infection (**Figures 17** and **18**).

#### **Figure 15.**

*A view of flap elevation, involving a triangular fasciocutaneous flap, fed by the perforator vessels of the lower abdominal artery.*

**Figure 16.** *A view of ileostoma creation; the ruptured ileum was encircled by two flaps.*

**19**

**3. Discursion**

**Figure 18.**

rate of only 71% [8].

**3.1 Management of complex abdominal wall wounds**

*The draining digestive juice could be controlled using a stoma bag.*

stoma fashioning are required at the same time [10].

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

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

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.

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

*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 18.** *The draining digestive juice could be controlled using a stoma bag.*
