Laparoscopy-assisted Chimeric Peritoneal-deep Inferior Epigastric Perforator Flap for Reconstruction of Hand and Foot

Management of hand and foot defects with exposed tendons is a big challenge for plastic surgeons. Thin vascularized tissue offers an ideal surface for tendon excursion. Objective. This study examines the reconstructive benefits of a laparoscopy-assisted chimeric peritoneal-deep inferior epigastric artery perforator (DIEP) flap in the treatment of hand and foot injury defects. Materials and Methods. A retrospective review was performed on 8 patients (6 men, 2 women) that received hand or foot reconstruction with laparoscopy-assisted chimeric peritoneal-DIEP flap. Soft tissue defects of the hand or foot ranged from 16 cm x 10 cm to 22 cm x 14 cm. The peritoneum supplied by the peritoneal branches of the deep inferior epigastric artery was retrieved by laparoscopy to cover exposed extensor tendons, while the DIEP flap consisted of the cutaneous component part of this chimeric flap. Results. The flaps survived in 7 of 8 patients. Partial necrosis of the chimeric flap was observed in 1 patient due to venous thrombosis. A split-thickness skin graft then was performed to achieve wound closure on that patient. Motor and sensory functions of these 8 patients improved gradually within the first-year follow-up. Conclusions. The laparoscopy-assisted chimeric peritoneal-DIEP flap is useful for reconstructing defects of the hand and foot with exposed tendons.

Despite progress in microvascular surgery, reconstruction of soft tissue defects of the hand and foot with exposed tendons remains a major challenge. Disappointing clinical outcomes are likely caused by tendon adhesion, extensive fibrosis, and prolonged immobilization.¹ Many attempts to use biochemical and physical means have been made to reduce pathological adhesion formation^2,3; however, certain limitations hinder the full effect of most applied therapies.⁴ Currently, physical membrane application has been adopted for its ability to prevent restrictive adhesion by separating the healing tendon from surrounding tissues. For instance, Salgado et al⁵ proposed that peritoneum interposition might reduce adhesion formation following surgery of exposed extensor tendons of the hand and foot. 

With the goal of applying a gliding surface for underlying tendon excursion, the authors introduced a laparoscopy- assisted chimeric peritoneal-deep inferior epigastric artery perforator (DIEP) flap.⁵ They believe the DIEP application could minimize adhesions and allow for cont- inued free tendon movement following reconstructive surgery. In the present report, the authors present the flap design and operative technique, along with 8 cases describing the outcome and effects of such an approach.

Patients and treatment

The study was reviewed and approved by the Institutional Ethics Committee of Zhejiang Provincial People’s Hospital, Hangzhou, China. All participants or their legally authorized representatives provided written informed consent. Eight patients were included and assessed in the present study. All 8 patients had hand or foot defects and underwent reconstruction via use of a laparoscopy- assisted chimeric peritoneal-DIEP flap from April 2012 to December 2012 in the Zhejiang Provincial People’s Hospital. Soft tissue defect sizes ranged from 16 cm x 10 cm to 22 cm x 14 cm. All dorsal defects were accompanied by injuries of the extensor tendons. 

Flap design and operative procedures

First, a laparoscope was introduced through the subumbilical port and 2 other trocars were placed in the right and left lower abdominal walls. The peritoneal branches of the deep inferior epigastric artery could be detected via video laparoscopy. Dissection of the cutaneous component of this chimeric flap followed standard techniques with intramuscular dissection of the musculocutaneous perforators through the rectus abdominis muscle. After identifying and selecting the perforating vessel with the largest diameter, the anterior rectus fascia was opened caudally, preserving a small cuff around the vessel. 

Laparoscopic division of the pedicles of the chimeric peritoneal-DIEP flap was performed using ultrasonic-activated scissors. Small peritoneal branches and the perforators chosen from the deep inferior epigastric vessels were preserved with the assistance of magnified laparoscopic imaging. The bilateral deep inferior epigastric artery was carefully isolated, double clipped, and transected at its origin to maximize pedicle length and diameter. 

The peritoneal component of this chimeric flap and the attached posterior rectus sheath were transplanted to conceal the exposed tendons and skeleton of the defect. The DIEP flap separately provided cutaneous coverage of the entire remaining open wound, as required by the initial intention of a single-stage wound closure.

Mean age of patients was 44 years (range, 22–52 years; 6 men, 2 women). All 8 patients had significant exposure of tendons and/or bone; therefore, a skin graft alone was insufficient for satisfactory reconstruction. Of the 8 transplanted chimeric peritoneal-DIEP flaps, 7 presented complete survival and 1 experienced partial necrosis. In that 1 case, the cutaneous portion of the chimeric flap showed necrosis due to postoperative venous thrombosis, which occurred in a female patient around the time of menstruation. A split-thickness skin graft was performed to cover the ensuing cutaneous defect of the free chimeric flap.

With a mean follow-up of 9 months, both the donor and recipient sites healed successfully. All patients demonstrated good long-term coverage, flap pliability, and contour with evidence of decreased underlying tendon adhesion or contracture at the flap site.

Case 1

A 22-year-old man sustained an extensive degloving injury to his right foot due to a motorcycle accident, which resulted in a partial loss of extensor tendons of the toes (Figure 1A). After debridement and reconstruction of the extensor tendons, the metatarsal bones and extensor tendons were exposed (Figure 1B). The soft-tissue defect over the dorsal foot measured 22 cm x 14 cm. A chimeric peritoneal-DIEP flap of 25 cm x 16 cm was harvested to cover the entire wound using posterior tibial vessels as the recipient vasculature (Figure 1C, 1D). The chimeric flap donor site required no grafting procedure and exhibited no wound breakdown. At 1-year follow-up, the patient was able to walk independently, and the skin coverage was stable (Figure 2).

