Introduction: Achieving abdominal closure following bowel transplantation is often a major challenge. There are also circumstances in other solid organ transplants where the ability to safely and effectively augment the abdominal wall is highly desirable. A variety of techniques have been described including tissue expansion, use of reduced grafts, plastic surgery and vascularised abdominal wall transplants.^[1][2]

Methods: The rectus abdominus and its fascia are excised from the donor as a single piece having elevated flaps of skin and subcutaneous tissues widely. The retrieval process can then be undertaken as normal and closure of the cadaver is the same as for a standard multiorgan donor as there is no loss of abdominal skin.
The rectus abdominus is stored in University of Winsconsin solution on ice and transferred to the implanting hospital. Prior to use the fascia is separated from the rectus abdominus muscle trying to minimise damage to the fascia. Both anterior and posterior layers are preserved and any defects closed with a nonadsorbable suture.
The graft is implanted at the end of the transplant to provide a tension free closure having mobilised flaps of subcutaneous tissues widely. Under most circumstances it is possible to achieve skin closure over the fascial graft although application of a vac dressing and subsequent skin grfating is possible. 

Results: We describe a series of 9 small bowel transplant recipients and 2 liver transplant recipients in which abdominal closure was effected by transplant of rectus abdominus fascia.  In one patient the fascia used was from a third party donor.  
One of the liver transplant recipients required super urgent transplantation for acute liver failure and so received a graft from a donor with a weight of 1.41 that of the recipient. The second recipient required fascial augmentation as a consequence of loss of abdominal domain (3rd liver transplant with chronic biliary fistula).
There have been no complications associated with this technique. There have been 6 subsequent laparotomies following the use of the fascia mostly for continuity surgery.  Experience suggests that unlike the use of commercially available biomaterials use of rectus abdominus fascia is associated with less in the way of intra abdominal adhesions and a greater degree of structural integrity.

Conclusions: The use of donor avascular rectus fascia grafts is associated with good functional outcomes and is a technique that is applicable not only to small bowel and multiviscaeral transplants but also other solid organ transplantation.

[1] Gondolesi G, Selvaggi G, Tzakis A, Rodriguez-Laiz G, Gonzalez-Campana A, Fauda M, Angelis M, Levi D, Nishida S, Iyer K, Sauter B, Podesta L, Kato T. Use of the abdominal rectus fascia as a nonvascularised allograft for abdominal wall closure after liver, intestinal and multivisceral transplantation, Transplantation 2009 Jun 27; 87 (12):1884-8
[2] Gondolesi GE, Aguirre NF. Techniques for abdominal wall reconstruction in intestinal transplantation. Curr. Opin. Organ Transplant 2017