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Method Article

In situ Transverse Rectus Abdominis Myocutaneous Flap: A Rat Model of Myocutaneous Ischemia Reperfusion Injury

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DOI:

10.3791/50473

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June 8th, 2013

 ,  , 
1Department of Surgery, Royal Infirmary of Edinburgh, 2Department of Nephrology, Royal Infirmary of Edinburgh

In This Article

Summary

Free tissue transfer is widely employed in reconstructive surgery to restore form and function following oncological resection and trauma. Preconditioning this tissue prior to surgery may improve outcome. This article describes an in situ transverse rectus abdominis myocutaneous flap (TRAM) in rats as a means for testing preconditioning strategies.

Abstract

Free tissue transfer is the gold standard of reconstructive surgery to repair complex defects not amenable to local options or those requiring composite tissue. Ischemia reperfusion injury (IRI) is a known cause of partial free flap failure and has no effective treatment. Establishing a laboratory model of this injury can prove costly both financially as larger mammals are conventionally used and in the expertise required by the technical difficulty of these procedures typically requires employing an experienced microsurgeon. This publication and video demonstrate the effective use of a model of IRI in rats which does not require microsurgical expertise. This procedure is an in situ model of a transverse abdominis myocutaneous (TRAM) flap where atraumatic clamps are utilized to reproduce the ischemia-reperfusion injury associated with this surgery. A laser Doppler Imaging (LDI) scanner is employed to assess flap perfusion and the image processing software, Image J to assess percentage area skin survival as a primary outcome measure of injury.

Introduction

The goal of this protocol is to demonstrate a reliable and reproducible model of the ischemia-reperfusion injury observed in free tissue transfer to enable interventional strategies to be investigated.

Free tissue transfer is defined as the vascular detachment of an isolated block of tissue followed by autologous transplant of that tissue with anastomosis of the flap's transected vessels to native vessels at the recipient site. The procedure is known as FTT and the tissue being transferred referred to as the free flap.

Free tissue transfer is the gold standard approach for the correction of complex, composite defects where local options are unsuitable or unavailable.1-4 Ischemia reperfusion injury (IRI) is inevitable in free tissue transfer, contributes to flap failure5,6 and has no effective treatment. The elective nature of free flap surgeries permits administration of pharmacological agents to precondition against IRI.

IRI results in impaired flow through the microcirculation by endothelial activation and metabolic dysfunction,7 increased capillary permeability and subsequent interstitial edema7, influx of inflammatory cells,8 release of inflammatory mediators, reactive oxygen species9 and complement deposition.10 This complex process of hypoxia and subsequent reperfusion injury ultimately leads to cell death. A model of myocutaneous IRI enables the effectiveness of preconditioning strategies on clinical outcomes to be assessed. Recent work has validated the use of animal models of IRI studies as a surrogate for human IRI by comparing the molecular changes observed in human subjects and existing animal data.10,11

The rat transverse rectus abdominis myocutaneous (TRAM) flap was first described in 1987 in German12 and in 199313 in English. This model gained wide popularity13-25 as a cheap, robust model to investigate different strategies to reduce IRI associated with free tissue transfer.14,17-22 The majority of these studies were designed as unipedicled TRAM flaps based on the deep, inferior, epigastric vascular pedicle.15-18,20-22 Comparison of the data from these studies is complicated by the use of different sized cutaneous islands (10.5 - 30 cm2) and different lengths of postoperative follow-up (2 - 10 days). The average total percentage area flap necrosis in the control arm of these studies is 69 ± 6.2% (mean ± SEM). It should be noted that these six papers all employ the rectus abdominis muscle as a carrier for the vascular pedicle but do not expose, divide and microanastomose or clamp the vessels. Zhang et al.23 have described a true, free rat TRAM flap based on the superior epigastric vessels in which the flaps were raised, vessels divided and the myocutaneous flap transferred and microanastomosed to the groin vessels. This difficult technique required the microanastomosis of 0.45 - 0.5 mm caliber vessels. Only fifteen were performed and of these 67% survived.23 The model described by Zhang et al.23 is an excellent model for the human free TRAM flap as it truly mirrors the injury incurred during FTT. The other published models of a rat TRAM flap more accurately reflect the injuries incurred during a human pedicled TRAM but do not accurately reflect the IRI as these flap in do not undergo an ischemic period followed by reperfusion as the vascular pedicle is never clamped or divided and microanastomosis performed. This protocol and video describe a new model of free tissue transfer using the rat TRAM in which the IRI is replicated using microclamps. This more faithfully replicates IRI than the pedicle TRAM predecessors but is technically easier than performing the microanastomosis. Microclamps have been widely employed by transplant researchers to recreate IRI associated with solid organ transplant;26-33however, this is the first time it has been described in the rat TRAM flap.

