Full text of DOI:10.1007/s002380100291

Eur J Plast Surg (2001) 24:303–306
DOI 10.1007/s002380100291
C A S E R E P O RT
P. Bogetti · M. Boltri · G. Spagnoli · R. Giani
A.H. Ganem
Reconstruction of the abdominal wall after excision
of a bulky desmoid tumor and postoperative electromyography
investigation to demonstrate its integrity
Received: 20 November 2000 / Accepted: 14 May 2001 / Published online: 23 October 2001
©
Springer-Verlag 2001
Abstract The reconstruction of the abdominal wall fol-
Although there are no metastases, this neoplasm
lowing the removal of a bulky desmoid tumor involving presents a difficult challenge for the oncological surgeon
the left rectus abdominis muscle from the xiphoid to the because the tumor must be removed radically to effect a
umbilicus is presented. After the tumor was removed, cure. Therefore, it is essential to work closely with a
only the lateral third of the left rectus abdominis re- plastic surgeon because the reconstructive process is
mained intact and, consequently, the muscles of the ab- complicated. [9, 10, 11, 12].
dominal wall were mobilized according to the Ramirez
The case of a young woman with a recurrent bulky
technique. A polypropylene mesh was placed between abdominal wall desmoid tumor was presented. The full
the two rectus abdominis muscles and their posterior thickness of the abdominal wall was reconstructed by us-
sheaths, the muscles having been sutured in the midline ing a retromuscular synthetic mesh, transposing the rec-
without tension. The anterior abdominal wall was further tus abdominis muscles as described by Ramirez and a
reinforced by using an inferiorly pedicled dermal flap in premuscular vascularized dermal flap [13, 14, 15]. This
the cutaneous area between the umbilicus and the pubis. resulted in good morphological and functional recon-
This is an area commonly removed in an abdominoplas- struction of the abdominal wall.
ty. An electromyographical study demonstrated that the
muscles involved were functioning perfectly – both at
rest and under stress – about 40 days after the surgery.
Case report
The patient was admitted with a recurrent bulky mass in her left
abdominal wall. At the age of 36 she had a 12-month swelling in
her left abdominal wall removed. A solid neoplasm with poorly-
defined edges was found during that surgery. It arose from the su-
perficial fascia of the abdominal wall and involved the left rectus
Keywords Desmoid tumor · Ramirez technique ·
Electromyography
Introduction
The desmoid tumor is a neoplasm that arises in the con-
nective tissue of the muscular-aponeurotic abdominal
wall; it can either be benign or malignant [1, 2, 3, 4, 5].
In its most undifferentiated form, the desmoid tumor has
a very aggressive growth that tends to reappear locally
and infiltrate the surrounding tissue [6, 7, 8].
P. Bogetti
Via Vico 10, 10128 Turin, Italy
M. Boltri ( ) · G. Spagnoli · A.H. Ganem
✉
Division of Plastic and Reconstructive Surgery,
San Giovanni Battista Hospital, University of Turin, Italy
e-mail: mario.boltri@libero.it
Tel.: +39-011-6615477
R. Giani
Division of Oncologic Surgery, San Giovanni Antica Sede,
Turin, Italy
Fig. 1 A CT scan shows a recurrent oval neoplasm and a solid,
non-homogeneous structure that involves the left rectus abdominis

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abdominis muscle. A frozen section showed a spindle-shaped cell
tumor. It was later definitively diagnosed as a desmoid tumor.
She also gave a history of having had a right-sided ovarian cyst
removed at age 24 and a pregnancy that required a Caesarean sec-
tion when she was 34.
An abdominal examination showed a solid, hard, painless 7 cm
swelling under a recent surgical scar. It completely filled the left
hypochondrium and produced an obvious bulge.
A computer-assisted tomography (CT) scan showed a recurrent
oval neoplasm with a diameter of over 7.4 cm and a solid, non-ho-
mogeneous structure that involved the left rectus abdominis
(
Fig. 1). A biopsy was performed and a desmoid tumor was diag-
nosed.
Surgical procedure
The lesion was widely resected and was followed by the
reconstruction of the abdominal wall using a polypropyl-
ene mesh covered with the rectus abdominis muscles
that, in turn, were overlaid with a deepithelialized der-
mal flap. This was a combined procedure by the onco-
logical and plastic surgery teams due to the technical dif-
ficulties caused by the wide excision and the need to re-
construct the full thickness of the abdominal wall. The
objective was to restore the anatomical and functional
integrity of the anterior abdominal wall and to prevent a
postoperative hernia from occurring.
Fig. 2 The wide abdominal flap lifts up and exposes the neoplasm
Two transverse abdominal incisions were made: the
superior one was concave downwards, 1 cm from the su-
perior edge of the navel, and the inferior one was con-
cave upwards, 3 cm from the pubis. The first incision
was full thickness and reached the deep fascia of the an-
terior abdominal wall; the second was full thickness in
its right half and to the dermal layer on its left half.
Using the first incision it was possible to lift up a
wide flap at the deep fascia level as far as the inferior rib
arch. This allowed excellent exposure of the tumor
(
Fig. 2) and it could be removed completely (Fig. 3).
The neoplasm was a whitish color and a wooden tex-
ture and was firmly attached to the sheath of the left rec-
tus abdominis muscle. In order to completely remove the
neoplasm, a portion of the peritoneum close to the tumor
was excised. Following this process, only the third later-
al of the left rectus abdominis muscle was intact; thus,
the anterior abdominal muscles were mobilized accord-
ing to the Ramirez technique. This made it possible to
reconstruct the widespread loss of tissue. The medial
edge of the remaining part of the left rectus muscle was
sutured without tension to the medial edge of the intact
right rectus muscle [14, 15].
Fig. 3 The neoplasm removed
In this procedure, each rectus muscle was dissected
from its posterior sheath and the external oblique mus-
cles were separated from the internal oblique muscles in
an avascular layer. The two rectus muscles could now be
advanced medially and sutured without tension (Fig. 4).
In order to guarantee that the anterior abdominal wall
was adequately reinforced, a sheet of synthetic polypro-
pylene mesh was inserted between the muscles and the
posterior sheath before the rectus muscles were sutured
[
16, 17] (Fig. 5). The previously mobilized external, Fig. 4 The two rectus muscles sutured without tension

