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CASE REPORT
Chest wall reconstruction with latissimus dorsi and an autologous thoracolumbar fascia graft in a dog A. de Battisti*, G. Polton†, M. de Vries‡ and E. Friend* *Langford Veterinary Services, Department of Clinical Veterinary Science, University of Bristol, Langford House, Langford, Bristol BS40 5DU †North Downs Specialist Referrals, The Friesian Buildings 3 & 4, The Brewerstreet Dairy Business Park, Brewer Street, Bletchingley, Surrey RH1 4QP ‡Animal Health Trust, Lanwades Park Kentford, Newmarket, Suffolk CB8 7UU
A new technique for autogenous chest wall reconstruction using a latissimus dorsi muscle flap and a free graft of thoracolumbar fascia was utilised in a two-year-old Dobermann after resection of a highgrade osteosarcoma from the left thoracic wall. En bloc excision of the chest wall mass, including six ribs, was performed. The resulting chest wall defect was too large to be reconstructed with only a pedicled muscle flap and was reconstructed with a latissimus dorsi muscle flap cranially and a free graft of thoracolumbar fascia caudally. The graft was harvested easily, and there was no donor site morbidity or postoperative complications. A free graft of thoracolumbar fascia can be considered as an option to supplement autogenous reconstruction of the chest wall. Journal of Small Animal Practice (2015) 56, 218–222 DOI: 10.1111/jsap.12270 Accepted: 8 July 2014; Published online: 16 September 2014
INTRODUCTION Many different techniques and materials have been used to reconstruct defects of the chest wall. Autogenous techniques in dogs include latissimus dorsi muscle or myocutaneous flap (Matthiesen et al. 1992, Montgomery et al. 1993, Pirkey-Ehrhart et al. 1995, Baines et al. 2002, Halfacree et al. 2007, Liptak et al. 2008a), deep pectoral muscle flap (Chambers 1999), external abdominal oblique muscle flap (Chambers 1999) and diaphragmatic advancement (Hall et al. 2010). Their large size, good survival rates and autogenous nature render pedicled muscle flaps ideal replacement materials (Chambers 1999, Halfacree et al. 2007, Liptak et al. 2008a). Occasionally, however, the defect is too large to be reconstructed with only pedicled muscle flaps. Prosthetic materials can be used to complete the reconstruction or as the sole means of reconstruction. Polypropylene mesh (PM) is the most commonly utilised prosthetic material in veterinary medicine (Matthiesen et al. 1992, Pirkey-Ehrhart et al. 1995, Bowman et al. 1998, Baines et al. 2002, Liptak et al. 2008a). Biodegradable grafts such as porcine small intestine submucosa (SIS) are being explored in human and veterinary medicine as alternatives to non-absorbable materials for reconstruction of the body wall (Clarke et al. 1996, 218
Stoll et al. 2002, Sandoval et al. 2006, Arnold et al. 2009, de Castro Marques et al. 2009). Experimental studies (Disa et al. 1996, 2001) describe the successful use of free grafts of autologous thoracolumbar fascia for reconstruction of abdominal wall defects. The use of fascia offers the benefits of an autologous, bioactive (Crawford 1969) and quickly re-vascularised tissue (Disa et al. 1996). Moreover, when fascia lata and PM were compared in vitro, they demonstrated equivalent mechanical properties (Arnold et al. 2009). This case report details the use of a free graft of thoracolumbar fascia (fgTLF) for reconstruction of a thoracic wall defect in a dog.
HISTORY A two-year-old, 48 kg, neutered male Dobermann presented for investigation of a rapidly growing mass, noted on the left side of the thoracic wall. Fine-needle aspirates (FNAs) of the mass were obtained which led to a suspicion of histiocytic sarcoma. A core biopsy was then performed with a TruCut needle but was non-diagnostic. Additional FNAs were obtained at the time of computed tomography (CT), which were supportive of the diagnosis of histiocytic sarcoma.
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FIG 1. Transverse computed tomographic (CT) images of the chest demonstrating a mass arising from the seventh rib and extending from the fifth rib to the eighth rib
CT of the thorax and of the abdomen was performed. CT of the abdomen was unremarkable. CT of the thorax revealed a 10 cm×9 cm×10 cm osteodestructive mass arising from the seventh rib and extending from the fifth rib to the eighth rib of the left thoracic wall (Fig 1). The abnormal tissue extended to the skin. No invasion of the pulmonary tissue or mediastinum was detected. No evidence of pulmonary metastasis was noted on CT. En bloc resection of the chest wall mass was planned to include removal of a total of six ribs (ribs four to nine). The subsequent reconstruction was planned by estimating the size of the chest wall defect and marking the dimensions of the latissimus dorsi muscle flap with a marker pen. Based on this assessment, it was estimated that the latissimus dorsi muscle flap would likely be insufficient to reconstruct the entire chest wall defect and an fgTLF was considered to supplement the reconstruction. Before surgery, 0·3 mg/kg methadone (Physeptone Injection™; Martindale Pharmaceuticals) was administered intramuscularly (im). Anaesthesia was induced with 1·5 mg/kg lidocaine (Lidocaine Hydrochloride Injection 2%; Hameln Pharmaceuticals) intravenously (iv) followed by 0·5 mg/kg diazepam (Diazemuls®; Actavis) and 2·0 mg/kg propofol (PropoFlo™; Abbot Animal Health) and maintained with isoflurane in 100% oxygen. Immediately after induction of anaesthesia, constant rate infusions (CRIs) of 30 µg/kg/min lidocaine and 5 µg/kg/ hour fentanyl (Sublimaze™; Janssen-Cilag) were started and maintained at these rates throughout the procedure; 20 mg/kg cefuroxime (Zinacef®; Glaxo-SmithKline) was administered iv at induction and every two hours intraoperatively. The fgTLF was harvested before approaching the chest wall defect. With the patient in right lateral recumbency, a 25-cmlong parasagittal incision was made through the skin and subcutis of the dorsum in the lumbar region. The subcutaneous tissue was undermined, and Gelpi retractors were used to expose the thoracolumbar fascia. A 20-cm-long incision was made immediately lateral to the spinous processes, and the fascia attachments were transected (Fig 2). A second parallel incision was made laterally, 1 cm dorsal to the attachments of the obliquus externus abdominis muscle and obliquus internus abdominis muscle on the thoracolumbar fascia. These two incisions were joined by two vertical incisions. The rectangular section of excised lumbar fascia measured approximately 20 cm×8 cm (Fig 3). The harvested fgTLF was larger than the expected size of the defect to compensate for potential errors in preoperative measurements. The subcutaneous Journal of Small Animal Practice
