VISUAL VIGNETTE
Rectus Abdominis Denervation After Subcostal Open Laparotomy Johnathan Ho, MD and James K. Richardson, MD From the Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan. Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. 0894-9115/15/9405-e43 American Journal of Physical Medicine & Rehabilitation Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/PHM.0000000000000256
FIGURE 1 Abdomen at rest.
A
58-yr-old man with type 2 diabetes mellitus underwent left subcostal open laparotomy on June 26, 2013, to remove a suspicious mass at the pancreatic tail. The procedure was initially laparoscopic but was converted to an open laparotomy because of inability to fully visualize the mass. A retractor was used to facilitate exposure. Postoperatively, he noticed a bulge in his left upper abdomen with abdominal muscle contraction and perceived increased difficulty lifting books. A year later, he was referred to the authors’ clinic for further evaluation. His abdomen appeared symmetric on inspection (Fig. 1). However, examination demonstrated altered sensation and absent abdominal reflex in the left upper quadrant (Fig. 2). The reflex was intact in the right hemiabdomen (Fig. 3) and the left lower quadrant. Upon lifting both legs off the examination table, the right hemiabdomen contracted whereas the left upper abdomen remained flaccid and Bbulged.[ Electromyography showed increased insertional and spontaneous activity in the rectus abdominis and evidence of reinnervation as indicated by one to two small-amplitude, highly polyphasic voluntary motor units. Middle and lower thoracic paraspinal muscles were sampled, but these areas did not reveal any evidence of thoracic radiculopathy, as can occur in the setting of diabetes. The evidence of reinnervation was a positive prognostic indicator for continued return in rectus abdominis strength. He was referred to physical therapy for core strengthening and neuromuscular reeducation. The prevalence and incidence of rectus abdominis paralysis after a subcostal laparotomy are unknown,1 as much of the surgical literature discusses intercostal nerve trauma secondary to chest tube placement, thoracotomy, and gynecologic procedures in the lower abdomen.1 The rectus abdominis is innervated by T7YT12 intercostal nerves.2,3 Damage to these nerves can be direct (via incision or trocar placement) or indirect (via retractor use). Rogers
All correspondence and requests for reprints should be addressed to: Johnathan Ho, MD, Department of Physical Medicine and Rehabilitation, University of Michigan, 325 E. Eisenhower Pkwy, SPC 5744, Ann Arbor, MI 48108.
FIGURE 2 Absent abdominal reflex in the left upper quadrant.
FIGURE 3 Intact abdominal reflex on the right.
and colleagues4 found that neural dysfunction at the opened intercostal space is reported to be 100% with retractor use. They also described conduction block in the nerves at least two intercostal spaces away, resulting from compression ischemic injury and stretch injury. The abdominal reflex is a superficial reflex that can help identify intercostal (T7YT12) nerve injury, as the authors did in this patient. He likely sustained axontomesis to T7 and T8 from the actual surgical incision and indirect trauma Visual Vignette
www.ajpmr.com Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
e43
to T9 and T10 from retractor use. Although infrequently used, the abdominal reflex was critical in helping the authors differentiate between an actual hernia and muscle denervation. Clinicians should be aware that open abdominal surgery can result in intercostal nerve damage leading to abdominal muscle weakness/paresis. REFERENCES 1. Van Ramshorst GH, Kleinrensink GJ, Hermans JJ, et al: Abdominal wall paresis as a complication of laparoscopic surgery. Hernia 2009;13:539Y43
e44
Visual Vignette
2. Pa¨tila¨ T, Sihvo EI, Ra¨sa¨nen JV, et al: Paralysis of the upper rectus abdominis muscle after video-assisted or open thoracic surgery: An underdiagnosed complication? Ann Thorac Surg 2009;88:1335Y7 3. Timmermans L, Klitsie PJ, Maat APW, et al: Abdominal wall bulging after thoracic surgery, an underdiagnosed wound complication. Hernia 2013;17:89Y94 4. Rogers ML, Henderson L, Mahajan RP, et al: Preliminary findings in the neurophysiological assessment of intercostal nerve injury during thoracotomy. Eur J Cardiothorac Surg 2002;21:298Y301
Am. J. Phys. Med. Rehabil. & Vol. 94, No. 5, May 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Rectus Abdominis Denervation After Subcostal Open Laparotomy Johnathan Ho, MD and James K. Richardson, MD From the Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, Michigan. Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article. 0894-9115/15/9405-e43 American Journal of Physical Medicine & Rehabilitation Copyright * 2015 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/PHM.0000000000000256
FIGURE 1 Abdomen at rest.
