Expanding the envelope:  the posterior rectus sheath-liver vascular composite allotransplant.
BACKGROUND
Primary abdominal wall reconstruction after liver transplantation presents a challenge in patients with size mismatch, multivisceral transplants, and prior recipient abdominal surgery. The authors report their experience with a novel technique for abdominal wall reconstruction with a new vascular composite allotransplant.


METHODS
Five posterior rectus sheath-liver composite vascular allotransplants were procured by a multidisciplinary team and transplanted into four patients over the course of 2 years. Liver transplantation was performed in the standard manner, and the posterior rectus sheath was inset as an inlay flap.


RESULTS
Abdominal wall integrity was reestablished with vascularized fascia in all five cases. In two cases, the fascia was closed immediately at the time of initial transplantation. In three cases, the abdomen was left open for a planned second look and closed definitively when the liver appeared satisfactory. In one patient, hepatic artery thrombosis was detected 11 days after transplantation, requiring a second posterior rectus sheath-liver transplant. Skin closure was performed for all transplants in either an immediate or a delayed fashion. Reoperation requiring elevation of the posterior rectus sheath flap for a suprahepatic vena cava stenosis was performed in one patient.


CONCLUSIONS
Closure of the abdominal cavity is critical to the success of liver transplantation for organ survival and overall patient morbidity and mortality. The authors describe their institutional experience with a novel method of concurrent abdominal wall reconstruction and liver transplantation using the posterior rectus sheath-liver vascular composite allotransplant in situations of size mismatch, multivisceral transplants, and compromised abdominal wall of the recipient.


METHODS
Therapeutic, V.
Chicago, Ill. From the Sections of Plastic and Reconstructive Surgery and Transplant Surgery, Department of Surgery, University of Chicago Medical Center.
Justine C
JC
Lee
Oyedolamu K
OK
Olaitan
Reynold
R
Lopez-Soler
John F
JF
Renz
J Michael
JM
Millis
Lawrence J
LJ
Gottlieb
D034861:Abdominal Wall / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D019651:Plastic Surgery Procedures / Q000379:methods*; D017568:Rectus Abdominis / Q000098:blood supply* / Q000637:transplantation*; D012189:Retrospective Studies; D013524:Surgical Flaps / Q000098:blood supply*; D055815:Young Adult