Interdisciplinary aspects of abdominal and plastic surgery – what does the (abdominal) surgeon need to know?

Decubital ulcer

Surgical treatment of decubital ulcer has developed to one of the leading diagnoses with regard to its frequent occurrence, treatment activities and case numbers, in particular, in more advanced stages, which preferentially need defect coverage by plastic surgery. An early case presentation in or even transferral to plastic surgery seems to be, therefore, recommendable [1, 2]. It often happens that due to fear of large, not manageable tissue defects, prolonged clinical course is provoked [3]. However, this can lead to a longer hospital stay or duration of treatment and decreased quality of life as well as increased treatment costs [4, 5]. Profession collaboration in “Wound Centers”, in particular, within greater hospitals, has been proven successfully. In case of newly diagnosed decubital ulcer, e.g., occurring during a prolonged or complicated hospital stay, consultation of plastic surgery is reasonable [6, 7]. Possibly, sufficient treatment can be already initiated during the same hospital stay or even reliably planned for the near future. Depending of the decubital ulcer site, various flap plasties are available [8–17].

Most frequent tissue defects:

Sacral and gluteal defects (examples):

1. Rotation flap plasty (fasciocutaneous, gluteal) – Figure 1,

2. V-Y flap plasty (myocutaneous); gluteal uni- or bilateral,

3. “Tensor-fascia-lata” flap plasty (TFL);

Figure 1:

Clinical finding of decubital ulcer pre- and post-operatively. (A) Preoperative situs: substantial skin defect with superficial infection; (B) postoperatively: wound area after local rotation flap plasty.

Tuber ischiadicum (examples):

1. V-Y flap plasty (myocutaneous; biceps-femoris flap plasty, Harmstring-flap plasty),

2. TFL-flap plasty.

Coverage of soft tissue defects

They may become required, e.g.,

1. after lymph node dissections,

2. in tumor lesions

3. in case of disturbed wound healing

after primary care by general or abdominal surgeons. The coverage of soft tissue can be either considered a “service” of plastic surgery. The basic disease is not treated in a sufficient manner but there is still a remaining defect, e.g., after extended lymph node dissections, persistent disturbance of wound healing may result occasionally associated with chronic fistulas. In such case, muscle flap plasty may be considered a good approach. After vascular surgical interventions with subsequent disturbed wound healing and open wound area with vascular prosthesis or venous bypass in the groin, plastic surgery for coverage of the wound area, e.g., by means of a fasciocutaneous or muscle flap plasty (TFL, rectus femoris, vastus medialis or lateralis) may preserve the extremity [18–20] (Figures 2 and 3).

Figure 2:

Infected wound area of the right forehead. (A) Preoperative infected wound with skin defect; (B) intraoperative wound sites after extensive excision; (C) at the end of the surgical intervention: rotation flap plasty with coverage of the fresh skin defect with mesh graft.

Figure 3:

Infected wound due to infected vascular prosthesis. (A) Infected wound area at the left groin prior to surgical revision; (B) coverage of the excized wound with “Gracilis-muscle” plasty (tissue transferral to the left groin and coverage of the left distal thigh with mesh graft).

Lymphatic vessel reconstructions

Tumor operations associated with the interruption or blockage of the lymphatic drainage can result in formation of lymphedema. The same can happen after radiation therapy (secondary lymphedema). Lymphtic vessels might be well developed congenitally (primary lymphedema). In both cases, there is an altered drainage of chyle leading to a chronic swelling and increased protein deposition within the tissue. This can lead to a low quality of life. Prior to the development of microsurgery, it was only possible to mitigate symptoms by conservative measures such as complex manual decongestion therapy. Using microsurgical techniques and its further development make it possible to reconstruct impaired lymphatic vessels to improve, thus, lymphatic transport. While lymphovenous anastomoses have been already created in suitable indications for many years, the free microvascular lymph node transfer has been used with better results in a few centers over the last years. For instance, after radical axillary dissection lymphedema of arms can be improved using free lymph node transfer from a healthy body part. In addition, transplanted lymph nodes are immuncompetent with the consequence that there is a lower frequency of infections.