Case 2

A 52-year-old man was injured in a car accident with complex, open fracture- dislocations of the right hand and severe muscle damage of the forearm and hand. In addition, the patient presented with extensive tissue loss of the dorsal hand and wrist combined with extensor tendon loss (Figure 3A). The palmaris longus tendon was used for tendon grafting of the lost extensor tendons. The dimension of the dorsal defect of the hand and wrist was 18 cm x 11 cm. This specific soft tissue coverage was accomplished via a chimeric peritoneal-DIEP flap measuring 21 cm x 14 cm dissected from the abdominal wall (Figure 3B–3D). No flap loss or infection was recorded. The flap donor site was closed primarily and showed good aesthetic appearance (Figure 4A). Partial functional recovery was observed after 6 months of physical therapy (Figure 4B).

Accumulating evidence suggests tissue reconstruction using a flap would involve tendon adhesion and functional impairment at the recipient site.^6,7 In an attempt to increase tendon movement and minimize interactions between injured tendons and surrounding tissues, the authors proposed reconstruction introducing a new laparoscopy-assisted chimeric peritoneal-DIEP flap. The peritoneal part of this chimeric flap was placed against the mobile tendons and joints to reduce contact with adjacent tissues.

Although various studies to date have emphasized preventing adhesion following tendon surgery, the results from previous studies using animal models have been less than satisfactory in supporting this level of emphasis.⁸ Functional tendon gliding effectively requires engraftment of vascularized tissue without scarring or adhesions,⁹ and, at minimum, a gliding path free from adhesions. There are several ways this has been achieved in the literature. Modification of the tendonous gliding path via engraftment of vascularized adipofascial free flap yielded promising results in restoring function in digital movement in hand and forearm surgery.^10,11 The extent of functionally useful vascularized fat needed is determined by total area to be treated by engraftment and the utility of this approach for improving gliding of tendons following repair. As such, it may not be the most effective approaches for all potential cases.

Other methods serve to support anti-adhesion approaches to therapy. Sodium hyaluronate and its combinations have been studied extensively as an adjunct to adhesion prevention in surgery involving digits. Khanna et al⁸ and Karakurum et al¹² have suggested that sodium hyaluronate and its combinations promote tendon healing and decreased adhesion formation, but Hagberg⁴ and Golash et al¹³ have not demonstrated significantly beneficial effects. Two prospective, double-blind, randomized, controlled clinical studies^4,13 showed no significant benefits of hyaluronic acid or ADCON-T/N (a glycosaminoglycan-rich substance similar to hyaluronic acid) in the prevention of digital adhesion in human subjects. In fact, these agents may lead to a foreign body reaction and, thus, result in the formation of additional scar tissue.

Salgado et al⁵ first introduced the posterior rectus sheath-peritoneal free flap for reconstruction of the hand and foot. This group dissected the peritoneal flap by making a paramedian incision under direct visualization. However, disadvantages associated with their procedure include potential abdominal wall herniation and postoperative ileus. Some of the patients described in their study did experience a prolonged postoperative ileus. A thin flap easily supporting a single-stage wound closure, as well as offering a gliding surface for tendon coverage, represents an ideal approach. Other important factors include minimal donor-site morbidity and an acceptable cosmetic result.

The present laparoscopic surgery has many advantages over the technique by Salgado et al.⁵ With the help of pneumoperitoneum and magnified visualization provided by the laparoscopic syste, the surgical procedures utilized herein are safer and afford easier dissection of the miniscule peritoneal branches and perforating vessels from the deep inferior epigastric vessels. The laparoscopy-assisted chimeric peritoneal- DIEP flap with a long common pedicle allows more flexible anastomosis. In addition, skin graft coverage is unnecessary to achieve wound closure if the chimeric flap completely survives postengraftment. Further debulking revision surgery also is not necessary if the initial thinning perforator flaps are effective without compromising patient rehabilitation. Last but not least, the donor site requires no grafting procedure. No abdominal wall herniation and postoperative ileus were observed in this study.

There are several limitations in this study. The authors did not compare current techniques with other classic techniques and a small patient sample size. Furthermore, the functional outcomes reported in this study could be improved. In future study, researchers should apply more standard quantitative measurements such as range of motion, grip strength, etc, to describe function. 

This study indicates that the laparoscopy- assisted chimeric peritoneal-DIEP flap is a suitable choice for soft-tissue defect coverage in the hand and foot with exposed tendons. However, larger randomized, controlled clinical trials and long-term follow-up are required to support the recommendation of this chimeric flap. 

Affiliations: Department of Hand Surgery, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, China

Correspondence: Qingping Xie, MD, Department of Hand Surgery, Zhejiang Provincial People’s Hospital, #158 Shangtang Road, Hangzhou, P.R.China 310014; qingping.xie@aol.com

Disclosure: This study was supported by grants from the Foundation of Sci-Tech Department of Zhejiang Province, China (No. 2012C13020-3) and from the Foundation of Health & Family Planning Commission of Zhejiang Province, China (No. 2014KYA011). Language editing was provided by Clarity Manuscript Consultant LLC (Indianapolis, IN).