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FIG 2. Intraoperative view of the harvesting of the thoracolumbar fascial graft
FIG 3. Excised section of thoracolumbar fascia measuring approximately 20 cm×8 cm when stretched
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adipose tissue attached to the fascial graft was removed. The graft was then wrapped in sterile saline-soaked swabs to maintain its hydration. The fascial defect was not closed, and the subcutaneous fat and skin were closed routinely. A left-sided lateral thoracotomy was performed through the ninth intercostal space. The thoracic cavity was explored and the extent of the mass assessed. No adhesions to intrathoracic organs, macroscopic invasion of thoracic structures or gross metastasis were noted. Three centimetres of macroscopically normal tissue were taken circumferentially around the mass including skin, subcutaneous tissue, muscles, ribs and pleura. The ribs were ostectomised with an oscillating saw starting from the ninth rib and continuing cranially to the fourth rib. The mass was excised with one unaffected rib cranial and caudal to the mass for a total of six ribs. A minimum of 3 cm of macroscopically normal rib tissue was taken dorsal and ventral to the mass. The intercostal vessels were ligated with 3-0 polydioxanone (PDS, Ethicon) before ostectomy of each rib. After removal of the thoracic wall specimen, the thoracic cavity was examined further, and no involvement of intrathoracic structures was noted. Gloves and instruments were changed. A 20-Fr thoracostomy tube was placed through the 10th intercostal space. The latissimus dorsi muscle was divided from its caudodorsal attachments to the thoracolumbar fascia and elevated from the thoracic wall. There was approximately 10 cm between the caudal aspect of the latissimus dorsi flap and the cranial aspect of the fgTLF donor site. The cranial aspect of the chest wall defect was reconstructed with the latissimus dorsi muscle flap using horizontal mattress sutures of 2-0 polypropylene (Prolene; Ethicon). A 6-cm-wide and 15-cm-long defect remained along the caudal aspect of the reconstruction. This was reconstructed with the previously harvested fgTLF using a horizontal mattress suture pattern of 2-0 polypropylene (Fig 4). Before closure of the chest wall, intercostal nerve blocks were performed by injection of 1·5 mg/kg ropivacaine (Naropin;
FIG 4. The chest wall defect was reconstructed cranially with the latissimus dorsi muscle flap. The defect remaining in the caudal portion of the wound, approximately 6 cm wide and 15 cm long, was reconstructed using a free graft of thoracolumbar fascia
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AstraZeneca). The subcutis was closed with vertical mattress sutures using size 1 Polyglactin 910 (Vicryl Ethicon) followed by an intradermal suture using a size 2-0 polyglecaprone 25 (Monocryl; Ethicon). The skin was closed with staples. The chest was drained; spontaneous respiration commenced. The thoracostomy tube was removed before recovery. Postoperative analgesia was provided by a CRI of 0·1 mg/ kg/hour morphine (Morphine Sulphate Injection BP; Martindale Pharmaceuticals) for 24 hours followed by 0·015 mg/kg buprenorphine (Vetergesic®; Alstoe Animal Health) im administered every six to eight hours for three days; 2 mg/kg carprofen twice daily was administered orally for 6 days. For 2·5 hours from the end of anaesthesia, haemoglobin saturation (SpO2), respiratory rate (RR), respiratory pattern, heart rate (HR), mucous membranes colour (MM), capillary refill time (CRT) and blood pressure (BP), measured through an arterial catheter placed in the right dorsal metatarsal artery, were continuously monitored. Samples for arterial blood gases were obtained through the arterial catheter when the dog recovered from anaesthesia and then every 30 minutes for the first hour and then every 60 minutes for an additional 2 hours. For the following 6 hours, SpO2, RR, respiratory pattern, HR, MM, CRT and BP were monitored every 30 minutes, and arterial blood gases were checked every 6 hours or more frequently if necessary. Arterial blood gases were monitored every 8 hours for the following 24 hours and SpO2, RR, HR, MM, CRT and BP every 4 hours or more frequently if needed. The dog was then moved from the intensive care unit to the surgery ward and SpO2, RR, HR, MM, CRT and BP were monitored every four to eight hours until discharge. For all the samples collected, arterial oxygen partial pressure (PaO2) was above 85 mmHg, SpO2 was between 97 and 100% and arterial carbon dioxide partial pressure was between 35 and 42 mmHg. All the samples were obtained without supplemental oxygen. RR, respiratory pattern, HR, MM, CRT, BP values and blood gas analysis remained within normal reference intervals postoperatively. Paradoxical movement of the reconstructed chest wall was present during respiration in the postoperative period. It was still present, although less evident, at time of discharge from the hospital, six days after surgery. The paradoxical movements of the chest wall were not clinically significant as the monitored parameters were within reference limits and dyspnoea was not present. The mass was histologically diagnosed as a high-grade osteosarcoma originating from the rib. Complete excision was achieved. At the four-week postoperative check, the surgical wounds were healed, no paradoxical movements of the chest were noted and the dog appeared bright, lively and comfortable. All vital parameters and SpO2 were within reference limits. A chemotherapy protocol was discussed with the owner; however, adjunctive treatment was declined. At re-examination seven months after surgery, there were no clinical signs of recurrence and examination was unremarkable. Ten months postoperatively, the dog developed epistaxis and signs of nasal obstruction and was euthanised without further investigation.
