Logo for University of Iowa Health Care This logo represents the University of Iowa Health Care
Overcoming Gag Reflex for Awake Transnasal Laryngeal SurgeryClick Here
Make a Donation

Rectus Abdominis Free Flap

last modified on: Wed, 01/24/2024 - 06:35

return to: Microvascular Surgery Protocols

GENERAL CONSIDERATIONS

  1. Indications
    1. With the increased use of the forearm flap for intraoral and pharyngeal reconstruction, the rectus has been relegated to a second-line choice for reconstruction of these areas. The flap may be advantageous for cases in which a large tongue defect requires reconstruction with the need for more bulk than is available through the forearm flap.
    2. Our primary use of this flap is in the reconstruction of skull base defects in which a large volume of conformable, vascularized muscle is required to obliterate a skull base defect and bolster a dural closure. In these cases, the flap is harvested without a cutaneous paddle unless skin closure of a palatal defect is required.
    3. The vascularized subcutaneous adipose tissue of a deepithelialized skin paddle will retain bulk; however, the denervated muscle will lose much of its original size over six to eight months. These different volume characteristics can be used in planning a reconstruction in which permanent volume is desirable.
  2. Contraindications
    1. See Microvascular Surgery General Considerations
    2. Flap-specific contraindications include previous abdominal or hernia surgery that may have disrupted the vascular pedicle and previous vascular surgery involving the femoral vessels for atherosclerotic disease.
    3. This flap should be avoided in patients with a history of large umbilical or periumbilical hernias. Although the flap may be harvested in relatively heavy patients, extreme obesity is a contraindication to harvest of this flap, particularly if a skin paddle is required.
  3. Pertinent Anatomy
    1. The rectus flap is a musculocutaneous flap based on the deep inferior epigastric artery and vein and terminal musculocutaneous perforators. These vessels arise from the external iliac artery and vein and course superomedially to run along the deep lateral aspect of the muscle. Within 1 to 2 cm of the arcuate line, the vessels enter the muscle. The major group of musculocutaneous perforators is found within 4 to 5 cm from the umbilicus. These vessels emerge through the anterior rectus sheath and then assume a superolateral orientation running toward the inferior angle of the scapula.
    2. When the flap is harvested, the anterior rectus sheath in the periumbilical area must be harvested with the flap to preserve these perforators. The anterior rectus sheath does not need to be harvested outside of the area where the perforators are concentrated. The anterior sheath should never be harvested below the arcuate line where there is no posterior sheath.
    3. The deep inferior epigastric vein is frequently found to be a system of paired veins/venae comitantes running with the artery. Just proximal to the external iliac vein, this system often forms one dominant vein. This should be sought during flap harvest.
    4. The muscle is horizontally segmented by tendinous inscriptions. These may be useful as robust areas in which to place sutures when the muscle is being sutured into a skull base defect.

PREOPERATIVE PREPARATION

  1. Evaluation
    1. Exclude the possibility of prior trauma to the harvest site through history and careful examination. Patients will frequently forget about a hernia repair done years in the past.
  2. Potential Complications
    1. See General microvascular protocol. Postoperative hernia is the most concerning complication. This complication is avoided through judicious harvest of only the area of the anterior rectus fascia that encompasses the cutaneous perforators and meticulous closure of the anterior rectus sheath.
    2. Patients may have a postoperative ileus due to manipulation of the bowel.