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Protocol

All surgery is performed in accordance with guidelines set out by the United Kingdom's Home Office and the University of Edinburgh's Veterinary Services Department.

1. Surgical Procedure Set-up Notes

  1. Change into clean surgical scrubs, gown, scrub cap and mask. Clean all surfaces of the operating room including equipment with 2% chlorhexidine in 70% isopropyl alcohol.
  2. Prior to surgery, autoclave all surgical supplies and instruments that will be used in the procedure. Sterile packs per operation should include: 3 drapes, gauze, cotton tip applicators, silicone sheeting and the surgical instruments, see the Table of Specific Surgical Materials and Tools and Figure 1. Weigh the rat and measure out the appropriate volume of buprenorphine (0.04 mg/kg) to be administered subcutaneously 1 hr before completing the procedure. Lay out; 3 x 1 ml syringes for subcutaneous fluid administration during surgery, 2 x 6-0 Vicryl sutures, 1 x 5-0 Ethilon sutures, a sterile marker with ruler and a 10-blade disposable scalpel, 4 - 5 pairs of sterile gloves and a hand-held cautery unit.
  3. Place 4 x 10 ml sterile, 0.9% saline vials in a water bath warmed to 37 °C. This will be used for subcutaneous fluid replacement (1 ml/kg/hr) and to rinse the surgical site. Set up the homeothermic blanket, rectal probe, heat lamp, operating microscope and anesthetic rig. Turn on the laser and its software, set-up another anesthetic rig and place a heat pad underneath the black mat on which the animal will lay during the scan.
  4. Use male, Lewis rats weighing 250-300 g. House rats for 7 days with food and water ad libitum with 12 hr light-dark cycles before any surgery is performed.

2. Anesthesia and Skin Preparation

  1. Place the rat in the anesthetic rig's induction chamber and administer 4% isoflurane with 1L/min O2 for 2-3 min to induce anesthesia. Remove the anesthetized rat from the chamber and place it supine on the clean, heated mat. Maintain isoflurane at 1.5% using a nose cone. Apply lacrilube or similar agent to prevent corneal abrasion during the procedure. Perform a foot-pad pinch test to ensure the animal is adequately anesthetized before proceeding. Repeat this last test before each major step in the procedure and adjust the inhalational anesthetic concentration accordingly.
  2. Closely shave the anterior abdominal using an electric shaver so that the entire abdominal surface is exposed. Apply depilating cream for the duration recommended by the supplier. Remove the cream and thoroughly rinse the skin with warmed sterile saline to remove all traces of the cream. Apply 2% chlorhexidine in 70% isopropyl alcohol to the skin and allow to dry before proceeding. This is the standard skin preparation in our unit based on current evidence for surgical site infection.34 Please discuss with your Veterinary Department what is standard procedure in your unit before electing a skin preparation protocol.
  3. Place 2 drapes either side of the rat and take care to keep them sterile. Put on sterile gloves and with the aid of an assistant open up the sterile packs. Place all the instruments on one drape and the sutures, gauze, cotton applicators, silicone sheeting and sterile marker pen with ruler on the other.
  4. Identify the midline using xiphisternum and the tail as reference points. Mark the midline. Measure 0.8 cm below the xiphisternum and mark this point. Draw a line perpendicular to the midline from this point. Taking the midline as the center of the flap mark out 1 cm and 2 cm to the left and the right of the midline. Draw vertical lines parallel to the midline from the points. Measure 4 cm below the original horizontal line and draw another parallel to it. Following these instructions a 4 x 4 cm flap divided into 4 equal strips is delineated (see Figure 2).

3. Laser Doppler Imaging

  1. Carefully move the rat to the nose cone of the second anesthetic rig at the LDI scanner. Continue anesthesia at 1.5% isoflurane, 1L/min O2. Turn on the laser and follow the manufacturer's instructions to start scanning. After saving the scanned file return the rat back to the first rig and re-insert the rectal probe of the homeothermic blanket using soft white paraffin as a lubricant.