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DISCUSSION Large tissue defects of the chest wall can be reconstructed with local muscle flaps, synthetic non-absorbable materials or a combination of these techniques (Matthiesen et al. 1992, Bowman et al. 1998, Baines et al. 2002, Liptak et al. 2008a). The aim of chest wall reconstruction is restoration of function. The repair should be airtight and watertight, allow effective ventilation and be associated with a low risk of wound dehiscence (Hunt 2012). The ideal material used for chest wall reconstruction should cause minimal inflammatory response, be integrated into the host tissue, have the same function as the original tissue, be resistant to bacterial contamination/infection, not cause rejection and cause minimal postoperative discomfort (Breitbart & Ablaza 2007). It should also be easy to handle, non-carcinogenic, nonallergenic, non-corrosive, non-teratogenic, non-toxic and inexpensive (Roush 2003). Fascia has excellent biological characteristics and may be considered an ideal replacement material (Disa et al. 1996, 1998). Autologous fascia grafts are incorporated as living tissue after implantation (Crawford 1969, Das et al. 1990, Disa et al. 1996). Intact graft vascularisation, intact cellular structure and tissue architecture were noted at histopathological examination three weeks after implantation of thoracolumbar fascia autografts to reconstruct full thickness abdominal wall defects in experimental rabbits (Disa et al. 1996). A mesothelial lining similar to peritoneum on the visceral surface and lack of adhesions to the underlying viscera were also noted at histopathological examination (Disa et al. 1996). Early re-vascularisation and lack of inflammatory reaction are consistent findings when histopathology is performed on implanted autologous free fascia grafts (Disa et al. 1996, Atalan et al. 2005). In the present case report, histological examination of the graft after implantation was not performed as the owner declined a postmortem examination. However, no clinical signs of failure of the graft were noted. If chemotherapy is planned, the potential benefits of an autologous and readily vascularised replacement material should be considered. In the present case, a chemotherapy protocol was recommended as it significantly increases the survival time for dogs undergoing surgical resection of rib osteosarcoma (PirkeyEhrhart et al. 1995, Liptak et al. 2008b). Fascia performs mechanically very similarly to PM when tested in vitro for suture pull-out, tensile strength and push-through resistance (Arnold et al. 2009) PM is the most commonly used prosthetic material for chest wall reconstruction in dogs (Matthiesen et al. 1992, PirkeyEhrhart et al. 1995, Bowman et al. 1998, Baines et al. 2002, Liptak et al. 2008b). Postoperative complications associated with PM use include seroma (0 to 50%), pleural effusion/peripheral oedema (20 to 22%) and infection (4·7 to 6·6%). With the major exception of pleural effusion, these complications are considered minor (Matthiesen et al. 1992, Pirkey-Ehrhart et al. 1995, Bowman et al. 1998, Liptak et al. 2008a). PM-related infections following surgery occur infrequently in veterinary medicine compared with other device-related Journal of Small Animal Practice
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infections (Matthiesen et al. 1992, Pirkey-Ehrhart et al. 1995, Bowman et al. 1998, Baines et al. 2002, Liptak et al. 2008b). They may, however, be of considerable clinical importance if they happen (Liptak et al. 2008a). Until stronger evidence is available, speculations can be made which support the use of fascia grafts for reconstructive procedures. Autologous thoracolumbar fascia grafts were found to be significantly more resistant to infection compared with expanded polytetrafluoroethylene (PTFE) meshes in abdominal wall reconstructions in rabbits which were contaminated at the time of surgery with 109 Staphylococcus aureus (Disa et al. 1996). PM has bigger pore size compared with PTFE mesh and it would be expected to have a higher resistance to infection. However, PTFE was found to be more resistant to contamination with 108 S. aureus than PM in an experimental study on abdominal wall reconstruction in guinea pigs (Brown et al. 1985). After implantation, PMs cause a moderate foreign body reaction and become encased in dense connective tissue (Clarke et al. 1996, Soiderer et al. 2004, Greca et al. 2008, Paulo et al. 2010). Histological examination of implanted autologous fascia graft demonstrates lack of foreign body reaction or inflammation and optimal graft vascularisation (Disa et al. 1996, Atalan et al. 2005, Bongartz et al. 2005). The lack of foreign body reaction and lack of formation of dense connective tissue noted with fascial grafts may decrease the likelihood of postoperative pleural effusion. A potential disadvantage of the use of fascial grafts for thoracic wall reconstruction is the additional anaesthesia and surgical time required for harvesting the graft and the subsequent possible increased risk of infection (Beal et al. 2000, Eugster et al. 2004). The size of fascial grafts which can be harvested for reconstruction of chest wall defects may be limited. In this study, harvesting a subjectively larger graft from the thoracolumbar area compared with fascia lata grafts was possible; however, the upper size limits of the fgTLF that can be harvested for chest wall reconstruction is not known. In the present case report, no clinical consequences were noted after harvesting a large amount of thoracolumbar fascia. A potential consequence is weakening of the attachments of the obliquus externus and internus abdominis muscles which may cause loss of strength of the abdominal wall and herniation. However, the attachment of the muscle transversus abdominis to the transverse processes of the lumbar vertebrae and to the thick, (Hermanson & Evans 1993) deepest leaf of the thoracolumbar fascia and the deepest leaf of the fascia itself are preserved in the described approach. It is possible that the preservation of these two structures contributes to abdominal wall strength and that abdominal wall defects are unlikely to develop following harvest of the fgTLF. In the present case, no problems were encountered. There is extensive human literature supporting the clinical use of fascia as a replacement material for body wall defects (FeldtRasmussen & Jensen 1956, Hamilton 1956, 1963, 1968, Disa et al. 1998); however, its use as body wall replacement material in the veterinary literature has been infrequently described in clinical cases. A clinical study described the successful use
