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The use of a biological graft for the closure of large abdominal wall defects following excision of soft tissue tumours

The use of a biological graft for the closure of large abdominal wall defects following excision... Primary soft tissue tumours arising from the abdominal wall are uncommon and surgical excision of such tumours can result in large abdominal wall defects. There are many techniques available for abdominal wall repair following tumour excision, each having its own advantages and disadvantages. The options range from direct closure to the use of tissue flap reconstructions and/or prosthetic meshes. Currently, synthetic material such as polypropylene mesh is a common choice for closure of abdominal wall defects after tumour excision. Biological meshes are an alternative option for repair, and this report outlines two cases of abdominal wall repair using the porcine intestinal submucosa biological graft following excision of abdominal wall tumours. There was no evidence of infection, recurrence, seroma or hernias at 2-year follow-up. Following excision of soft tissue tumours of the abdominal wall, biological reconstructions can be successfully used to bridge the defect with minimal morbidity. Medical™)porcine smallintestinalsubmucosal(non-cross- INTRODUCTION linked) graft. Both of the procedures described were primary sur- Permanent synthetic meshes composed of materials such as geries for large defects secondary to soft tissue tumour excision, polypropylene, polyester or expanded polytetrafluoroethylene an application of the porcine intestinal biological graft which is are widely regarded as durable and ergonomically sound options not yet widely documented in the literature. for abdominal wall reconstruction [1, 2]. However, significant complications including mesh migration, bacterial colonization CASE REPORT and fistula formation necessitated the development of an alter- native [3]. The use of synthetic meshes can cause of adhesions, Case 1 chronic sinus (2–6%), fistula formation (0–2%) and wound infec- tions (2–17%). The development of biological grafts reduced the A 43-year-old Caucasian female presented to her General Practi- incidence of the aforementioned complications [3, 4]. Today, an tioner in April 2012 with a 2-year history of a firm, painful swel- array of grafts is available, including human, bovine and porcine ling in the right flank. MRI revealed a 5.0 × 6.0 × 7.0 cm enhancing dermis, as well as porcine small intestinal submucosa and bovine lesion with areas of necrosis, which was invading the antero-lat- pericardium [5]. The following cases concern the successful eral abdominal wall (Fig. 1 ). With radiological features highly repair of abdominal wall defects using the Biodesign (Cook suggestive of a sarcoma, she underwent an ultrasound-guided Received: March 1, 2015. Revised: April 11, 2015. Accepted: June 1, 2015 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2015. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 2 | E. Illingworth et al. Figure 3: Twelve-month postoperative MRI. Figure 1: T MRI showing a soft tissue abdominal wall tumour involving external oblique, internal oblique and transversus abdominis and not involving the peritoneum (arrow). Figure 4: T MRI showing a soft tissue tumour of the anterior abdominal wall involving external oblique and internal oblique and not involving the peritoneum. had undergone a right-sided inguinal hernia synthetic mesh re- Figure 2: Depicting the porcine intestinal biological mesh in place after tumour pair in 2010. MRI with contrast confirmed a 6.9 × 6.7 × 4.6 cm mass excision. invading the abdominal wall musculature (Fig. 4). Radiological features were suggestive of sarcoma or aggressive fibromatosis. biopsy, which classified the mass as a borderline myoepithelial Histology from an ultrasound-guided biopsy revealed aggressive tumour. The patient underwent an uncomplicated resection of fibromatosis. The patient opted for a surgical excision of the mass the mass, which left a 10 × 10 cm right-sided antero-lateral ab- with abdominal wall reconstruction. The tumour was excised dominal wall defect. The defect was repaired using a Biodesign with the internal oblique, leaving the peritoneum and external biological graft. Initially, a layer of the biological mesh was used ring cord structures intact. A 13 × 15 cm sheet of porcine intes- to cover the intact peritoneum with attachments cranially to the tinal biological mesh was used to repair the abdominal wall ribs and inferiorly to the right iliac crest. The external oblique was defect (Fig. 5). Inferiorly, the mesh was doubled over in the pre- mobilized to partially cover the mesh, and a further layer of the peritoneal space to reconstruct the inguinal ligament, and biological mesh attached over it with Ethilon™ (Fig. 2). The pa- sutured to the external oblique. The histology confirmed a final tient had an uncomplicated postoperative recovery. The tumour diagnosis of aggressive fibromatosis excised with 1 mm margins. histology revealed a 6.5 × 6.0 × 5.5 cm myxoid mass; immunohis- At 24 months, there was good wound healing and no hernia, ser- tochemistry analysis favoured a benign/borderline myofibroblas- oma or evidence of recurrence