Since the first report in 1994 [3], the number of patients underwent DIEP free flap reconstruction was increasing. The autologous reconstruction accounts for up to 50% of total reconstruction until about 2010 in Asia [8, 9]. Recent investigator reported that the reconstruction rate using autologous tissue was decreased to about 20–30% with the spread of prosthesis-based reconstruction [10]; however, it is still a popular method in autologous reconstruction for breast cancer.
Breast reconstruction using DIEP flap can prevent muscle sacrifice and maintain postoperative rectus abdominis strength and resistance for abdominal pressure. As a result, patients can prevent donor site complications such as bulging and herniation. Despite these advantages of DIEP flap, we experienced that the case of acute spontaneous rupture.
Previous reports showed that the incidence of abdominal complications after autologous reconstruction was ranged from 3.4 to 25.8%. Some reports considered that a higher BMI was associated with higher morbidity in abdominal complications [5,6,7, 11]. However, the bulging and herniation of the donor site is rare in previous reports. Recently, the frequency of abdominal herniation after DIEP flap reconstruction is reported 1.8–3.9% [12, 13]. There were no any consensus of the risk factor, prevention, and treatment for the bulging and herniation. The mechanism of bulging and herniation is thought to be due to muscle denervation or fascial attenuation by surgical trauma [14]. Another mechanism is assumed that the weakness of the abdominal wall is caused by repeated pregnancy, previous abdominal surgery and obesity, or the increased intra-abdominal pressure [15].
Spontaneous rupture of abdomen in the adult age is also very rare [16,17,18,19,20,21,22,23]. In the previous reports, all cases were occurred following abdominal hernia. Many of these cases were repaired by prolene mesh. In our knowledge, there were no reports about acute abdominal rupture after breast reconstruction without our case.
One of reasons for abdominal wall rupture in our case was considered the unconscious injury of peritoneum when inferior epigastric vessels were harvested. In the present case, the rupture area was located at caudal side of arcuate line. The bowel herniation occurred from peritoneum to subcutaneous area through lateral of rectus abdominis and anterior sheath, in which the location did not match the course of pedicle dissection. This rupture seems to be not iatrogenic but spontaneous because the perforator located medial of the rectus abdominis and the rupture occurred through lateral of the muscle. It was not completely denied that this case was iatrogenic; however, we raised DIEP flaps in a standard manner, and we could not perform irregular procedure without abdominoplasty.
The other possibility was the weakness of abdominal wall caused by two transvaginal deliveries. Although she underwent abdominoplasty due to separated linea alba, abdominal wall rupture occurred. The last possibility was that the resistance of the abdominal pressure could not be maintained by sacrificed intercostal nerve. Spontaneous rupture in our case is considered the complex of these elements.
This patient had no obesity (BMI 24.2), and there were no surgical risks other than separated linea alba due to two deliveries. Patients who are expected to have weak fascia of rectus abnomitis, such as separated linea alba and repeated pregnancy, may be recommended mesh reinforcement to prevent postoperative herniation and rupture after DIEP flap reconstruction. A recent study reported the reinforcement of rectus abnomitis with onlay mesh reduce the risk of postoperative bulge after DIEP reconstruction [24]. Onlay mesh reinforcement may have a disadvantage such as infection. The other study which evaluated the prevention of incisional hernia in midline laparotomies reported that a significant reduction in incidence of incisional hernia was achieved with onlay mesh reinforcement group with sublay mesh group and primary suture group [25]. In addition, they showed that the incidence of wound infection did not differ between the three groups. So, the disadvantage of infection using onlay mesh may be acceptable.
Of course, patients who choose autologous reconstruction tend to avoid implant. Furthermore, it is essential to inform the risk and benefit of mesh reinforcement. To avoid severe postoperative complication for high-risk patients, we think that mesh reinforcement is acceptable. Although abdominal rupture after breast reconstruction using DIEP is considered very rare, it might be safe to apply onlay mesh on the abdominal wall for reinforcement after breast reconstruction using DIEP flap in case of the patients such as separated linea alba and repeated pregnancy.
