POSTERIOR RECTUS SHEATH AS A VASCULARIZED COMPOSITE ALLOGRAFT IN MULTIVISCERAL BOWEL TRANSPLANTATION

Kadiyala Ravindra¹, Scott Hollenbeck¹, Deepak Vikraman¹, Abigail Martin¹, Todd Brennan¹, Bradley Collins¹, Detlev Erdmann¹, Debra Sudan¹.

¹Department of Surgery, Duke University, Durham, NC, USA.

Introdution: Congenital anomalies such Prune belly syndrome are associated with poor abdominal wall musculature. This poses problems when these patients receive small bowel or multivisceral transplantation. A recent innovation uses the vascularized anterior rectus sheath in continuity with the liver (Fig.1). We applied this in a child with Prune Belly syndrome.

Patient and Method: A 2 year male with Prune belly syndrome listed to receive a multivisceral graft (Liver with small bowel). His abdominal wall was extremely lax – particularly on the right side. We conducted a fresh cadaver dye study to document the presence of blood flow to the posterior rectus sheath from the hepatic artery through branches in the falciform ligament.

At organ procurement the posterior rectus sheath was harvested in continuity with the falciform ligament attached to the multivisceral graft. After implantation of the graft, the rectus sheath appeared well vascularized and was used to restore the abdominal wall (Fig.2).

Results: The abdominal wall healed uneventfully. At 8 months, the child is on enteral nutrition with restoration of abdominal wall.

Conclusions: Posterior rectus sheath above the umbilicus receives blood flow from the hepatic artery, enabling its use as a composite tissue graft with a liver or mutivisceral allograft. This procedure has a potential application in patients undergoing multivisceral transplantation when the abdominal wall structure and function has been compromised by developmental defects or scarring from previous surgeries.