on follow-up MRI. tic tumour. At 24-month follow-up, she had good wound healing with a small area of paraesthesia inferior to the scar. An MRI showed good graft incorporation and no evidence of disease re- DISCUSSION currence or hernia (Fig. 3). Large soft tissue tumours of the abdominal wall are very rare. When faced with selecting an appropriate technique for both of Case 2 the reported procedures, consideration of the defect size (both A 31-year-old man presented to his General Practitioner in May being larger than 10 cm), the absence of any potential contamin- 2012 with a 6-week history of a painful mass in the right iliac ation and the excellent degree of cutaneous integrity were all fossa. There was no regional lymphadenopathy and hip examin- central to the decision to use the porcine intestinal biological ation was unremarkable. He was a smoker with a BMI of 33 and graft. A further alternative is the use of autogenous tissue in Use of a biological graft for the closure of large abdominal wall defects | 3 The choice of technique for abdominal wall reconstruction following excision of a large abdominal wall soft tissue tumour is a difficult clinical decision. Though biological meshes are cost- lier than the synthetic meshes, reduction of postoperative com- plications may justify the use of the biological graft. The two cases reported highlight the necessity to consider each patient according to factors such as the defect size and location, the over- lying skin integrity and the sterility of the wound. The porcine in- testinal biological graft thus appears a suitable alternative choice for successful repair of abdominal wall defects with good incorp- oration and minimal postoperative morbidity in patients with large anterior/antero-lateral abdominal wall defects following soft tissue tumour excision. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Hsu PW, Salgado CJ, Kent K, Finnegan M, Pello M, Simons R, Figure 5: Depicting the use of porcine intestinal biological mesh to repair an et al. Evaluation of porcine dermal collagen (Permacol) used anterior abdominal wall defect left by aggressive fibromatosis. in abdominal wall reconstruction. J Plast Reconstr Aesthet Surg 2009;62:1484–9. the form of advancement or regional flaps. This is considered an 2. Brown P. Abdominal wall reconstruction using biological tis- excellent option when the cutaneous coverage is inadequate to sue grafts. AORN J 2009;90:513–20; quiz 21–4. maintain a successful closure with mesh alone [6]. When used 3. Morris-Stiff GJ, Hughes LE. The outcomes of nonabsorbable at the peritoneal surface, laminar prostheses have been reported mesh placed within the abdominal cavity: literature review as having a lower incidence of adhesion formation, which is con- and clinical experience. J Am Coll Surg 1998;186:352–67. sidered to be secondary to early mesotheliation [7]. Biological tis- 4. Cook Medical. Biodesign Advanced Tissue Repair. Cook Medical, sue grafts are increasingly being utilized in abdominal wall 2011. https://www.cookmedical.com/data/resources/product repair. Importantly, they permit and encourage host tissue in- References/SUR-BMRM-HFB3-EN-201407_M3.pdf?905860. corporation, promote neovascularization and, in theory, degrade 5. Bellows CF, Alder A, Helton WS. Abdominal wall reconstruc- in response to increasing wound strength and fascia formation tion using biological tissue grafts: present status and future [8]. Although superior with regard to biocompatibility, allogenic opportunities. Expert Rev Med Devices 2006;3:657–75. grafts (e.g. Alloderm ) used in complex abdominal wall repairs 6. Mathes SJ, Steinwald PM, Foster RD, Hoffman WY, Anthony JP. have been shown to be more prone to stretch and have up to an Complex abdominal wall reconstruction: a comparison of flap 80% recurrence rate when used in a bridged repair (compared and mesh closure. Ann Surg 2000;232:586–96. with a reinforced repair) [9]. With specificregardtothe two 7. Danino AM, Malka G, Revol M, Servant JM. A scanning electron cases discussed, alternative methods to a biological mesh for re- microscopical study of the two sides of polypropylene mesh construction were considered; the use of a biological or synthetic (Marlex) and PTFE (Gore Tex) mesh 2 years after complete ab- graft was deemed more appropriate than a local tissue flap as dominal wall reconstruction. A study of 15 cases. Br J Plast Surg both biopsy results were suggestive of aggressive soft tissue tu- 2005;58:384–8. mours. An important factor not addressed by this case report is 8. Novitsky YW, Rosen MJ. The biology of biologics: basic science the long-term outcome of patients who have undergone abdom- and clinical concepts. Plast Reconstr Surg 2012;130(5 Suppl 2): inal wall reconstruction with a biological mesh following tumour 9S–17S. excision. Nevertheless, most of the reported complications relat- 9. Jin J, Rosen MJ, Blatnik J, McGee MF, Williams CP, Marks J, et al. ing to this option including infection, hernia and chronic inflam- Use of acellular dermal matrix for complicated ventral hernia mation are observed in the early follow-up and we have not repair: does technique affect outcomes? JAm CollSurg observed these problems. 2007;205:654–60. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