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of a free fascia lata graft for perineal hernia repair in 12 dogs. Histopathology performed 10 months after implantation of one of the grafts demonstrated lack of dehiscence and lack of fibrosis, granulation tissue or tissue reaction (Bongartz et al. 2005). Free or pedicled fascia grafts have also been successfully used in a variety of procedures other than body wall reconstruction: repair of scleral defects (Grundon et al. 2011); creation of venous patch grafts (Csebi et al. 2011); repair of urethral defects (Atalan et al. 2005); replacement of patellar tendon (Gemmill & Carmichael 2003); intraarticular cranial cruciate reconstruction (Kowaleski et al. 2012); caudal cruciate reconstruction (Kowaleski et al. 2012), and Achilles tendon reconstruction (Swiderski et al. 2005). Definite conclusions cannot be drawn from a case report; however, fgTLF should be considered an option to supplement autogenous reconstruction of large chest wall defects. Conflict of interest None of the authors of this article has a financial or personal relationship with other people or organisations that could inappropriately influence or bias the content of the paper. References Arnold, G. A., Mathews, K. G., Roe, S., et al. (2009) Biomechanical comparison of four soft tissue replacement materials: an in vitro evaluation of single and multilaminate porcine small intestinal submucosa, canine fascia lata, and polypropylene mesh. Veterinary Surgery 38, 834-844 Atalan, G., Cihan, M., Sozmen, M. et al. (2005) Repair of urethral defects using fascia lata autografts in dogs. Veterinary Surgery 34, 514-518 Baines, S. J., Lewis, S. & White, R. A. S. (2002) Primary thoracic tumours of mesenchymal origin in dogs: a retrospective study of 46 cases. Veterinary Record 150, 335-339 Beal, M. W., Brown, D. C. & Shofer, F. S. (2000) The effects of perioperative hypothermia and the duration of anesthesia on postoperative wound infection rate in clean wounds: a retrospective study. Veterinary Surgery 29, 123-127 Bongartz, A., Carofiglio, F., Balligand, M., et al. (2005) Use of autogenous fascia lata graft for perineal herniorrhaphy in dogs. Veterinary Surgery 34, 405-413 Bowman, K. L., Birchard, S. J. & Bright, R. M. (1998) Complications associated with the implantation of polypropylene mesh in dogs and cats: a retrospective study of 21 cases (1984-1996). Journal of the American Animal Hospital Association 34, 225-233 Breitbart, A. S. & Ablaza, V. J. (2007) Implant materials. In: Plastic Surgery. Ed C. H. Thorne. Lippincott Williams & Wilkins, a Wolter Kluwer Business, Philadelphia, PA, USA. p 58 Brown, G. L., Richardson, J. D., Malangoni, M. A., et al. (1985) Comparison of prosthetic materials for abdominal wall reconstruction in the presence of contamination and infection. Annals of Surgery 201, 705-711 Chambers, J. (1999) Pedicled muscle flaps. In: Manual of Canine and Feline Wound Management and Reconstruction. Eds D. Fowler and J. M. Williams. BSAVA, Gloucester. pp 95-105 Clarke, K. M., Lantz, G. C., Salisbury, S. K., et al. (1996) Intestine submucosa and polypropylene mesh for abdominal wall repair in dogs. Journal of Surgical Research 60, 107-114 Crawford, J. S. (1969) Nature of fascia lata and its fate after implantation. American Journal of Ophthalmology 67, 900 Csebi, P., Nemeth, T., Jakab, C., et al. (2011) Experimental results of using autologous rectus fascia sheath for venous patch grafts in dogs. Acta Veterinaria Hungarica 59, 373-384 Das, S. K., Davidson, S. F., Walker, B. L., et al. (1990) The fate of free autogenous fascial grafts in the rabbit. British Journal of Plastic Surgery 43, 315-317
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De Castro Marques, A. I., Hipwell, F. & Yool, D. A. (2009) The use of porcine smallintestinal submucosa for abdominal wall reconstruction--a clinical case. Journal of Small Animal Practice 50, 619-623 Disa, J. J., Klein, M. H. & Goldberg, N. H. (1996) Advantages of autologous fascia versus synthetic patch abdominal reconstruction in experimental animal defects. Plastic and Reconstructive Surgery 97, 801-806 Disa, J. J., Goldberg, N. H., Carlton, J. M., et al. (1998) Restoring abdominal wall integrity in contaminated tissue-deficient wounds using autologous fascia grafts. Plastic and Reconstructive Surgery 101, 979-986 Disa, J. J., Chiaromonte, M. F., Girotto, J. A., et al. (2001) Advantages of autologous fascia versus synthetic patch abdominal reconstruction in experimental animal defects. Plastic and Reconstructive Surgery 108, 2086-2087 Eugster, S., Schawalder, P., Gaschen, F., et al. (2004) A prospective study of postoperative surgical site infections in dogs and cats. Veterinary Surgery 33, 542-550 Feldt-Rasmussen, K. & Jensen, O. A. (1956) Large ventral herniae treated with free fascial grafts. A follow-up study. Acta chirurgica Scandinavica 111, 403-408 Gemmill, T. J. & Carmichael, S. (2003) Complete patellar ligament replacement using a fascia lata autograft in a dog. Journal of Small Animal Practice 44, 456-459 Grundon, R. A., Hardman, C., O’reilly, A., et al. (2011) Repair of a scleral defect with an autogenous fascia lata graft in a dog. Veterinary Ophthalmology 14, 271-274 Halfacree, Z. J., Baines, S. J., Lopscomb, V. J., et al. (2007) Use of a latissimus dorsi myocutaneous flap for one-stage reconstruction of the thoracic wall after en bloc resection of primary rib chondrosarcoma in five dogs. Veterinary Surgery 36, 587-592 Hall, A., Dujowich, M. & Merkley, D. F. (2010) Diaphragmatic support of a thoracic wall defect in a dog. Journal of the American Animal Hospital Association 46, 341-5 Hamilton, J. E. (1956) Free matressed fascia lata patches in the repair of large abdominal incisional hernias. American surgeon 22, 217-226 Hamilton, J. E. (1963) Free matressed fascia lata patches in the repair of large or difficult hernias: a 16 years experience. Annals of Surgery 157, 925-930 Hamilton, J. E. (1968) The repair of large or difficult hernia with matressed onlay grafts of fascia lata: a 21 years experience. Annals of Surgery 167, 85-90 Hermanson, J. W. & Evans, H. (1993) Evans Miller’s anatomy of the dog. Saunders (Elsevier), Philadelphia, PA, USA. pp 310 and 320 Hunt, G. (2012) Veterinary Surgery Small Animals. Eds K. M. Tobias and S. A. Johnson. Elsevier, St. Louis, MO, USA. pp 1769-1786 Kowaleski, P., Boudrieau, R. & Pozzi, A. (2012) Stifle joint. In: Veterinary Surgery Small Animals. chapter 62. Eds K. M. Tobias and S. A. Johnson. Elsevier, St. Louis, MO, USA. pp 934-944 Liptak, J. M., Dernell, W. S., Rizzo, S. A., et al. (2008a) Reconstruction of chest wall defects after rib tumor resection: a comparison of autogenous, prosthetic, and composite techniques in 44 dogs. Veterinary Surgery 37, 479-487 Liptak, J. M., Kamstock, D. A., Dernell, W. S., et al. (2008b) Oncologic outcome after curative-intent treatment in 39 dogs with primary chest wall tumors (19922005). Veterinary Surgery 37, 488-496 Matthiesen, D. T., Clark, G. N., Orsher, R. J., et al. (1992) En bloc resection of primary rib tumors in 40 dogs. Veterinary Surgery 21, 201-204 Montgomery, R. D., Henderson, R. A., Powers, R. D., et al. (1993) Retrospective study of 26 primary tumors of the osseous thoracic wall in dogs. Journal of the American Animal Hospital Association 29, 68-72 Pirkey-Ehrhart, N., Withrow, S. J., Straw, R. C., et al. (1995) Primary rib tumors in 54 dogs. Journal of the American Animal Hospital Association 31, 65-69 Roush, J. K. (2003) Biomaterials and surgical implants. Textbook of Small Animal Surgery. Ed D. H. Slatter. Saunders, Philadelphia, PA, USA, p 141 Sandoval, J. A., Lou, D., Engum, S. A., et al. (2006) The whole truth: comparative analysis of diaphragmatic hernia repair using 4-ply vs 8-ply small intestinal submucosa in a growing animal model. Journal of Pediatric Surgery 41, 518-523 Stoll, M. R., Cook, J. L., Pope, E. R., et al. (2002) The use of porcine small intestinal submucosa as a biomaterial for perineal herniorrhaphy in the dog. Veterinary Surgery 31, 379-390 Swiderski, J., Fitch, R. B., Staatz, A. et al. (2005) Sonographic assisted diagnosis and treatment of bilateral gastrocnemius tendon rupture in a Labrador retriever repaired with fascia lata and polypropylene mesh. Veterinary and Comparative Orthopaedics and Traumatology 18, 258-263