Bariatric surgery

As substantial part of bariatric operations, cooperation of general/abdominal surgery and plastic surgery has been established for years. Thus, patients can be notified on the treatment (e.g., “gastric sleeve resection”) including possible surgical interventions provided by plastic surgery resecting fatty or connective tissue after substantial loss of body weight. The close collaboration of the disciplines in “Obesity Centers” guarantees short ways for the patients and accompanies them after weight loss. Even for other medical disciplines such as gynecology, urology, plastic surgeons provide “service operations” in morbidly obese patients [20 –22]. For example, resection of pendulous abdomen as part of abdominosurgical interventions can facilitate access and overview as well as it can promote postoperative healing.

Abdominoperineal rectum extirpation (APE)

The cylindric APE (abdominoperineal rectum extirpation) according to Holm’s procedure has led to an oncological advantage of rectal cancer with regard to the prognosis versus conventional APE [23–25]. This comprises the extralevatory resection of low rectal cancer providing – in contrast to conventional APE – an extended circumferential resection at the mesorectum and the insertion of the levatory muscle at the sphincter muscle. Frequently, disturbances of perineal wound healing can occur, which can be a big challenge for the postoperative wound management [26]. In addition, such chronic and sometimes secretive wounds can become a heavy burden for the patient and her/his relatives. The closure of resulting defects using a myocutaneous flap plasty has proved successful [27]. According to the extent of the defect, various flap plasties are considered [23, 24, 28–35]. While smaller defects can be covered with myocutaneous gluteal flap plasties or simple gracilis-muscle flap plasties, the VRAM-flap plasty (“Vertical Rectus-Abdominis-Muscle” flap plasty) for large perineal defects. This comprises – as the flap desgination already indicates – that a rectus-abdominus muscle including a superficial skin part is transferred via a transpelvine route to the defect. Thus,

1. the tissue defect can be filled with muscle and skin defect can be sufficiently closed to outside, and

2. by the muscle transfer, a sufficient blood supply can be provided in the target area.

This can substantially improve the local situation, in particular, after neoadjuvant radiochemotherapy (Figure 4).

Figure 4:

Postoperative (formally perianal) wound area after Holm’s procedure for rectal cancer and “Rectal-muscle” plasty. (A) View onto the postoperative wound area – lithotomy position; (B) view onto the postoperative wound area of the patient laying on the bed.

Hernia surgery

Hernia treatment is one of the domains of general and abdominal surgery. This comprises open surgical techniques as well as minimally invasive techniques. In particular, various types of adapted meshes are used [36]. In complicated courses with infected meshes or large defects of the abdominal wall, plastic surgery can be helpful. Frequently, complicated recurrent hernias or defects of the abdominal wall can be covered by own tissue using flap plasties [37, 38, 39–41]. Such approach is superior to a “simple” mesh graft, e.g., directly on the intestine or mesh. On one hand, a better stability and coverage of the tissue defect can be achieved and, on the other hand, with regard to later surgical interventions, there will be a lower risk for potential intestinal alterations. Compound separation according to Ramirez can be performed both by abdominal or plastic surgeons, depending on individual skills.

By a functional reconstruction of abdominal wall defects, e.g., using innervated muscle, abdominal wall is sufficiently resistant to pressure and tension. For defects of the lower abdominal wall, a pediculated rectus-femoris-muscle flap plasty is recommendable [38, 40–43], particularly since morbidity of the flap mobilization is low. If a pediculated flap plasty in the required area cannot be performed, also free flap plasties are available, which can be used according to the defect site.