NURSING CONSIDERATIONS

  1. Room Setup
    1. See Free Flap Room Setup
  2. Instrumentation and Equipment
    1. Standard
      1. Major Instrument Tray 1, Otolaryngology
      2. Major Instrument Tray 2, Otolaryngology
      3. Bipolar Forceps Trays
      4. Microsurgery Instrument Tray, Otolaryngology
    2. Special
  3. Medications (specific to nursing)
    1. Antibiotic ointment (see Antibiotic Prophylaxis in Head and Neck Surgery protocol)
    2. Heparin sodium injection, 1,000 units per ml, 10 ml vial
    3. Papaverine injection, 30 mg/ml
    4. PhysioSol irrigation solution, 500 ml (be sure the PhysioSol is in the warmer in sufficient time to be warm when the surgeon requests it)
  4. Prep and Drape
    1. Standard prep, 10% providone iodine
      1. Prep abdomen and chest on ipsilateral side down to symphysis. Prep should extend for 6 to 7 cm beyond midline and laterally to midaxillary line. Separate groin from operative field with sticky drape. Prep head and neck as required for ablative procedure.
    2. Drape
      1. Prep head and neck separately from free flap operative site
      2. Towels to square off operative site including chest and abdomen down to symphysis
      3. Separate groin from operative field with a sticky drape
      4. Split sheet
  5. Drains and Dressings
    1. Varidyne vacuum suction drain x 2
    2. Antibiotic ointment to suture line
  6. Special Considerations
    1. Heparin sodium injection 5,000 units in sodium chloride 0.9% 500 ml in syringe, Luer tip 5 cc syringe with 24-gauge IV cannula is used to irrigate vessels.
    2. Papaverine 60 mg in 500 cc sodium chloride 0.9% in a Luer tip 10 cc syringe with 18-gauge IV cannula will be used topically to irrigate for vasospasm.
    3. Use all measures to keep body temperature at least 37°C (warming blanket, room temperature).
    4. See Skin graft protocol if necessary for procedure
    5. See General microvascular protocol
    6. Order abdominal binder to be placed in the operating room.
    7. Separate surgical table and scrub nurse for the flap harvest and donor site closure.

ANESTHESIA CONSIDERATIONS

  1. Positioning
    1. The patient is placed supine, and a Mayfield headrest is used. The arms should be tucked. The patient will be turned 180° from the anesthesiologist.
  2. Specific
    1. The anesthesia tubing should be on the contralateral side to flap harvest. If possible, the IV and arterial line should also be on the contralateral side.
    2. Advise the anesthesiologist that nitrous oxide should not be used during the case.

OPERATIVE PROCEDURE

  1. Draw linea alba, linea semilunaris, inguinal ligament, symphysis, costal margin, and approximate position of arcuate line (at level of anterior iliac spine). Draw intended skin paddle. The skin paddle may take on many different shapes and orientations; however, some of the paddle must be situated in the periumbilical area to capture the perforators.
  2. The incision to gain access to the muscle and begin flap elevation is oriented vertically just medial to the linea semilunaris encompassing the lateral margin of the intended skin paddle. This incision is carried down to the anterior rectus fascia. The anterior rectus fascia is carefully incised vertically with care to skirt around the periumbilical area. An area of anterior rectus fascia with a length of approximately 7 cm and width of 4 to 5 cm is not elevated from the muscle in this area to preserve the perforators.
  3. The anterior rectus fascia is elevated medially off of the anterior muscle surface. The muscle is freed from the posterior rectus fascia beginning superiorly. As this dissection is carried inferiorly, the vascular pedicle will be identified in the area of the arcuate line. The vascular pedicle is dissected free from the inferior rectus muscle.
  4. The medial border of the skin paddle is incised down to the anterior rectus fascia. The muscle is divided superior to the skin paddle and reflected inferiorly. The muscle is then divided below the entry point of the vascular pedicle. With patience, the vascular pedicle is dissected to its origin from the external iliac vessels.
  5. The flap may be left in position until the recipient site is prepared.
  6. Following flap harvest, meticulous hemostasis is obtained. The anterior rectus sheath is closed over a 10 mm fully-perforated suction drain with 0-0 prolene suture. The drain is brought in superiorly. The skin is closed with subcutaneous sutures of 2-0 vicryl over a 10 mm fully- perforated suction drain brought in inferiorly. The skin is closed with staples, and an abdominal binder is applied.

POSTOPERATIVE CARE

  1. See Microvascular Surgery General Considerations
  2. The suction drains are removed when drainage is less than 10 cc per eight-hour shift.
  3. The patient wears the abdominal binder for two weeks and is instructed against any heavy lifting for six weeks.

REFERENCES

Ebihara H, Maruyama Y. Free abdominal flaps: variations in design and application to soft tissue defects of the head. J Recon Microsurg. 1989;5:193-201.

Harii K. Inferior rectus abdominis flaps. In: Baker SR, ed. Microsurgical Reconstruction of the Head and Neck. New York, NY: Churchill-Livingston. 1988:191-210.

Urken ML, Turk JB, Weinberg H, et al. The rectus abdominis free flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 1991;117:857-866.