Clinical outcomes in abdominal wall autologous flap reconstruction: a systematic review

Clinical Snapshot

Key Findings

• P Value: Not reported; no formal statistical testing performed

• Effect Size: Pedicled flaps predominated (n=4,095; 92.6%); free flaps used in 146 patients (3.3%); mixed approaches in 180 (4.1%). Hernia-related pathology was the commonest indication (n=3,751; 84.8%), followed by malignancy (n=470; 10.6%). Flap failure and long-term hernia recurrence described as 'low' without quantified pooled rates.

• Primary Outcome: Clinical outcomes of autologous flap reconstruction for complex abdominal wall defects, including complication rates, flap failure, and hernia recurrence across flap types and defect aetiologies

• Nnt Or Sensitivity: Weighted mean defect size: 401 cm² for free flaps versus 250 cm² for pedicled flaps (size ranges overlapped). No NNT, sensitivity, specificity, or hazard ratio calculable from available data.

• Confidence Interval: Not reported; descriptive synthesis only

Clinical Application

Pedicled flap techniques (anterolateral thigh, tensor fascia lata, rectus-based, latissimus dorsi-based) are feasible in most tertiary surgical centres with reconstructive plastic surgery expertise. Free flap reconstruction requires dedicated microsurgical infrastructure and is appropriately reserved for larger or more complex defects. Multidisciplinary collaboration between general/colorectal surgery and plastic surgery is essential. The defect-composition-driven selection framework described is clinically practical. In Australia, complex abdominal wall reconstruction is performed at major tertiary referral centres including those affiliated with state trauma networks and cancer centres. The RACGP and relevant surgical colleges (RACS) do not have specific guidelines for autologous flap abdominal wall reconstruction, reflecting the specialist nature of this practice. Mesh-based reconstruction remains standard for most hernias under Australian practice, with autologous flap techniques reserved for contaminated fields, mesh failure, or oncologic defects. There are no specific PBS item numbers for autologous flap abdominal wall reconstruction beyond standard flap and hernia repair MBS items; coding requires specialist input. The TGA regulates biological and synthetic mesh products relevant to the comparator landscape. Australian centres performing this work include major metropolitan teaching hospitals in Sydney, Melbourne, Brisbane, and Perth. The findings support existing specialist practice patterns in Australia but do not provide sufficient evidence to alter current RACS or RACGP guidance. Adult patients with complex abdominal wall defects requiring reconstruction, particularly those with hernia-related pathology, abdominal wall malignancy, traumatic defects, contaminated wounds, enterocutaneous fistulae, or full-thickness defects where prosthetic mesh is contraindicated or has failed. Most applicable in tertiary plastic and reconstructive surgery centres with microsurgical capability.

Abstract

PURPOSE: Complex abdominal wall defects present major reconstructive challenges when restoration of fascial continuity must be combined with durable soft-tissuecoverage, visceral protection, and, in selected cases, functional repair. Although autologous flap reconstruction is well established for selected indications, its overall role across defect types has yet to be established. METHODS: A systematic review was performed in accordance with PRISMA guidelines (PROSPERO: CRD42023491916). PubMed/MEDLINE, Embase, Scopus, Web of Science, Cochrane Library, and Google Scholar were searched from inception to April 2026 for studies reporting adult autologous flap-based abdominal wall reconstruction. Given substantial clinical and methodological heterogeneity, data were analysed descriptively. RESULTS: 172 studies comprising 4,421 patients were included. Pedicled flaps predominated (n=4,095, 92.6%), with free flaps used in 146 patients (3.3%) and mixed approaches in 180 (4.1%). Hernia-related pathology was the commonest indication (n=3751, 84.8%), followed by malignancy (n=470, 10.6%). Frequently used flap categories included anterolateral thigh, tensor fascia lata, rectus-based, and latissimus dorsi-based flaps. Flap selection was primarily defect-driven: fascia-bearing regional and turnover techniques were used mainly for structurally focused hernia repair, whereas composite flaps were used more often for oncologic, fistulating, traumatic, contaminated, or full-thickness defects. Common short-term complications include seroma, surgical site infection, and wound dehiscence. Flap failure and reported long term hernia recurrence were low. Free flaps were used more often for larger defects weighted mean 401 cm² vs 250 cm² for pedicled flaps), although size ranges overlapped. CONCLUSIONS: Autologous flap reconstruction is a durable and versatile option for selected complex abdominal wall defects. Reconstructive strategy should be guided primarily by defect composition.

References

1. 1.Hadjiandreou, M., Kim, S., Kiew, C. Y. K., Patel, B., Sadigh, P. L., Pahal, G. S., Ross, D., & Pafitanis, G. (2026). Clinical outcomes in abdominal wall autologous flap reconstruction: a systematic review. Hernia: The Journal of Hernias and Abdominal Wall Surgery. https://doi.org/10.1097/GOX.0000000000006433