Necrotizing fasciitis

Necrotizing fasciitis (NF) is defined as a rare and life-threatening infection of subcutaneous tissue and fascia [44] as well as a fast progression of the disease associated with severe pain, which cannot be referred to the initially moderate clinical finding. Since laboratory parameters as well as imaging are unspecific, diagnosis finding is pursued with clinical issues. Already the suspicion requires a prompt radical debridement, in the majority of cases, repeatedly added by intensive care and antibiotic therapy. After stabilization of general condition and wound situation, coverage of defects and reconstruction by plastic surgery techniques is sometimes required [18, 37, 40, 45]. This includes mesh grafting, but also muscle or myocutaneous flaps. The fear of large defects as consequence of radical surgery can result in fatal outcome. Under such circumstances, a plastic surgeon needs to be involved early. For genital region, collaboration with the urologist can be helpful.

Soft tissue tumor lesions

In the treatment of soft tissue tumor lesions, there is overlap of several surgical disciplines, such as abdominal surgery, maxillary surgery, otorhinolaryngology, neurosurgery, orthopedic surgery etc. There are benign and malignant tumor lesions at each site of the body [19, 20]. In particular, in malignant or locally aggressive tumor lesions, primary wound closure is not always possible to achieve R0-resection status. If radical or extensive surgery is substantial for an appropriate therapy and prognosis, fear of a large tissue defect should not hinder the surgeon to achieve appropriate radicality. In this context, interdisciplinary tumor board conference is a suitable forum to derive the best tumor- and patient-associated therapy.

Liposuction

Liposuction can be considered rather a domain of plastic surgery. However, it is not only used for aesthetic purpose [46, 47–51]; it can become part

1. of various disciplines,

2. bariatric operations,

3. in lipedema (and)

4. for reconstruction (e.g., “lipofilling”).

A novel approach using liposuction – mainly in obese patients – is also possible in shunt surgery. Therein, deep vessels, in particular, veins can be elevated by liposuction closer to the surface with no need to dissect the vessel [52].

Lipofilling

Over the last years, treatment with own fatty tissue has been established, in particular, in plastic surgery [51, 53–55]. There is an option to use endogeneous “material”. In addition, the spectrum of indications has been distinctly extended. Variably processed fatty tissue can be used for several indications:

1. rhizarthrosis (intraarticular injection),

2. wrinkle treatment with own fatty tissue (instead of hyaluronic acid),

3. treatment of scars,

4. breast augmentation (aesthetic and for reconstruction),

5. treatment of chronic ulcers.

Sternum osteomyelitis

Sternum osteomyelitis – can be relevant even in abdominal surgery. It occurs after sternotomy, e.g., as part of bypass operations, after other thoracic surgery interventions or after trauma. It can be considered a severe complication with a mortality up to 30 % according to the literature [56]. In addition to the exogeneous spread, the endogeneous spread can also become life-threatening, and may lead to a fulminant mediastinitis. Therefore, the aim should be to sanitize the infection including a sufficient plastic-surgery coverage of the defect [18, 34]. An insufficient radical debridement can lead to a prolonged hospital stay with possible chronification, which can mean lifelong suffering, a persistent infectious risk and a reduced quality of life. Furthermore, there will be increased costs by the long duration of treatment.

Occasionally, complete removal of the sternum is necessary. In the meantime, wound conditioning can be performed using vacuum-assisted closure. The early consultation of a plastic surgeon should be considered. Knowing the possible options of coverage of tissue defects, inhibition level might be lower in performing radical debridement (Figure 5).

Figure 5:

Postoperative results after plastic surgery of sternum osteomyelitis. (A) From distance; (B) near the scar.

To cover tissue defects, the following flap plasties are available if a primary woud closure is not possible:

1. Pectoral-muscle flap (pediculated; unilateral or bilateral),

2. Latissimus-dorsi flap (pediculated; with skin insula),

3. VRAM (Vertical Rectus-Abdominis-Myocutaneous flap),

4. Free flap plasties.

Table 1 summarizes the suggestions for interdisciplinary treatment of the pathologies described above.