PMC8173211_01
(A) Recurrent ulcerated colonic adenocarcinoma involving abdominal wall. (B) Residual 26.5 x 18.5 cm abdominal wall defect. (C) Vicryl mesh sutured to margins of defect. (D) TopClosure sets applied perpendicular to wound, 3-4 cm from wound edges (insert shows relation of tension sutures to AP and underlying structures). (E) First stage wound approximation (insert; inner layer fenestrated non-permeable surface of sponge apposing Vicryl mesh). (F) Second sponge layer under ASs. ASs in center of wound permit further approximation by mechanical creep. (G) Complete cover and insulation of wound by ROI-NPT apparatus. (H) Six months after surgery. Lateral deviation (black line) from midline (blue line) of the umbilicus (circle).
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F1
A 41-year-old woman with recurrent, infected, ulcerated colonic adenocarcinoma and extensive involvement of the abdominal wall underwent resection of the sigmoid colon, radical right iliac lymph node dissection and substantial excision of the abdominal wall (Figures 1A,B). Vicryl mesh was sutured to the margins of a 490 cm2 defect (bordered by the right linea alba, residual right rectus abdominis muscle, right subcostal abdominal wall, right flank along the length of the right iliac bone from the iliac crest to the pubis, and laterally from the remnant of the right external oblique muscle and anterior superior iliac spine to the fascia lata of the right leg) to cover the small and large bowel (Figure 1C). The left abdominal wall was stretched across to the right using 1/0 nylon tension sutures running over nine of twelve TopClosure  attachment plates (AP) (IVT Medical Ltd, Ra'anna, Israel) (Figure 1D-insert). APs to be pulled together gradually postoperatively by their connecting approximation straps (AS) (Figure 1D). A soft, compressible open-cell sponge, a component of the Vcare alpha  system (IVT Medical Ltd., Ra'anna, Israel) was placed in the defect-the impermeable polyurethane layer in apposition with the Vicryl mesh-pushing down to obliterate a potential dead-space and protect the bowel from direct contact with the sponge to avoid fistulation (Figures 1E,F). Regulated oxygen and irrigation-negative pressure-assisted therapy (ROI-NPT) tubes were sited at opposite limits of the wound to create unidirectional, three-dimensional flow (Figure 1G). The umbilicus has been pulled laterally into the right iliac fossa (Figure 1H).