The use of a biological graft for the closure of large abdominal wall defects following excision of soft tissue tumours

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Publisher
Oxford University Press
Copyright
Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2015.
eISSN
2042-8812
DOI
10.1093/jscr/rjv063
pmid
26109681
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Abstract

Primary soft tissue tumours arising from the abdominal wall are uncommon and surgical excision of such tumours can result in large abdominal wall defects. There are many techniques available for abdominal wall repair following tumour excision, each having its own advantages and disadvantages. The options range from direct closure to the use of tissue flap reconstructions and/or prosthetic meshes. Currently, synthetic material such as polypropylene mesh is a common choice for closure of abdominal wall defects after tumour excision. Biological meshes are an alternative option for repair, and this report outlines two cases of abdominal wall repair using the porcine intestinal submucosa biological graft following excision of abdominal wall tumours. There was no evidence of infection, recurrence, seroma or hernias at 2-year follow-up. Following excision of soft tissue tumours of the abdominal wall, biological reconstructions can be successfully used to bridge the defect with minimal morbidity. Medical™)porcine smallintestinalsubmucosal(non-cross- INTRODUCTION linked) graft. Both of the procedures described were primary sur- Permanent synthetic meshes composed of materials such as geries for large defects secondary to soft tissue tumour excision, polypropylene, polyester or expanded polytetrafluoroethylene an application of the porcine intestinal biological graft which is are widely regarded as durable and ergonomically sound options not yet widely documented in the literature. for abdominal wall reconstruction [1, 2]. However, significant complications including mesh migration, bacterial colonization CASE REPORT and fistula formation necessitated the development of an alter- native [3]. The use of synthetic meshes can cause of adhesions, Case 1 chronic sinus (2–6%), fistula formation (0–2%) and wound infec- tions (2–17%). The development of biological grafts reduced the A 43-year-old Caucasian female presented to her General Practi- incidence of the aforementioned complications [3, 4]. Today, an tioner in April 2012 with a 2-year history of a firm, painful swel- array of grafts is available, including human, bovine and porcine ling in the right flank. MRI revealed a 5.0 × 6.0 × 7.0 cm enhancing dermis, as well as porcine small intestinal submucosa and bovine lesion with areas of necrosis, which was invading the antero-lat- pericardium [5]. The following cases concern the successful eral abdominal wall (Fig. 1 ). With radiological features highly repair of abdominal wall defects using the Biodesign (Cook suggestive of a sarcoma, she underwent an ultrasound-guided Received: March 1, 2015. Revised: April 11, 2015. Accepted: June 1, 2015 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2015. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 2 | E. Illingworth et al. Figure 3: Twelve-month postoperative MRI. Figure 1: T MRI showing a soft tissue abdominal wall tumour involving external oblique, internal oblique and transversus abdominis and not involving the peritoneum (arrow). Figure 4: T MRI showing a soft tissue tumour of the anterior abdominal wall involving external oblique and internal oblique and not involving the peritoneum. had undergone a right-sided inguinal hernia synthetic mesh re- Figure 2: Depicting the porcine intestinal biological mesh in place after tumour pair in 2010. MRI with contrast confirmed a 6.9 × 6.7 × 4.6 cm mass excision. invading the abdominal wall musculature (Fig. 4). Radiological features were suggestive of sarcoma or aggressive fibromatosis. biopsy, which classified the mass as a borderline myoepithelial Histology from an ultrasound-guided biopsy revealed aggressive tumour. The patient underwent an uncomplicated resection of fibromatosis. The patient opted for a surgical excision of the mass the mass, which left a 10 × 10 cm right-sided antero-lateral ab- with abdominal wall reconstruction. The tumour was excised dominal wall defect. The defect was repaired using a Biodesign with the internal oblique, leaving the peritoneum and external biological graft. Initially, a layer of the biological mesh was used ring cord structures intact. A 13 × 15 cm sheet of porcine intes- to cover the intact peritoneum with attachments cranially to the tinal biological mesh was used to repair the abdominal wall ribs and inferiorly to the right iliac crest. The external oblique was defect (Fig. 5). Inferiorly, the mesh was doubled over in the pre- mobilized to partially cover the mesh, and a further layer of the peritoneal space to reconstruct the inguinal ligament, and biological mesh attached over it with Ethilon™ (Fig. 2). The pa- sutured to the external oblique. The histology confirmed a final tient had an uncomplicated postoperative recovery. The tumour diagnosis of aggressive fibromatosis excised with 1 mm margins. histology revealed a 6.5 × 6.0 × 5.5 cm myxoid mass; immunohis- At 24 months, there was good wound healing and no hernia, ser- tochemistry analysis favoured a benign/borderline myofibroblas- oma or evidence