**2. Case presentations of abdominal wall defect with wound infection with and without the previous stoma**

## **2.1 Case 1. Abdominal reconstruction with a free latissimus dorsi musclocutaneous flap for the patient with previous stoma**

A 38-year-old female originally had squamous cell carcinoma of the cervix uteri and had undergone radical hysterectomy and oophorectomy followed by postoperative chemotherapy and radiotherapy. After a disease-free period of 13 years, cervical cancer recurred, and she underwent pelvic exenteration including the bladder, rectum, sigmoid colon, and vagina. The end colostomy and ileal conduit were fashioned. However, her postoperative course was complicated by small bowel necrosis, which required another laparotomy to remove it. The mid-abdominal wound developed dehiscence. The pelvic cavity, which extended from the pubic symphysis to the coccyx internally and communicated with the perineal defect measuring 8 × 6 cm, was packed with saline-soaked gauze dressing every day. The remaining bowel and omentum were adherent at the center of the abdominal cavity, possibly due to the previous radiation (**Figures 1**–**3**). Furthermore, the adhered colon developed necrosis, which drained stools into the pelvic cavity, resulting in chronic peritonitis (**Figures 4** and **5**). Surgery was planned so that the empty pelvic cavity could be filled with a large vascularized muscle to prevent chronic peritonitis and create a new stoma for the ruptured colon to separate the pelvic cavity from drained stools (**Figure 6**). At first, the abdominal full-thickness defect combined with its communication with the pelvic cavity was de-epithelialized and curetted carefully. The patient was then placed in a right lateral decubitus position, and a left combined serratus anterior and latissimus dorsi musclocutaneous flaps with a 25 × 7-cm elliptical skin island, both of which were based on the thoracodorsal vessels, was harvested in the standard manner (**Figure 7**).

Following primary closure of the donor defect, these muscle flaps were inserted into the pelvic cavity. Then, the thoracodorsal artery was connected by end-to-end anastomosis with a branch of the profunda femoris artery, and two thoracodorsal veins were connected by end-to-end anastomosis with the branches of the venae

**11**

**Figure 2.**

**Figure 1.**

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

comitantes of this profunda femoris (**Figure 8**). Finally, a skin paddle was applied to cover the abdominal fistula, and a new colon stoma was fashioned through the

*A view of the abdominal wound, demonstrating the ruptured colon at the center of the abdominal cavity (1),* 

slit made in the skin flap (**Figures 9** and **10**).

*Computed tomography scan image demonstrating a necrotic colon (arrow).*

*and the fistula penetrating the pelvic cavity (2).*

*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 1.**

*Gastrointestinal Stomas*

abdominal surgical site infection associated with abdominal wall defect develops,

In these cases, reconstruction of a wall defect after abdominoperineal resection is very demanding with regard to the functional outcome. Several surgical methods have been performed involving re-suture, free skin grafting, and local flaps, which can be useful when the defect is relatively small [4]. However, larger abdominal wall defects usually require large flaps [5–7]. If the bilateral abdominal skin was not damaged by previous surgical procedures, abdominal defect may be reconstructed using a large pedicled flap. On the other hand, in the case of larger defects with further complications, such as an antecedent formation of a colostomy or iliac conduit, the free flap transfer is required, because local flaps around the wound cannot be

The aim of this article is to describe techniques of stoma creation on the flaps in

cases of postoperative fascial necrosis with internal bowel fistulae causing continuous peritoneal contamination. Especially, surgical methods for the two major types of the complications: abdominal wall defect with wound infection "with and without previous stoma" using free and perforator flaps are especially highlighted.

**2. Case presentations of abdominal wall defect with wound infection** 

**2.1 Case 1. Abdominal reconstruction with a free latissimus dorsi musclocutaneous** 

A 38-year-old female originally had squamous cell carcinoma of the cervix uteri and had undergone radical hysterectomy and oophorectomy followed by postoperative chemotherapy and radiotherapy. After a disease-free period of 13 years, cervical cancer recurred, and she underwent pelvic exenteration including the bladder, rectum, sigmoid colon, and vagina. The end colostomy and ileal conduit were fashioned. However, her postoperative course was complicated by small bowel necrosis, which required another laparotomy to remove it. The mid-abdominal wound developed dehiscence. The pelvic cavity, which extended from the pubic symphysis to the coccyx internally and communicated with the perineal defect measuring 8 × 6 cm, was packed with saline-soaked gauze dressing every day. The remaining bowel and omentum were adherent at the center of the abdominal cavity, possibly due to the previous radiation (**Figures 1**–**3**). Furthermore, the adhered colon developed necrosis, which drained stools into the pelvic cavity, resulting in chronic peritonitis (**Figures 4** and **5**). Surgery was planned so that the empty pelvic cavity could be filled with a large vascularized muscle to prevent chronic peritonitis and create a new stoma for the ruptured colon to separate the pelvic cavity from drained stools (**Figure 6**). At first, the abdominal full-thickness defect combined with its communication with the pelvic cavity was de-epithelialized and curetted carefully. The patient was then placed in a right lateral decubitus position, and a left combined serratus anterior and latissimus dorsi musclocutaneous flaps with a 25 × 7-cm elliptical skin island, both of which were based on the thoracodorsal