Journal of Small Animal Practice
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Vol 56
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March 2015
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© 2014 British Small Animal Veterinary Association
CASE REPORT
Chest wall reconstruction with latissimus dorsi and an autologous thoracolumbar fascia graft in a dog A. de Battisti*, G. Polton†, M. de Vries‡ and E. Friend* *Langford Veterinary Services, Department of Clinical Veterinary Science, University of Bristol, Langford House, Langford, Bristol BS40 5DU †North Downs Specialist Referrals, The Friesian Buildings 3 & 4, The Brewerstreet Dairy Business Park, Brewer Street, Bletchingley, Surrey RH1 4QP ‡Animal Health Trust, Lanwades Park Kentford, Newmarket, Suffolk CB8 7UU
A new technique for autogenous chest wall reconstruction using a latissimus dorsi muscle flap and a free graft of thoracolumbar fascia was utilised in a two-year-old Dobermann after resection of a highgrade osteosarcoma from the left thoracic wall. En bloc excision of the chest wall mass, including six ribs, was performed. The resulting chest wall defect was too large to be reconstructed with only a pedicled muscle flap and was reconstructed with a latissimus dorsi muscle flap cranially and a free graft of thoracolumbar fascia caudally. The graft was harvested easily, and there was no donor site morbidity or postoperative complications. A free graft of thoracolumbar fascia can be considered as an option to supplement autogenous reconstruction of the chest wall. Journal of Small Animal Practice (2015) 56, 218–222 DOI: 10.1111/jsap.12270 Accepted: 8 July 2014; Published online: 16 September 2014
INTRODUCTION Many different techniques and materials have been used to reconstruct defects of the chest wall. Autogenous techniques in dogs include latissimus dorsi muscle or myocutaneous flap (Matthiesen et al. 1992, Montgomery et al. 1993, Pirkey-Ehrhart et al. 1995, Baines et al. 2002, Halfacree et al. 2007, Liptak et al. 2008a), deep pectoral muscle flap (Chambers 1999), external abdominal oblique muscle flap (Chambers 1999) and diaphragmatic advancement (Hall et al. 2010). Their large size, good survival rates and autogenous nature render pedicled muscle flaps ideal replacement materials (Chambers 1999, Halfacree et al. 2007, Liptak et al. 2008a). Occasionally, however, the defect is too large to be reconstructed with only pedicled muscle flaps. Prosthetic materials can be used to complete the reconstruction or as the sole means of reconstruction. Polypropylene mesh (PM) is the most commonly utilised prosthetic material in veterinary medicine (Matthiesen et al. 1992, Pirkey-Ehrhart et al. 1995, Bowman et al. 1998, Baines et al. 2002, Liptak et al. 2008a). Biodegradable grafts such as porcine small intestine submucosa (SIS) are being explored in human and veterinary medicine as alternatives to non-absorbable materials for reconstruction of the body wall (Clarke et al. 1996, 218
Stoll et al. 2002, Sandoval et al. 2006, Arnold et al. 2009, de Castro Marques et al. 2009). Experimental studies (Disa et al. 1996, 2001) describe the successful use of free grafts of autologous thoracolumbar fascia for reconstruction of abdominal wall defects. The use of fascia offers the benefits of an autologous, bioactive (Crawford 1969) and quickly re-vascularised tissue (Disa et al. 1996). Moreover, when fascia lata and PM were compared in vitro, they demonstrated equivalent mechanical properties (Arnold et al. 2009). This case report details the use of a free graft of thoracolumbar fascia (fgTLF) for reconstruction of a thoracic wall defect in a dog.
HISTORY A two-year-old, 48 kg, neutered male Dobermann presented for investigation of a rapidly growing mass, noted on the left side of the thoracic wall. Fine-needle aspirates (FNAs) of the mass were obtained which led to a suspicion of histiocytic sarcoma. A core biopsy was then performed with a TruCut needle but was non-diagnostic. Additional FNAs were obtained at the time of computed tomography (CT), which were supportive of the diagnosis of histiocytic sarcoma.
Journal of Small Animal Practice
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Vol 56
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March 2015
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© 2014 British Small Animal Veterinary Association
Chest wall reconstruction
FIG 1. Transverse computed tomographic (CT) images of the chest demonstrating a mass arising from the seventh rib and extending from the fifth rib to the eighth rib
CT of the thorax and of the abdomen was performed. CT of the abdomen was unremarkable. CT of the thorax revealed a 10 cm×9 cm×10 cm osteodestructive mass arising from the seventh rib and extending from the fifth rib to the eighth rib of the left thoracic wall (Fig 1). The abnormal tissue extended to the skin. No invasion of the pulmonary tissue or mediastinum was detected. No evidence of pulmonary metastasis was noted on CT. En bloc resection of the chest wall mass was planned to include removal of a total of six ribs (ribs four to nine). The subsequent reconstruction was planned by estimating the size of the chest wall defect and marking the dimensions of the latissimus dorsi muscle flap with a marker pen. Based on this assessment, it was estimated that the latissimus dorsi muscle flap would likely be insufficient to reconstruct the entire chest wall defect and an fgTLF was considered to supplement the reconstruction. Before surgery, 0·3 mg/kg methadone (Physeptone Injection™; Martindale Pharmaceuticals) was administered intramuscularly (im). Anaesthesia was induced with 1·5 mg/kg lidocaine (Lidocaine Hydrochloride Injection 2%; Hameln Pharmaceuticals) intravenously (iv) followed by 0·5 mg/kg diazepam (Diazemuls®; Actavis) and 2·0 mg/kg propofol (PropoFlo™; Abbot Animal Health) and maintained with isoflurane in 100% oxygen. Immediately after induction of anaesthesia, constant rate infusions (CRIs) of 30 µg/kg/min lidocaine and 5 µg/kg/ hour fentanyl (Sublimaze™; Janssen-Cilag) were started and maintained at these rates throughout