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Objective: Applications for Abdominal Wall Vascularized Composite Allotransplantation may expand if a functional graft with decreased immunosuppressive requirements can be designed. We hypothesize that it is anatomically feasible to prepare a functional, innervated, and vascularized abdominal composite graft using a multilayered component separation technique. Including vascularized bone in the graft design may decrease the immunosuppressive requirements by inducing immunologic chimerism. Methods: Two cadaver torsos were used. Adipocutaneous flaps were elevated from the midaxillary lines, preserving deep inferior epigastric artery perforators. A 2-layered component separation through the external and internal oblique fasciae was carried out, exposing segmental intercostal thoracolumbar nerves. Superiorly directed muscle release over the subcostal margin provided for a 3-rib segment with attached rectus abdominis muscle. The remainder of the full-thickness allograft was harvested with its vasculature. Flap inset into the recipient cadaver abdomen, with osteosynthesis fixation between donor and recipient ribs, was achieved. Results: The harvested grafts had an average size of 845 ± 205 cm2 with a total procurement time of 110 minutes. On one cadaver, 4 thoracolumbar nerves were isolated bilaterally, while the other cadaver yielded 3 nerves. The nerves were transected with an average length of 5.7 ± 1.2 cm. The graft vasculature was transected with a length of 4.40 ± 0.10 cm. Conclusion: Using the principles of component separation technique, we demonstrated a novel approach to harvest and transfer a neurotized osteomyofasciocutaneous abdominal wall allotransplant as a multipedicled, single functional unit.

Surgical manipulation of the groin can lead to persistent lymphorrhea or lymphoceles with a reported incidence of 1.8%–18.9%.1 The wound complications associated with such leaks lymphatic leak can lead to prolonged hospital stays, additional operations, and increased healthcare costs for the patient and society.2 Initial management with pressure dressings and immobilization can progress to include aspiration, drain placement, sclerosant, radiotherapy, negative pressure wound therapy, lymphovenous anastomosis, surgical tissue transfer, and exploration with lymphatic ligation.2–5 Up to half of all patients with lymphatic leak develop an associated infection which can be catastrophic in the setting of a vascular graft.4 Vital dyes, such as isosulfan blue (Lymphazurin, Tyco Healthcare, Norwalk, Conn.), are commonly used for intraoperative identification of lymphatic leaks, thereby reducing time to resolution, complications, and need for reoperation.6 Indocyanine green (ICG) imaging is an emerging modality for lymphatic vessel visualization. We report the utility of laser-assisted ICG lymphography for intraoperative identification of lymphatic leaks presenting after surgical groin manipulation.

Crossed fused renal ectopia in the presence of abdominal aortic aneurysms (AAAs) is a rare challenge to therapy. A 68-year-old man had a 6.9-cm AAA, a 6.6-cm left common iliac aneurysm, and a 3.2-cm right internal iliac aneurysm. He had multiple comorbidities and a right-sided crossed fused kidney supplied by two small renal arteries arising from the AAA. Aortorenal bypass with staged endovascular aneurysm repair was used to treat the aneurysmal disease. Two-stage open aortorenal bypass followed by endovascular repair for complex aneurysms is feasible in the rare patient with such a congenital anomaly.