Novel Technique for Innervated Abdominal Wall Vascularized Composite Allotransplantation

A Separation of Components Approach

Devinder P. Singh, MD; Vasilios D. Mavrophilipos, BA; Jeffrey A. Zapora, MD; Jens Berli, MD; Justin Broyles, MD; Karan Chopra, MD; Jennifer Sabino, MD; Jamil Matthews, MD; E. Bryan Buckingham, MD; John S. Maddox, MD; Rachel Bluebond-Langner, MD; Ronald P. Silverman, MD

Disclosures

ePlasty. 2014;14 

In This Article

Methods

Two fresh cadaver torsos were latex injected and obtained from the Maryland State Anatomy Board on June 6, 2013. The operative plan was for the procurement of an osteomyofasiocutaneous abdominal wall allotransplant, which could be neurotized and inset as a single multipedicled functional graft. To this effect, a hexagonal skin incisional was planned (see Fig 1). Incisions were carried down to the level of the abdominal fascia. Adipocutaneous skin flaps were elevated from lateral to medial direction on both sides of the torso, taking great care to preserve Huger Zone I perforating blood vessels from the deep inferior epigastric artery and vein (see Figs 2 and 3). The external oblique fascia lateral to the semilunar line was properly identified (see dotted line on Fig 4). Fasciotomy was carried along a vertical direction, exposing the internal oblique layer (see upperly directed arrow Fig 5). Internal oblique layer was then marked (see dotted line Fig 6) and carefully released as second stage of a "multilayered" component separation. Segmental intercostal thoracolumbar nerves were identified and dissected in continuity within the plane between internal oblique and transversus abdominis layers (Fig 7). These steps were repeated bilaterally (Fig 8).

Figure 1.

Hexagonal AW-VCA incisional outline indicated by blue markings.

Figure 2.

Adipocutaneous skin flaps elevated in a lateral to medial direction.

Figure 3.

Deep inferior epigastric perforators (Huger Zone I) are preserved during skin flap elevation.

Figure 4.

External oblique fascia with semilunar line indicated by dotted line. This is the site of the first layer component separation.

Figure 5.

First layer component separation completed exposing internal oblique layer.

Figure 6.

Demarcation of second stage of component separation 2 cm lateral to semilunar line.

Figure 7.

Segmental intercostal thoracolumbar nerves identified between the internal oblique and transversus abdominis muscle layer.

Figure 8.

Left sided dissection complete, and skin flap elevation on the right.

Superiorly directed muscle release was carried up and over the subcostal margin, similar to the component separation modification used in the repair of subcostal or epigastric hernias; this maneuver revealed the attachments of rectus abdominis to the lowermost ribs (see Fig 9). Using a Stryker reciprocating saw and osteotome (see Fig 10), a 6-cm chest wall segment with 3 vertebrochondral ribs and attached rectus abdominis muscle was freed (see Fig 11). Right-sided internal mammary vessels were identified and preserved on cadaver 2.

Figure 9.

Rectus abdominis muscle attachment to lowermost ribs.

Figure 10.

Release of 3 vertebrochondral ribs with attached rectus abdominis muscle.

Figure 11.

Complete release of vertebrochondral ribs with observable marrow.

The allograft harvest was continued by carrying the dissection through to the peritoneum cavity beginning at the costal margin with full-thickness incisions in the abdominal wall between bony landmarks such as anterior superior iliac spine and symphysis (see Fig 12) and then reflecting in a cranial to caudal exposure (see Fig 13). The falciform ligament was encountered, ligated, and transected in this technique. The deep inferior epigrastric pedicle was then easily identified bilaterally (see Fig 13 arrows) running along the posterior rectus sheath, and it was fully dissected (see Fig 14) and transected bilaterally at its origin from the external iliac vessels. The composite allograft was then transplanted into a second recipient cadaver abdomen, where segmental intercostal thoracolumbar nerves were similarly prepared using the multilayered component separation technique (see Fig 15). Simulated osteosynthesis between donor and recipient ribs was carried out using Stryker fixation plate and screws (Stryker, 2825 Airview Boulevard, Kalamazoo, Michigan) (see Fig 16).

Figure 12.

Full-thickness dissection of graft continued through the peritoneal cavity.

Figure 13.

Graft was reflected in a cranial to caudal manner to identify and preserve the deep inferior epigastric pedicle indicated by the arrows. These pedicles provide the main blood supply to the graft.

Figure 14.

Dissection of the deep inferior epigastric pedicles.

Figure 15.

Graft transferred to recipient cadaver illustrating the potential nerve coaptation and bone synthesis.

Figure 16.

Simulated osteosynthesis between donor and recipient ribs using fixation plate and screws.

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