Following primary closure of the donor defect, these muscle flaps were inserted into the pelvic cavity. Then, the thoracodorsal artery was connected by end-to-end anastomosis with a branch of the profunda femoris artery, and two thoracodorsal veins were connected by end-to-end anastomosis with the branches of the venae

fashioning an intestinal stoma is very challenging [3, 4].

harvested due to the damages of the abdominal skin.

**with and without the previous stoma**

**flap for the patient with previous stoma**

vessels, was harvested in the standard manner (**Figure 7**).

**10**

*A view of the abdominal wound, demonstrating the ruptured colon at the center of the abdominal cavity (1), and the fistula penetrating the pelvic cavity (2).*

comitantes of this profunda femoris (**Figure 8**). Finally, a skin paddle was applied to cover the abdominal fistula, and a new colon stoma was fashioned through the slit made in the skin flap (**Figures 9** and **10**).

**Figure 2.** *Computed tomography scan image demonstrating a necrotic colon (arrow).*

#### **Figure 3.**

*Computed tomography scan image demonstrating the pelvic cavity, which extended from the pubic symphysis to coccyx internally.*

#### **Figure 4.** *A view of the abdominal wound, demonstrating that the ruptured colon drained stools into the pelvic cavity, resulting in chronic peritonitis.*

**13**

**Figure 7.**

*a skin island.*

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

*Illustration of the sagittal section demonstrating the ruptured colon (arrow) and fistula in the pelvic cavity.*

*Schematic illustration of the surgical procedure of free combined serratus anterior and latissimus dorsi* 

*Intraoperative view showing a left combined serratus anterior and latissimus dorsi musclocutaneous flaps with* 

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

**Figure 5.**

**Figure 6.**

*musclocutaneous flaps transfer.*

*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 5.**

*Gastrointestinal Stomas*

**Figure 3.**

*coccyx internally.*

*Computed tomography scan image demonstrating the pelvic cavity, which extended from the pubic symphysis to* 

*A view of the abdominal wound, demonstrating that the ruptured colon drained stools into the pelvic cavity,* 

**12**

**Figure 4.**

*resulting in chronic peritonitis.*

*Illustration of the sagittal section demonstrating the ruptured colon (arrow) and fistula in the pelvic cavity.*

#### **Figure 6.**

*Schematic illustration of the surgical procedure of free combined serratus anterior and latissimus dorsi musclocutaneous flaps transfer.*

#### **Figure 7.**

*Intraoperative view showing a left combined serratus anterior and latissimus dorsi musclocutaneous flaps with a skin island.*

#### **Figure 8.**

*Intraoperative view showing the muscle flaps inserted into the pelvic cavity and the thoracodorsal vessels connected with a branch of the deep vessels of the thigh (arrow).*

#### **Figure 9.**

*Intraoperative view showing a skin paddle applied to cover the abdominal fistula and a new colon stoma fashioned through the slit made in the skin flap.*

**15**

**Figure 12.**

**Figure 10.**

**Figure 11.**

*muscle.*

*stoma fashioned in the skin flap (2).*

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

*Illustration of a sagittal section demonstrating the pelvic cavity filled with the muscle (1) and a new colon* 

*Computed tomography scan image taken after 2 weeks, showing the pelvic cavity filled with the transported* 

*A view of the abdominal wall 3 months after surgery revealed favorable coverage of the wound and a new colon stoma fashioned on the flap (1). It also showed a conventional stoma (2) and conventional urinary stoma (3).*

*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 10.**

*Gastrointestinal Stomas*

**14**

**Figure 9.**

*fashioned through the slit made in the skin flap.*

**Figure 8.**

*Intraoperative view showing the muscle flaps inserted into the pelvic cavity and the thoracodorsal vessels* 

*Intraoperative view showing a skin paddle applied to cover the abdominal fistula and a new colon stoma* 

*connected with a branch of the deep vessels of the thigh (arrow).*

*Illustration of a sagittal section demonstrating the pelvic cavity filled with the muscle (1) and a new colon stoma fashioned in the skin flap (2).*

#### **Figure 11.**

*Computed tomography scan image taken after 2 weeks, showing the pelvic cavity filled with the transported muscle.*

#### **Figure 12.**

*A view of the abdominal wall 3 months after surgery revealed favorable coverage of the wound and a new colon stoma fashioned on the flap (1). It also showed a conventional stoma (2) and conventional urinary stoma (3).*

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