Jeffrey A Blatnik, MD1, Eric M Pauli, MD2, John Ammori, MD1, Julian Kim, MD1, Yuri Novitsky, MD1. 1University Hospitals Case Medical Center, 2Penn State Hershey Medical Center
Abdominal wall tumors are a rare soft tissue tumor known to occur in the abdominal wall musculature. Such types of tumors include desmoid tumors with low risk of metastasis, but high local recurrence; and soft tissue sarcomas which have varying degrees of aggression. The current standard for treatment involves surgical resection with negative margins. As a result, many patients are left with large muscular defects and high risk for herniation. The transversus abdominis muscle release is a method of ventral hernia repair which allows for midline advancement and the placement of extraperitoneal mesh while minimizing large skin flaps. We report a case series of the TAR method of hernia repair for the reconstruction of full thickness abdominal wall muscular defects following resection of abdominal wall tumors.
Patients with large abdominal wall tumors who underwent oncologic resection leaving them with full thickness muscular defects were evaluated. At the time of initial operation resection of the tumor was performed with preservation of soft tissue and skin when possible. Following tumor resection a TAR was used to create an extraperitoneal plane. This is performed by taking down the posterior rectus sheath (when preserved) laterally to approximately 1 cm medial to the linea semiluminaris. The posterior sheath is then incised along the length of the abdomen to enter an extraperitoneal plane and continued laterally to the psoas muscle. Following closure of the posterior sheath, the remaining muscular defect is reinforced with a large piece of synthetic mesh. Patients were followed for tumor recurrence and longevity of hernia repair.
A total of 5 patients (40% male) with an average age of 42 years and BMI of 27.5 underwent surgical resection. The average tumor size was 15cm x 10cm x 8cm. Following tumor resection a TAR was performed which allowed the creation of an extraperitoneal plan for all patients regardless of tumor size. When possible the remaining abdominal muscle was secured in the midline to the underlying mesh in an effort to prevent further retraction laterally. Skin and soft tissue were preserved and closed in multiple layers over the mesh. One patient who underwent additional abdominal resection at the same time suffered minor wound morbidity, but did not require mesh removal. The average follow-up was 10 months, and there is no evidence of hernia recurrence and 60% of patients remain tumor free.
The use of TAR for immediate reconstruction following resection of abdominal wall tumors provides a good option for reinforcement in a challenging reconstructive field. This technique allows for wide placement of synthetic mesh, low risk for herniation and low wound morbidity.