the procedure; 20 mg/kg cefuroxime (Zinacef®; Glaxo-SmithKline) was administered iv at induction and every two hours intraoperatively. The fgTLF was harvested before approaching the chest wall defect. With the patient in right lateral recumbency, a 25-cmlong parasagittal incision was made through the skin and subcutis of the dorsum in the lumbar region. The subcutaneous tissue was undermined, and Gelpi retractors were used to expose the thoracolumbar fascia. A 20-cm-long incision was made immediately lateral to the spinous processes, and the fascia attachments were transected (Fig 2). A second parallel incision was made laterally, 1 cm dorsal to the attachments of the obliquus externus abdominis muscle and obliquus internus abdominis muscle on the thoracolumbar fascia. These two incisions were joined by two vertical incisions. The rectangular section of excised lumbar fascia measured approximately 20 cm×8 cm (Fig 3). The harvested fgTLF was larger than the expected size of the defect to compensate for potential errors in preoperative measurements. The subcutaneous Journal of Small Animal Practice
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FIG 2. Intraoperative view of the harvesting of the thoracolumbar fascial graft
FIG 3. Excised section of thoracolumbar fascia measuring approximately 20 cm×8 cm when stretched
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adipose tissue attached to the fascial graft was removed. The graft was then wrapped in sterile saline-soaked swabs to maintain its hydration. The fascial defect was not closed, and the subcutaneous fat and skin were closed routinely. A left-sided lateral thoracotomy was performed through the ninth intercostal space. The thoracic cavity was explored and the extent of the mass assessed. No adhesions to intrathoracic organs, macroscopic invasion of thoracic structures or gross metastasis were noted. Three centimetres of macroscopically normal tissue were taken circumferentially around the mass including skin, subcutaneous tissue, muscles, ribs and pleura. The ribs were ostectomised with an oscillating saw starting from the ninth rib and continuing cranially to the fourth rib. The mass was excised with one unaffected rib cranial and caudal to the mass for a total of six ribs. A minimum of 3 cm of macroscopically normal rib tissue was taken dorsal and ventral to the mass. The intercostal vessels were ligated with 3-0 polydioxanone (PDS, Ethicon) before ostectomy of each rib. After removal of the thoracic wall specimen, the thoracic cavity was examined further, and no involvement of intrathoracic structures was noted. Gloves and instruments were changed. A 20-Fr thoracostomy tube was placed through the 10th intercostal space. The latissimus dorsi muscle was divided from its caudodorsal attachments to the thoracolumbar fascia and elevated from the thoracic wall. There was approximately 10 cm between the caudal aspect of the latissimus dorsi flap and the cranial aspect of the fgTLF donor site. The cranial aspect of the chest wall defect was reconstructed with the latissimus dorsi muscle flap using horizontal mattress sutures of 2-0 polypropylene (Prolene; Ethicon). A 6-cm-wide and 15-cm-long defect remained along the caudal aspect of the reconstruction. This was reconstructed with the previously harvested fgTLF using a horizontal mattress suture pattern of 2-0 polypropylene (Fig 4). Before closure of the chest wall, intercostal nerve blocks were performed by injection of 1·5 mg/kg ropivacaine (Naropin;
FIG 4. The chest wall defect was reconstructed cranially with the latissimus dorsi muscle flap. The defect remaining in the caudal portion of the wound, approximately 6 cm wide and 15 cm long, was reconstructed using a free graft of thoracolumbar fascia
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AstraZeneca). The subcutis was closed with vertical mattress sutures using size 1 Polyglactin 910 (Vicryl Ethicon) followed by an intradermal suture using a size 2-0 polyglecaprone 25 (Monocryl; Ethicon). The skin was closed with staples. The chest was drained; spontaneous respiration commenced. The thoracostomy tube was removed before recovery. Postoperative analgesia was provided by a CRI of 0·1 mg/ kg/hour morphine (Morphine Sulphate Injection BP; Martindale Pharmaceuticals) for 24 hours followed by 0·015 mg/kg buprenorphine (Vetergesic®; Alstoe Animal Health) im administered every six to eight hours for three days; 2 mg/kg carprofen twice daily was administered orally for 6 days. For 2·5 hours from the end of anaesthesia, haemoglobin saturation (SpO2), respiratory rate (RR), respiratory pattern, heart rate (HR), mucous membranes colour (MM), capillary refill time (CRT) and blood pressure (BP), measured through an arterial catheter placed in the right dorsal metatarsal artery, were continuously monitored. Samples for arterial blood gases were obtained through the arterial catheter when the dog recovered from anaesthesia and then every 30 minutes for the first hour and then every 60 minutes for an additional 2 hours. For the following 6 hours, SpO2, RR, respiratory pattern, HR, MM, CRT and BP were monitored every 30 minutes, and arterial blood gases were checked every 6 hours or more frequently if necessary. Arterial blood gases were monitored every 8 hours for the following 24 hours and SpO2, RR, HR, MM, CRT and BP every 4 hours or more frequently if needed. The dog was then moved from the intensive care unit to the surgery ward and SpO2, RR, HR, MM, CRT and BP were monitored every four to eight hours until discharge. For all the samples collected, arterial oxygen partial pressure (PaO2) was above 85 mmHg, SpO2 was between 97 and 100% and arterial carbon dioxide partial pressure was between 35 and 42 mmHg. All the samples were obtained without supplemental oxygen. RR, respiratory pattern, HR, MM, CRT, BP values and blood gas analysis remained within normal reference intervals postoperatively. Paradoxical movement of the reconstructed chest wall was present during respiration in the postoperative period. It was still present, although less evident, at time of discharge from the hospital, six days after surgery. The paradoxical movements of the chest wall were not clinically significant as the monitored parameters were within reference limits and dyspnoea was not present. The mass was histologically diagnosed as a high-grade osteosarcoma originating from the rib. Complete excision was achieved. At the four-week postoperative check, the surgical wounds were healed, no paradoxical movements of the chest were noted and the dog appeared bright, lively and comfortable. All vital parameters and SpO2 were within reference limits. A chemotherapy protocol was discussed with the owner; however, adjunctive treatment was declined. At re-examination seven months after surgery, there were no clinical signs of recurrence and examination was unremarkable. Ten months postoperatively, the dog developed epistaxis and signs of nasal obstruction and was euthanised without further investigation.