4. In situ TRAM flap - Myocutaneous Model of IRI

  1. Re-scrub hands and put on fresh sterile gloves. Cut out a 5 cm diameter circle in the center of the remaining sterile drape and place this over the exposed abdomen to create a draped sterile-field.
  2. Make an incision down the left lateral marked edge (Figure 3A and B). Achieve hemostasis. Make similar incisions down the horizontal lines to the left of the midline. Achieve hemostasis.
  3. The fat overlying the left inferior rectus sheath should be visible. Using forceps and fine iris scissors carefully get underneath this fat. Take care not to damage the perforators coming through the left, anterior rectus sheath. The plane opened up by such dissection is that immediately above the anterior abdominal wall fascia. Continue dissecting in this plane around the demarcated margins. In the left iliac fossa lies the large, superficial circumflex iliac vessels- these can be tied or cauterized. Then extend the dissection medially with caution and only as far as the lateral margin of the left rectus muscle. There is an obvious color change at this point from pink to near white (Figure 3C). Carefully irrigate the area with sterile saline and check that hemostasis has been achieved before placing moist gauze over the area.
  4. Repeat the procedure on the contralateral side but this time extend to the linea alba (mid line). Take care to identify and cauterize all the musculocutaneous perforators arising in the center of the right rectus abdominis muscle (Figure 3D). If this is not done properly it can result in a postoperative hematoma and spurious results. Similarly achieve hemostasis, irrigate and place moist gauze over the raised flap.
  5. Return to the inferior margin of the left anterior rectus (Figure 3E and F). Cauterize the most inferior perforator seen. Proceed to cut a small (approx. 0.6 cm x 0.6 cm) window in the anterior rectus sheath using microscissors and pointed curved Graeffe forceps. Blunt dissect slowly down the lateral margin of the muscle until the muscle thins out but before the posterior sheath is breached. Then rotate the forceps and blunt dissect medially until the belly of the muscle is atop the curved edge of the forceps and the tips are free at the medial margin. Feed approximately 6 cm of 5-0 Ethilon into the jaws of the forceps and tie off the inferior rectus sheath. Upon completion of this step the myocutaneous flap is isolated on one dominant vessel- the deep superior epigastric vessels. Cover with a moist gauze.
  6. Cut the silicone sheeting into ovals with smooth corners, (Figure 3G). These should be large enough to cover most of the area exposed under the fasciocutaneous portions of the flap. However, caution must be taken to ensure that the skin edge can be closed without any tension and the medial curve of the oval may have to be paired back to prevent it impairing flow through the remaining perforators. These are then sutured in place with 6-0 Vicryl (Figure 3H). Cover with moist gauze.
  7. Using simple interrupted 5-0 Ethilon sutures 'peg out' the flap to reduce heat and water loss (Figure 3I). Cover with a moist gauze.
  8. Extend the wound superiorly to the left of the xiphisternum (Figure 3I). Suture this to the upper left quadrant to improve the field-of-view.
  9. Cut away any overlying fat to reveal the superior, left, anterior rectus sheath. Cut a small (0.6 cm x 0.6 cm) window in this sheath (Figure 3J). Extend the wound medially until a change in muscle fiber trajectory from vertical to oblique and consistency from tightly packed to loose fibrils is seen.
  10. Insert the curved forceps carefully between these two muscles and open up a plane by blunt dissection. Carefully cut down only as far as the superior surface of these curved forceps cutting through the belly of the left rectus abdominis muscle to reveal the underlying deep, superior epigastric artery and vein (Figure 3K).
  11. Using micro-instruments and high power on the operating microscope, carefully separate the artery and vein and strip off any surrounding fat.
  12. Apply atraumatic Acland clamps to the artery and vein (B-1, "V" type) and start the timer to count down the 30 min ischemic period. Irrigate the clamped pedicle and cover with gauze. We did not employ vessel dilators such as verapamil or pabavarine but should vessel spasm be a problem, these drugs should be considered.
  13. Administer the buprenorphine (0.04 mg/kg) and warmed, sterile saline (1 ml/kg/hr).
  14. Starting at the top left corner, suture the flap in place with 6-0 Vicryl subcuticular sutures stopping and tying off at the xiphisternum.
  15. When the 30 min ischemic time is over, carefully remove the clamps and irrigate the pedicle with warmed saline. Check that flow has been re-established. Please note that this ischaemic time was stipulated by the UK Home Office authority. Researchers working in other authorities may be able to extend this time. Extending the ischemic time will likely lead to worse clinical outcome.
  16. Suture the cut edges of the rectus back in place with 6-0 Vicryl. Take care not to apply too much tension as this can lead to kinking of the vessels.
  17. Complete the subcutaneous suturing taking care to bury all knots below the skin (Figure 3K).
  18. Clean the wound area and allow it to dry. Re-draw the zones on the flap.
  19. Re-scan the animal to obtain a postoperative image.
  20. Re-apply lacrilube to the animal's eyes and place in a warmed incubator (37 °C) for 1 hr to recover before returning to the husbandry unit.

Critical steps within the protocol

The crux of the procedure is in identifying the deep, superior epigastric vessels. This is shown clearly in the accompanying film. In brief, a window is cut in the anterior rectus sheath to expose the underlying muscle fibers which will be running longitudinally. By extending the superficial dissection of the anterior rectus sheath medially a change in muscle fiber trajectory is observed from longitudinal to oblique. Insert blunt ended, curved, Graeffe forceps (or similar) at the intersection of these two bundles of muscle fibers. Blunt dissect laterally. Cut down, using micro scissors, onto the upper surface of the curved forceps held in this plane between the muscle fiber bundles. On removal of the Graeffe forceps the deep, superior epigastric artery and vein will be observed at the midpoint of the rectus abdominis muscle body. Strip off the fat overlying the vessels using micro instruments and apply the clamps.

