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Total Abdominal Wall Transplantation: An Anatomical study and Classification system
David Light, MD, Risal Djohan, MD, Neil Kundu, MD, Brian Gastman, MD, Robert Lohman, MD, Cristiano Quintini, MD, Namita Gandhi, MD, Richard Drake, PhD, James Zins, MD, Maria Siemionow, MD.
Cleveland Clinic, Cleveland, OH, USA.

Purpose:
In 2003 Levi et al reported on 160 intestinal transplants and found that in 20% of cases they were unable to close the abdominal wall using traditional modalities. Included in this report were nine partial abdominal wall transplants. In 2007 Cipriani et al described a modified technique utilizing microsurgical anastamoses to perform three partial abdominal wall transplants.
The goal of this study is outline a classification system to describe the location of the abdominal wall defects and aid in selecting a reconstructive option, determine which vessels to include in the pedicle to optimize graft survival, and develop a dissection technique for a total abdominal wall vascularized composite allotransplantation.
Methods:
Twenty total abdominal wall cadaveric dissections where performed. During each dissection anatomic variants were noted, the origins of the deep circumflex iliac (DCIA), superficial circumflex iliac (SCIA), deep inferior epigastric (DIEA) and superficial inferior epigastric arteries (SIEA) were measured in relation to the inguinal ligament, and a dissection technique was developed.
CT angiography was performed to evaluate perfusion. Injections were performed through the common femoral artery with the deep circumflex artery clamped and opened. Perfusion of the external and internal oblique and transversus abdominus muscles were compared to determine if the addition of the circumflex iliac system improved perfusion and thereby graft survival.
Results
Measurements of the origins of the DCIA, SCIA, DIEA and SIEA demonstrated that all four vessels can be found along a 5 cm cuff of the iliofemoral artery centered on the inguinal ligament, allowing for a focused and expedited dissection of the pedicle.
The venous anatomy was also evaluated and the common femoral vein was found to contain a valve in 75% of the specimens. In order to avoid issues with venous drainage of the graft and the need to incapacitate valves prior to venous anastomosis, the donor’s external iliac vein should be anastomosed to the recipient’s femoral or iliac vein.
CT angiography of the abdominal grafts revealed an obvious improvement in perfusion of the lateral musculature when the deep circumflex iliac artery was patent.
The classification system for abdominal defects is summarized in table 1.
Conclusion:
Total abdominal wall transplantation is a feasible and potentially lifesaving option for multivisceral transplant patients. Compared to other vascular composite allotransplantion whose greatest morbidity is immunosuppresion, abdominal wall transplant patients do not require additional immmunosuppresion beyond what they already receive for their visceral grafts. All patients have been maintained on a tacrolimus based immunosuppressive regime, making innervation of the graft promising given the nerve regenerative properties of tacrolimus.


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