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

摘要

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).