Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 20:
Rectus Abdominis Muscle Transplantation
  The rectus abdominis has a dual blood supply that branches freely in the central region of the muscle. The superior epigastric artery, a terminal branch of the internal mammary, enters at the junction of the xiphisternum and high diaphragmatic fiber insertion. The inferior epigastric artery arises from the external iliac artery below and behind the inguinal ligament to enter the posterior and lateral sheath at the level of the arcuate line. Each artery is accompanied by its venae comitantes, which drain into the internal mammary vein superiorly and the external iliac vein inferiorly. The inferior epigastric artery averages 2 to 4 mm and the superior 1 to 2 mm. Additionally, small segmental branches enter the sheath posteriorly and laterally from the lower six intercostal arteries. These vessels accompany the intercostal thoracic nerve between the transversalis and internal oblique muscles. There are also small connections with the ascending branch of the deep circumflex iliac vessels. The deep muscular system can support the skin overlying a large portion of the abdomen by several perforating vessels that communicate with the superficial vascular network. The most important of these perforators are located around the umbilicus.

The nerve supply, both sensory and motor, is segmental it nature, arising from T7 to T12.

Functionally, the rectus is a major anterior abdominal wall flexor.



A. In this preparation, a paramedian incision is made. The anterior rectus sheath is exposed and split in the middle. Muscle sheath attachments are divided to the medial and lateral borders of the muscle.

B. Intercostal branches are isolated and tied. The segmental nerves accompanying the vessels may be preserved for functional transfers.

C. Dissection is done from the medial side approaching the lateral pedicle. The upper portion can be done by blunt dissection. In the lower portion of the muscle one may encounter peritoneal branches from the deep inferior epigastric artery. Care must be taken separating the inscriptions to the anterior rectus sheath, where they are densely adherent. Perforations of the sheath may occur, but are preferable to thinning the muscle and vascular pedicle anteriorly. The cutaneous perforators are ligated, especially around the umbilicus. These must be preserved if a skin flap is to be used. The pedicle is isolated by careful dissection down the lateral side. The artery and vein can be followed to their origins.

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