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Chest wall reconstruction
DISCUSSION Large tissue defects of the chest wall can be reconstructed with local muscle flaps, synthetic non-absorbable materials or a combination of these techniques (Matthiesen et al. 1992, Bowman et al. 1998, Baines et al. 2002, Liptak et al. 2008a). The aim of chest wall reconstruction is restoration of function. The repair should be airtight and watertight, allow effective ventilation and be associated with a low risk of wound dehiscence (Hunt 2012). The ideal material used for chest wall reconstruction should cause minimal inflammatory response, be integrated into the host tissue, have the same function as the original tissue, be resistant to bacterial contamination/infection, not cause rejection and cause minimal postoperative discomfort (Breitbart & Ablaza 2007). It should also be easy to handle, non-carcinogenic, nonallergenic, non-corrosive, non-teratogenic, non-toxic and inexpensive (Roush 2003). Fascia has excellent biological characteristics and may be considered an ideal replacement material (Disa et al. 1996, 1998). Autologous fascia grafts are incorporated as living tissue after implantation (Crawford 1969, Das et al. 1990, Disa et al. 1996). Intact graft vascularisation, intact cellular structure and tissue architecture were noted at histopathological examination three weeks after implantation of thoracolumbar fascia autografts to reconstruct full thickness abdominal wall defects in experimental rabbits (Disa et al. 1996). A mesothelial lining similar to peritoneum on the visceral surface and lack of adhesions to the underlying viscera were also noted at histopathological examination (Disa et al. 1996). Early re-vascularisation and lack of inflammatory reaction are consistent findings when histopathology is performed on implanted autologous free fascia grafts (Disa et al. 1996, Atalan et al. 2005). In the present case report, histological examination of the graft after implantation was not performed as the owner declined a postmortem examination. However, no clinical signs of failure of the graft were noted. If chemotherapy is planned, the potential benefits of an autologous and readily vascularised replacement material should be considered. In the present case, a chemotherapy protocol was recommended as it significantly increases the survival time for dogs undergoing surgical resection of rib osteosarcoma (PirkeyEhrhart et al. 1995, Liptak et al. 2008b). Fascia performs mechanically very similarly to PM when tested in vitro for suture pull-out, tensile strength and push-through resistance (Arnold et al. 2009) PM is the most commonly used prosthetic material for chest wall reconstruction in dogs (Matthiesen et al. 1992, PirkeyEhrhart et al. 1995, Bowman et al. 1998, Baines et al. 2002, Liptak et al. 2008b). Postoperative complications associated with PM use include seroma (0 to 50%), pleural effusion/peripheral oedema (20 to 22%) and infection (4·7 to 6·6%). With the major exception of pleural effusion, these complications are considered minor (Matthiesen et al. 1992, Pirkey-Ehrhart et al. 1995, Bowman et al. 1998, Liptak et al. 2008a). PM-related infections following surgery occur infrequently in veterinary medicine compared with other device-related Journal of Small Animal Practice
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infections (Matthiesen et al. 1992, Pirkey-Ehrhart et al. 1995, Bowman et al. 1998, Baines et al. 2002, Liptak et al. 2008b). They may, however, be of considerable clinical importance if they happen (Liptak et al. 2008a). Until stronger evidence is available, speculations can be made which support the use of fascia grafts for reconstructive procedures. Autologous thoracolumbar fascia grafts were found to be significantly more resistant to infection compared with expanded polytetrafluoroethylene (PTFE) meshes in abdominal wall reconstructions in rabbits which were contaminated at the time of surgery with 109 Staphylococcus aureus (Disa et al. 1996). PM has bigger pore size compared with PTFE mesh and it would be expected to have a higher resistance to infection. However, PTFE was found to be more resistant to contamination with 108 S. aureus than PM in an experimental study on abdominal wall reconstruction in guinea pigs (Brown et al. 1985). After implantation, PMs cause a moderate foreign body reaction and become encased in dense connective tissue (Clarke et al. 1996, Soiderer et al. 2004, Greca et al. 2008, Paulo et al. 2010). Histological examination of implanted autologous fascia graft demonstrates lack of foreign body reaction or inflammation and optimal graft vascularisation (Disa et al. 1996, Atalan et al. 2005, Bongartz et al. 2005). The lack of foreign body reaction and lack of formation of dense connective tissue noted with fascial grafts may decrease the likelihood of postoperative pleural effusion. A potential disadvantage of the use of fascial grafts for thoracic wall reconstruction is the additional anaesthesia and surgical time required for harvesting the graft and the subsequent possible increased risk of infection (Beal et al. 2000, Eugster et al. 2004). The size of fascial grafts which can be harvested for reconstruction of chest wall defects may be limited. In this study, harvesting a subjectively larger graft from the thoracolumbar area compared with fascia lata grafts was possible; however, the upper size limits of the fgTLF that can be harvested for chest wall reconstruction is not known. In the present case report, no clinical consequences were noted after harvesting a large amount of thoracolumbar fascia. A potential consequence is weakening of the attachments of the obliquus externus and internus abdominis muscles which may cause loss of strength of the abdominal wall and herniation. However, the attachment of the muscle transversus abdominis to the transverse processes of the lumbar vertebrae and to the thick, (Hermanson & Evans 1993) deepest leaf of the thoracolumbar fascia and the deepest leaf of the fascia itself are preserved in the described approach. It is possible that the preservation of these two structures contributes to abdominal wall strength and that abdominal wall defects are unlikely to develop following harvest of the fgTLF. In the present case, no problems were encountered. There is extensive human literature supporting the clinical use of fascia as a replacement material for body wall defects (FeldtRasmussen & Jensen 1956, Hamilton 1956, 1963, 1968, Disa et al. 1998); however, its use as body wall replacement material in the veterinary literature has been infrequently described in clinical cases. A clinical study described the successful use