of recurrence on follow-up MRI. tic tumour. At 24-month follow-up, she had good wound healing with a small area of paraesthesia inferior to the scar. An MRI showed good graft incorporation and no evidence of disease re- DISCUSSION currence or hernia (Fig. 3). Large soft tissue tumours of the abdominal wall are very rare. When faced with selecting an appropriate technique for both of Case 2 the reported procedures, consideration of the defect size (both A 31-year-old man presented to his General Practitioner in May being larger than 10 cm), the absence of any potential contamin- 2012 with a 6-week history of a painful mass in the right iliac ation and the excellent degree of cutaneous integrity were all fossa. There was no regional lymphadenopathy and hip examin- central to the decision to use the porcine intestinal biological ation was unremarkable. He was a smoker with a BMI of 33 and graft. A further alternative is the use of autogenous tissue in Use of a biological graft for the closure of large abdominal wall defects | 3 The choice of technique for abdominal wall reconstruction following excision of a large abdominal wall soft tissue tumour is a difficult clinical decision. Though biological meshes are cost- lier than the synthetic meshes, reduction of postoperative com- plications may justify the use of the biological graft. The two cases reported highlight the necessity to consider each patient according to factors such as the defect size and location, the over- lying skin integrity and the sterility of the wound. The porcine in- testinal biological graft thus appears a suitable alternative choice for successful repair of abdominal wall defects with good incorp- oration and minimal postoperative morbidity in patients with large anterior/antero-lateral abdominal wall defects following soft tissue tumour excision. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1. Hsu PW, Salgado CJ, Kent K, Finnegan M, Pello M, Simons R, Figure 5: Depicting the use of porcine intestinal biological mesh to repair an et al. Evaluation of porcine dermal collagen (Permacol) used anterior abdominal wall defect left by aggressive fibromatosis. in abdominal wall reconstruction. J Plast Reconstr Aesthet Surg 2009;62:1484–9. the form of advancement or regional flaps. This is considered an 2. Brown P. Abdominal wall reconstruction using biological tis- excellent option when the cutaneous coverage is inadequate to sue grafts. AORN J 2009;90:513–20; quiz 21–4. maintain a successful closure with mesh alone [6]. When used 3. Morris-Stiff GJ, Hughes LE. The outcomes of nonabsorbable at the peritoneal surface, laminar prostheses have been reported mesh placed within the abdominal cavity: literature review as having a lower incidence of adhesion formation, which is con- and clinical experience. J Am Coll Surg 1998;186:352–67. sidered to be secondary to early mesotheliation [7]. Biological tis- 4. Cook Medical. Biodesign Advanced Tissue Repair. Cook Medical, sue grafts are increasingly being utilized in abdominal wall 2011. https://www.cookmedical.com/data/resources/product repair. Importantly, they permit and encourage host tissue in- References/SUR-BMRM-HFB3-EN-201407_M3.pdf?905860. corporation, promote neovascularization and, in theory, degrade 5. Bellows CF, Alder A, Helton WS. Abdominal wall reconstruc- in response to increasing wound strength and fascia formation tion using biological tissue grafts: present status and future [8]. Although superior with regard to biocompatibility, allogenic opportunities. Expert Rev Med Devices 2006;3:657–75. grafts (e.g. Alloderm ) used in complex abdominal wall repairs 6. Mathes SJ, Steinwald PM, Foster RD, Hoffman WY, Anthony JP. have been shown to be more prone to stretch and have up to an Complex abdominal wall reconstruction: a comparison of flap 80% recurrence rate when used in a bridged repair (compared and mesh closure. Ann Surg 2000;232:586–96. with a reinforced repair) [9]. With specificregardtothe two 7. Danino AM, Malka G, Revol M, Servant JM. A scanning electron cases discussed, alternative methods to a biological mesh for re- microscopical study of the two sides of polypropylene mesh construction were considered; the use of a biological or synthetic (Marlex) and PTFE (Gore Tex) mesh 2 years after complete ab- graft was deemed more appropriate than a local tissue flap as dominal wall reconstruction. A study of 15 cases. Br J Plast Surg both biopsy results were suggestive of aggressive soft tissue tu- 2005;58:384–8. mours. An important factor not addressed by this case report is 8. Novitsky YW, Rosen MJ. The biology of biologics: basic science the long-term outcome of patients who have undergone abdom- and clinical concepts. Plast Reconstr Surg 2012;130(5 Suppl 2): inal wall reconstruction with a biological mesh following tumour 9S–17S. excision. Nevertheless, most of the reported complications relat- 9. Jin J, Rosen MJ, Blatnik J, McGee MF, Williams CP, Marks J, et al. ing to this option including infection, hernia and chronic inflam- Use of acellular dermal matrix for complicated ventral hernia mation are observed in the early follow-up and we have not repair: does technique affect outcomes? JAm CollSurg observed these problems. 2007;205:654–60.

Journal

Journal of Surgical Case ReportsOxford University Press

Published: Jun 24, 2015

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