Tissue expander-assisted component separation for pediatric abdominal wall reconstruction
Rachel M. Segal B.S.1, Alvin Wong M.D.2, Kevin Englar M.D.3, Michelle-Zaldana Flynn M.D.3, Samuel Lance M.D.2, Amanda Gosman M.D.2 1 UC San Diego School of Medicine, San Diego, CA 2 Rady Children's Hospital, San Diego, CA 3 Division of Plastic Surgery, Department of Surgery, UC San Diego San Diego, CA,
Background: The treatment of large congenital abdominal wall defects in the pediatric patient population remains a challenging problem, with patient age and size limiting local options. Tissue expander-assisted component separation is one potential solution, with prior groups utilizing intra-abdominal tissue expanders to increase the amount of skin, muscle, and fascial components available via a staged approach without the need for flap reconstruction. This study is the largest case series using the tissue expander-assisted component separation technique for treatment of congenital abdominal wall defects in a pediatric patient population.
Methods: A retrospective chart review was performed. Nine patients with large congenital abdominal wall defects not initially amenable to primary repair underwent abdominal wall reconstruction via a staged approach with tissue expander-assisted component separation between 2009 and 2020. Demographic information, perioperative data, and complications were recorded. Patients first underwent placement of tissue expanders, followed by removal once they had reached a sufficient expander volume. Component separation, with and without mesh placement, was performed in order to achieve abdominal wall closure.
Results: The average age of patients at primary repair was 3.23 years (SD +/- 1.72 years). Eight patients (88.8%) carried a diagnosis of congenital omphalocele and one patient (11.1%) had gastroschisis; none were amenable to primary repair. Seventeen tissue expanders were placed in nine patients, 82.4% of which were placed in the plane between the external and internal oblique muscles. The remaining were placed in the plane between transversalis muscle and the internal oblique muscle. No patients required transfusions or ventilation following the placement procedure. Patients were seen in clinic an average of 6.82 times (SD +/- 3.33 visits) for volume expansion into the tissue expander, receiving an average of 32.03 mL in each expander per visit. During this time, one patient (1.11%) experienced migration of the tissue expander and another patient experienced continued volume loss in the expander, both requiring a second surgery to remove and replace the devices. No patients experienced infection or extrusion of the tissue expander at this time. There was an average of 4.31 months (SD +/- 1.79 months) between placement and removal of the expanders. At the time of tissue expander removal and abdominal wall closure, the defects ranged from 30 cm2 to 132 cm2 (mean = 54 cm2). All defects were successfully repaired using a component separation and bilateral fasciocutaneous flap advancement. Mesh was used in three patients (33.3%). All repairs achieved primary closure in the midline. Two patients (2.22%) experienced infection of the surgical site and seroma, both of which required debridement and were managed with placement of a wound vacuum. One patient (1.11%) experienced partial thickness skin necrosis that was managed non-surgically. The overall complication rate for the 20 surgeries in this cohort was 25%.
Conclusion: Omphalocele and gastroschisis can produce abdominal wall defects that are not amenable to primary repair. Staged reconstruction using tissue expander-assisted component separation is a safe and effective method of obtaining adequate local soft tissue to achieve primary closure.
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