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of a free fascia lata graft for perineal hernia repair in 12 dogs. Histopathology performed 10 months after implantation of one of the grafts demonstrated lack of dehiscence and lack of fibrosis, granulation tissue or tissue reaction (Bongartz et al. 2005). Free or pedicled fascia grafts have also been successfully used in a variety of procedures other than body wall reconstruction: repair of scleral defects (Grundon et al. 2011); creation of venous patch grafts (Csebi et al. 2011); repair of urethral defects (Atalan et al. 2005); replacement of patellar tendon (Gemmill & Carmichael 2003); intraarticular cranial cruciate reconstruction (Kowaleski et al. 2012); caudal cruciate reconstruction (Kowaleski et al. 2012), and Achilles tendon reconstruction (Swiderski et al. 2005). Definite conclusions cannot be drawn from a case report; however, fgTLF should be considered an option to supplement autogenous reconstruction of large chest wall defects. Conflict of interest None of the authors of this article has a financial or personal relationship with other people or organisations that could inappropriately influence or bias the content of the paper. References Arnold, G. A., Mathews, K. G., Roe, S., et al. (2009) Biomechanical comparison of four soft tissue replacement materials: an in vitro evaluation of single and multilaminate porcine small intestinal submucosa, canine fascia lata, and polypropylene mesh. Veterinary Surgery 38, 834-844 Atalan, G., Cihan, M., Sozmen, M. et al. (2005) Repair of urethral defects using fascia lata autografts in dogs. Veterinary Surgery 34, 514-518 Baines, S. J., Lewis, S. & White, R. A. S. (2002) Primary thoracic tumours of mesenchymal origin in dogs: a retrospective study of 46 cases. Veterinary Record 150, 335-339 Beal, M. W., Brown, D. C. & Shofer, F. S. (2000) The effects of perioperative hypothermia and the duration of anesthesia on postoperative wound infection rate in clean wounds: a retrospective study. Veterinary Surgery 29, 123-127 Bongartz, A., Carofiglio, F., Balligand, M., et al. (2005) Use of autogenous fascia lata graft for perineal herniorrhaphy in dogs. Veterinary Surgery 34, 405-413 Bowman, K. L., Birchard, S. J. & Bright, R. M. (1998) Complications associated with the implantation of polypropylene mesh in dogs and cats: a retrospective study of 21 cases (1984-1996). Journal of the American Animal Hospital Association 34, 225-233 Breitbart, A. S. & Ablaza, V. J. (2007) Implant materials. In: Plastic Surgery. Ed C. H. Thorne. Lippincott Williams & Wilkins, a Wolter Kluwer Business, Philadelphia, PA, USA. p 58 Brown, G. L., Richardson, J. D., Malangoni, M. A., et al. (1985) Comparison of prosthetic materials for abdominal wall reconstruction in the presence of contamination and infection. Annals of Surgery 201, 705-711 Chambers, J. (1999) Pedicled muscle flaps. In: Manual of Canine and Feline Wound Management and Reconstruction. Eds D. Fowler and J. M. Williams. BSAVA, Gloucester. pp 95-105 Clarke, K. M., Lantz, G. C., Salisbury, S. K., et al. (1996) Intestine submucosa and polypropylene mesh for abdominal wall repair in dogs. Journal of Surgical Research 60, 107-114 Crawford, J. S. (1969) Nature of fascia lata and its fate after implantation. American Journal of Ophthalmology 67, 900 Csebi, P., Nemeth, T., Jakab, C., et al. (2011) Experimental results of using autologous rectus fascia sheath for venous patch grafts in dogs. Acta Veterinaria Hungarica 59, 373-384 Das, S. K., Davidson, S. F., Walker, B. L., et al. (1990) The fate of free autogenous fascial grafts in the rabbit. British Journal of Plastic Surgery 43, 315-317
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De Castro Marques, A. I., Hipwell, F. & Yool, D. A. (2009) The use of porcine smallintestinal submucosa for abdominal wall reconstruction--a clinical case. Journal of Small Animal Practice 50, 619-623 Disa, J. J., Klein, M. H. & Goldberg, N. H. (1996) Advantages of autologous fascia versus synthetic patch abdominal reconstruction in experimental animal defects. Plastic and Reconstructive Surgery 97, 801-806 Disa, J. J., Goldberg, N. H., Carlton, J. M., et al. (1998) Restoring abdominal wall integrity in contaminated tissue-deficient wounds using autologous fascia grafts. Plastic and Reconstructive Surgery 101, 979-986 Disa, J. J., Chiaromonte, M. F., Girotto, J. A., et al. (2001) Advantages of autologous fascia versus synthetic patch abdominal reconstruction in experimental animal defects. Plastic and Reconstructive Surgery 108, 2086-2087 Eugster, S., Schawalder, P., Gaschen, F., et al. (2004) A prospective study of postoperative surgical site infections in dogs and cats. Veterinary Surgery 33, 542-550 Feldt-Rasmussen, K. & Jensen, O. A. (1956) Large ventral herniae treated with free fascial grafts. A follow-up study. Acta chirurgica Scandinavica 111, 403-408 Gemmill, T. J. & Carmichael, S. (2003) Complete patellar ligament replacement using a fascia lata autograft in a dog. Journal of Small Animal Practice 44, 456-459 Grundon, R. A., Hardman, C., O’reilly, A., et al. (2011) Repair of a scleral defect with an autogenous fascia lata graft in a dog. Veterinary Ophthalmology 14, 271-274 Halfacree, Z. J., Baines, S. J., Lopscomb, V. J., et al. (2007) Use of a latissimus dorsi myocutaneous flap for one-stage reconstruction of the thoracic wall after en bloc resection of primary rib chondrosarcoma in five dogs. Veterinary Surgery 36, 587-592 Hall, A., Dujowich, M. & Merkley, D. F. (2010) Diaphragmatic support of a thoracic wall defect in a dog. Journal of the American Animal Hospital Association 46, 341-5 Hamilton, J. E. (1956) Free matressed fascia lata patches in the repair of large abdominal incisional hernias. American surgeon 22, 217-226 Hamilton, J. E. (1963) Free matressed fascia lata patches in the repair of large or difficult hernias: a 16 years experience. Annals of Surgery 157, 925-930 Hamilton, J. E. (1968) The repair of large or difficult hernia with matressed onlay grafts of fascia lata: a 21 years experience. Annals of Surgery 167, 85-90 Hermanson, J. W. & Evans, H. (1993) Evans Miller’s anatomy of the dog. Saunders (Elsevier), Philadelphia, PA, USA. pp 310 and 320 Hunt, G. (2012) Veterinary Surgery Small Animals. Eds K. M. Tobias and S. A. Johnson. Elsevier, St. Louis, MO, USA. pp 1769-1786 Kowaleski, P., Boudrieau, R. & Pozzi, A. (2012) Stifle joint. In: Veterinary Surgery Small Animals. chapter 62. Eds K. M. Tobias and S. A. Johnson. Elsevier, St. Louis, MO, USA. pp 934-944 Liptak, J. M., Dernell, W. S., Rizzo, S. A., et al. (2008a) Reconstruction of chest wall defects after rib tumor resection: a comparison of autogenous, prosthetic, and composite techniques in 44 dogs. Veterinary Surgery 37, 479-487 Liptak, J. M., Kamstock, D. A., Dernell, W. S., et al. (2008b) Oncologic outcome after curative-intent treatment in 39 dogs with primary chest wall tumors (19922005). Veterinary Surgery 37, 488-496 Matthiesen, D. T., Clark, G. N., Orsher, R. J., et al. (1992) En bloc resection of primary rib tumors in 40 dogs. Veterinary Surgery 21, 201-204 Montgomery, R. D., Henderson, R. A., Powers, R. D., et al. (1993) Retrospective study of 26 primary tumors of the osseous thoracic wall in dogs. Journal of the American Animal Hospital Association 29, 68-72 Pirkey-Ehrhart, N., Withrow, S. J., Straw, R. C., et al. (1995) Primary rib tumors in 54 dogs. Journal of the American Animal Hospital Association 31, 65-69 Roush, J. K. (2003) Biomaterials and surgical implants. Textbook of Small Animal Surgery. Ed D. H. Slatter. Saunders, Philadelphia, PA, USA, p 141 Sandoval, J. A., Lou, D., Engum, S. A., et al. (2006) The whole truth: comparative analysis of diaphragmatic hernia repair using 4-ply vs 8-ply small intestinal submucosa in a growing animal model. Journal of Pediatric Surgery 41, 518-523 Stoll, M. R., Cook, J. L., Pope, E. R., et al. (2002) The use of porcine small intestinal submucosa as a biomaterial for perineal herniorrhaphy in the dog. Veterinary Surgery 31, 379-390 Swiderski, J., Fitch, R. B., Staatz, A. et al. (2005) Sonographic assisted diagnosis and treatment of bilateral gastrocnemius tendon rupture in a Labrador retriever repaired with fascia lata and polypropylene mesh. Veterinary and Comparative Orthopaedics and Traumatology 18, 258-263
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