Autologous closure of giant abdominal wall defects

Split-thickness skin graft coverage of exposed and granulating intestines within large abdominal wall defects provides a life-saving permanent biologic dressing. The resultant abdominal wall defect often is closed with mesh, which may infect and fistulize. This report describes bilateral advancement flaps of the external oblique and recti muscles in 11 patients treated over 3 years. The defects, which averaged 16 x 24 cm, were due to necrotizing fasciitis subsequent to trauma with bowel perforation (3 patients), multiple ventral herniorrhaphies (2 patients), perforated diverticulitis (4 patients), and perforated peptic ulcer (2 patients). Eight patients were initially treated elsewhere where closure was achieved by split-thickness skin graft in five patients or mesh in 3 patients; 3 developed enterocutaneous fistulae and were transferred for closure while receiving long-term antibiotic and total parenteral nutrition therapy. All 11 patients had successful primary closure. The 8 patients operated on electively had primary healing; 2 developed seromas. Two of the three patients operated on urgently developed superficial wound infections; both healed by second intent without compromise of the primary closure. The following conclusions can be drawn: (1) the linea alba survives despite necrotizing fasciitis, (2) a tension-free primary closure is feasible; (3) morbidity is minimal, and (4) the long-term result is excellent.