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Fig. 5 The synthetic polypropylene mesh inserted between the
recta muscles and their posterior sheath
Fig. 7a,b Postoperative view at 12 months
Fig. 6 The inferiorly pedicled abdominal dermal flap rotated, ad- to generate an active potential starting from the cortical
vanced superiorly and sutured to the rib cage and to the fascial
layer. The navel, isolated on its subcutaneous pedicle, placed in
motor neuron depolarization induced an active potential
the new position
cells by applying magnetic fields to the scalp. Cortical
along the pyramidal tract to the spinal motor neuron and
successively along the motor nerve to the target muscle
oblique muscles were now advanced medially and su- that, in this case, was the rectus abdominis. According to
tured along the lateral edge of the anterior sheaths of the this technique, this resulted in a transcranial magnetic
rectus abdominis muscles. The elliptical flap between the stimulation of the motor cortex. Motor potentials were
two abdominal incisions was now deepithelized, the fat recorded from a bipolar needle electrode inserted into the
below the dermis was removed and an inferiorly pedi- rectus abdominis in the periumbilical area 4 cm from the
cled vascularized dermal flap was obtained [13]. The re- linea alba. The motor potentials had a normal morpho-
sulting flap was rotated and advanced superiorly, the up- logical and repetitive pattern with a latent period of
per edge was sutured to the rib cage and to the fascial 19 ms on the left and 20 ms on the right. This confirmed
layer so that the anterior abdominal wall was further re- that the muscles were intact and functioning perfectly.
inforced. The navel, which had been previously isolated
A postoperative follow-up examination at 12 months
on its subcutaneous pedicle, was placed in its new posi- showed no recurrence and a good aesthetic result
tion (Fig. 6). The edges of the defect could now be su- (Fig. 7a,b).
tured without tension.
The postoperative course was uneventful and she left
hospital after 10 days. Histology confirmed the diagno- Discussion
sis.
About 40 days after surgery an electromyography A desmoid tumor of the abdominal wall is rare; it repre-
(
EMG) was carried out to establish whether the nerve fi- sents about 0.03% of all neoplastic diseases. It occurs
bers to the rectus muscles that had been moved were in- mainly in women, especially those between the ages of
tact [14]. The EMG technique used was that suggested 30 and 50 and particularly after a recent pregnancy [8,
by Barker et al. [18] in 1985 and is based on the capacity 19, 20, 21].

3
06
Though it is histologically benign, the tumor poses
5. Basile F, Sandonato L, Sagliembene F, Rui S, Jelo P, Costa N
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difficult problems for the surgeon because of its extreme
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currence rate after 3–10 years [22] and can be correlated
with the biological features of the neoplasm [23]. At
present the trend is to resect widely and use mesh to re-
construct the abdominal wall.
Radiotherapy does not seem to play a significant role
in reducing the incidence of local recurrence; therefore,
its use is recommended only in cases that cannot be
treated surgically or that have doubtful resection edges.
Different techniques of abdominal wall reconstruction
It Chir, Firenze
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9
have been described, e.g. Mersilene, polypropylene mesh 10. Mchinnon JG, Neifeld JP, Kay S, Parker GA, Foster WC,
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1
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In the reconstruction performed in the case described,
the wide gap was filled by placing a mesh of non-resorb-
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(
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addominale con valutazione E.M.G. Riv It Chir Plast 29:55–
6
1
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15]. The interest in this case was that the abdominal
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larized dermal flap [13] that “slid” upwards as far as the
rib cage and was then stitched to it and to the anterior
fascia of the rectus abdominis muscles.
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[
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1
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