“Square Peg into a Round Hole”: Closure of a Laparotomy Wound Dehiscence with a Modified Rhomboid Flap

Abstract

The case of closure of a laparotomy wound dehiscence using a modified rhomboid flap is reported. A 61-year-old man, with a body mass index of 37.3 and a 120 pack-year smoking history, developed an incisional hernia following a left hemicolectomy. Repeated recurrences resulted in four mesh repairs. The fourth was complicated by a polymicrobial wound infection and superficial dehiscence in the supra-umbilical portion of the wound. The residual defect, composed of granulation tissue overlying polypropylene mesh, measured 10cm by 12cm. Both vacuum-assisted closure and split thickness skin grafting were attempted before successfully closing the defect with a modified rhomboid fasciocutaneous flap. Although there have been many technical innovations since the advent of rhomboid flaps, it offered a simple, yet effective therapeutic option in this case. INTRODUCTION First described by Alexander Limberg [1], the classical rhomboid flap is constructed around a defect converted into a geometric four-sided rhombus. Later modifications suggested that the flap could also be used to fill circular and irregular shaped defects [2]. A modified rhomboid flap was used, in this case, to close an irregularly shaped laparotomy wound dehiscence. CASE REPORT A 61-year-old man, with a body mass index of 37.3 and a 120 pack-year smoking history, developed an incisional hernia following a left hemicolectomy. Repeated recurrences resulted in four mesh repairs over a nine-year period. The fourth repair was complicated by a polymicrobial wound infection, and following clip removal on the tenth post-operative day, superficial dehiscence in the supra-umbilical portion of the wound. Vacuum-assisted closure therapy was commenced. Two months later the defect, composed of granulation tissue overlying polypropylene mesh, measured 10cm by 12cm (Figure 1). A fenestrated split thickness skin graft was applied. It was complicated by a beta haemolytic streptococcus wound infection and only 40% take was achieved (Figure 2). Figure 1 Figure 1: Superficial dehiscence in the supra-umbilical portion of the wound resulting in a 10 by 12cm defect composed of granulation tissue overlying polypropylene mesh. “Square Peg into a Round Hole”: Closure of a Laparotomy Wound Dehiscence with a Modified Rhomboid Flap 2 of 3 Figure 2 Figure 2: Modified rhomboid fasciocutaneous flap oversized to allow for debridement of the defect. The defect was subsequently closed using a modified rhomboid fasciocutaneous flap incorporating the laparotomy scar (Figure. 3). The flap was oversized to allow for debridement of the defect and inserted using a combination of polyglactin and poliglecaprone sutures and skin clips. The post-operative course was uneventful and the wound healed without complication (Figure 4). The cosmetic appearance was satisfactory to the patient. Figure 3 Figure 3: Healed wound at 16 weeks post procedure. DISCUSSION Most commonly used in head and neck reconstruction [2], rhomboid flaps may also play a role in the management of pilonidal sinus disease [3], decubitus ulcers [4] and contractures [5]. This case further highlights its versatility. Quaba and Sommerlad's modification [2] was used in this case, whereby no attempt was made to engineer a rhombic defect. Despite this, the flap provided effective closure of a large, irregularly shaped wound dehiscence. Although there have been many technical innovations since the advent of the rhomboid flap, it provided a simple, effective solution in this case and should still be considered as a therapeutic option in certain cases. References 1. Limberg AA. Mathematical principles of local plastic procedures on the surface of the human body. Leningrad: Medgis, 1946 2. Quaba AA, Sommerlad BC. "A square peg into a round hole": a modified rhomboid flap and its clinical application. Br. J. Plast. Surg. 40: 163-170, 1987 3. Eryilamz R, Sahin M, Alimoglu O, Dasiran F. Surgical treatment of sacrococcygeal pilonidal sinus with the Limberg transposition flap. Surgery. 134: 745-749, 2003 4. Kierney PC, Engrav LH, Isik FF, Esselman PC, Cardenas DD, Rand RP. Results of 268 pressure sores in 158 patients managed jointly by plastic surgery and rehabilitation medicine. Plast. Reconstr. Surg. 102: 765-772, 1998 5. Ulkur E, Acikel C, Evinc R, Celikoz B. Use of rhomboid flap and double Z-plasty technique in the treatment of chronic postburn contractures. Burns 32: 765-769, 2006 “Square Peg into a Round Hole”: Closure of a Laparotomy Wound Dehiscence with a Modified Rhomboid Flap 3 of 3 Author Information Anne M. Collins, MB Bch MRCS Senior House Officer, Department of Plastic and Reconstructive Surgery, St. Vincent's University Hospital Syed H.A. Shah Registrar, Department of Plastic and Reconstructive Surgery, St. Vincent's University Hospital Tom O'Reilly, FRCSI Consultant Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, St. Vincent's University Hospital