The fasciocutaneous portions of the rat TRAM flap are thin enough to permit the flap to take as a full thickness skin graft. To prevent this and to ensure that this is a true model of IRI a thin, flexible silicon sheet is placed underneath the fasciocutaneous portions of the flap.35 This step has been adopted by other researchers undertaking rat TRAM models.17,21,25

Rats chew through knots so make sure all sutures are subcuticular and all knots are buried. In carrying out meticulous suturing autocannabilism of flaps as reported by other researchers can be avoided. 24

Following administration of Buprenorphine reduce maintenance anesthesia to 1% Isoflurane (1L/min O2).

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Results

Rat models are more economical than larger animals models,36 are disease-resistant in nature and may be genetically manipulated. Loose skinned animals, such as rodents, were thought to have a different arrangement of cutaneous blood supply compared to fixed skinned animals such as humans and pigs. In loose skinned animals, skin is supplied primarily by direct cutaneous blood vessels passing through the subcutaneous fat to the overlying skin (Figure 4) By contrast, fixed skinned animals derive...

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Discussion

Modifications and trouble shooting

The protocol presented here reproduces the IRI seen in free tissue transfer in an experimental system enabling further understanding of that process and provides a means to investigate means of ameliorating IRI and improving outcome. This could easily be modified to produce a more severe injury if it were based on the non-dominant, deep, inferior epigastric pedicle or if the ischemic time were increased.

Limitations of technique

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Disclosures

We have no disclosures.

Acknowledgements

This work was funded by the Medical Research Council grant G1000299.

The corresponding author would like to thank Gary Borthwick, University of Edinburgh, for assisting during the surgery.

The authors would like to acknowledge advice from Helen Douglas and Iain Mackay and allowing us to observe their Deep Inferior Epigastric (DIEP) flap procedure (Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G4 0SF, UK).

The authors would also like to thank Gary Blackie at the University of Edinburgh for his help in producing the video for this article.

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Materials

List of materials used in this article
NameCompanyCatalog NumberComments
Moor LD12 laser doppler imaging scannerhttp://gb.moor.co.uk/product/moorldi2-laser-doppler-imager/8
Complete homeothermic blanket system with flexible probe. Small. 230 VAC, 50 Hz507221Fwww.harvardapparatus.com
Graeffe forceps 0.8 mm tips curved11052-102, http://www.finescience.de
Acland clamps00398 VB-1 ’V’ pattern clamps used on both artery and vein. http://www.merciansurgical.com/acland-clamps.pdf
Clamp applicatorCAF-4http://www.merciansurgical.com/acland-clamps.pdf
Gemini cautery unit726067www.harvardapparatus.com
Micro-vessel dilators 11 cm 0.3 mm tips 00124D-5a.2http://www.merciansurgical.com
Micro Jewellers Forceps 11cm angulated 00109JFA-5bhttp://www.merciansurgical.com
Micro Jewellers Forceps 11 cm straight 00108JF-5http://www.merciansurgical.com
Acland Single Clamps B-1V (Pair)396http://www.merciansurgical.com
Micro Scissors Round Handles 15 cm Straight67http://www.merciansurgical.com
Iris Scissors 11.5 cm Curves EASY-CUTEA7613-11http://www.merciansurgical.com
Mayo Scissors 14 cm Straight Chamfered Blades EASY-CUTEA7652-14http://www.merciansurgical.com
Derf Needle Holders 12 cm TC703DE12http://www.merciansurgical.com
Ethilon 5-0W1618http://www.farlamedical.co.uk/
Vicryl rapide 6-0W9913http://www.millermedicalsupplies.com/
Instrapac - Adson Toothed Forceps (Extra Fine)7973http://www.millermedicalsupplies.com/
Castroviejo needle holders12565-14http://s-and-t.ne
Heat Lamphttp://www.chicken-house.co.uk
Silicone sheeting 0.3 mm translucenthttp://www.silex.co.uk/
Image J softwarehttp://rsbweb.nih.gov/ij/
Zeiss OPMI picohttp://www.zeiss.co.uk/
Operating microscope
Vet tech solution isofluorane righttp://www.vet-tech.co.uk/
Vet tech solution isofluorane righttp://www.vet-tech.co.uk/

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Laser Doppler ImagingImage J AnalysisAtraumatic ClampsFlap Perfusion AssessmentSkin Survival MeasurementSurgical Procedure
In situ Transverse Rectus Abdominis Myocutaneous Flap: A Rat Model of Myocutaneous Ischemia Reperfusion Injury
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