Challenging abdominal wall defects.
BACKGROUND: We propose a simple algorithm for management of patients with challenging abdominal fascial defects. METHODS: The medical records of 64 patients with complicated abdominal wall defects representing a consecutive series by a single surgeon over a 4-year period were reviewed. Group I patients presented with massive fascial defects and closed wounds. They were reconstructed with autogenous tissue using either the separation of parts (SOP) procedure or free tensor fascia lata (TFL) grafts. Group 2 patients had fascial defects with open wounds. Wound closure was first accomplished with either STSG or primary skin closure over viscera. These patients, now "converted" into patients with closed wounds, were reconstructed months later as in group 1. RESULTS: Average defect size was 320 cm2. Wound closure was achieved in one procedure in all patients with open wounds. Time to discharge after this procedure averaged 9 days. The only morbidity of wound closure was skin graft donor site pain. Average time from temporary staged closure with skin grafts to definitive closure with autogenous tissue was 5 months. Repair of closed fascial defects with autogenous tissue was performed in 51 patients. Average time to discharge after autogenous tissue repair was 6.6 days. Recurrence of hernia was noted in 2 (3.9%) patients with an average follow-up of 24 months. CONCLUSIONS: Treatment of challenging abdominal wall defects can be accomplished simply and safely utilizing the above surgical algorithm. Open wounds are converted into closed wounds and fascial defects are repaired with autogenous tissue. This treatment plan has proved to be effective in a wide variety of situations.