A
58-yr-old man with type 2 diabetes mellitus underwent left subcostal open laparotomy on June 26, 2013, to remove a suspicious mass at the pancreatic tail. The procedure was initially laparoscopic but was converted to an open laparotomy because of inability to fully visualize the mass. A retractor was used to facilitate exposure. Postoperatively, he noticed a bulge in his left upper abdomen with abdominal muscle contraction and perceived increased difficulty lifting books. A year later, he was referred to the authors’ clinic for further evaluation. His abdomen appeared symmetric on inspection (Fig. 1). However, examination demonstrated altered sensation and absent abdominal reflex in the left upper quadrant (Fig. 2). The reflex was intact in the right hemiabdomen (Fig. 3) and the left lower quadrant. Upon lifting both legs off the examination table, the right hemiabdomen contracted whereas the left upper abdomen remained flaccid and Bbulged.[ Electromyography showed increased insertional and spontaneous activity in the rectus abdominis and evidence of reinnervation as indicated by one to two small-amplitude, highly polyphasic voluntary motor units. Middle and lower thoracic paraspinal muscles were sampled, but these areas did not reveal any evidence of thoracic radiculopathy, as can occur in the setting of diabetes. The evidence of reinnervation was a positive prognostic indicator for continued return in rectus abdominis strength. He was referred to physical therapy for core strengthening and neuromuscular reeducation. The prevalence and incidence of rectus abdominis paralysis after a subcostal laparotomy are unknown,1 as much of the surgical literature discusses intercostal nerve trauma secondary to chest tube placement, thoracotomy, and gynecologic procedures in the lower abdomen.1 The rectus abdominis is innervated by T7YT12 intercostal nerves.2,3 Damage to these nerves can be direct (via incision or trocar placement) or indirect (via retractor use). Rogers
All correspondence and requests for reprints should be addressed to: Johnathan Ho, MD, Department of Physical Medicine and Rehabilitation, University of Michigan, 325 E. Eisenhower Pkwy, SPC 5744, Ann Arbor, MI 48108.
FIGURE 2 Absent abdominal reflex in the left upper quadrant.
FIGURE 3 Intact abdominal reflex on the right.
and colleagues4 found that neural dysfunction at the opened intercostal space is reported to be 100% with retractor use. They also described conduction block in the nerves at least two intercostal spaces away, resulting from compression ischemic injury and stretch injury. The abdominal reflex is a superficial reflex that can help identify intercostal (T7YT12) nerve injury, as the authors did in this patient. He likely sustained axontomesis to T7 and T8 from the actual surgical incision and indirect trauma Visual Vignette
www.ajpmr.com Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
e43
to T9 and T10 from retractor use. Although infrequently used, the abdominal reflex was critical in helping the authors differentiate between an actual hernia and muscle denervation. Clinicians should be aware that open abdominal surgery can result in intercostal nerve damage leading to abdominal muscle weakness/paresis. REFERENCES 1. Van Ramshorst GH, Kleinrensink GJ, Hermans JJ, et al: Abdominal wall paresis as a complication of laparoscopic surgery. Hernia 2009;13:539Y43
e44
Visual Vignette
2. Pa¨tila¨ T, Sihvo EI, Ra¨sa¨nen JV, et al: Paralysis of the upper rectus abdominis muscle after video-assisted or open thoracic surgery: An underdiagnosed complication? Ann Thorac Surg 2009;88:1335Y7 3. Timmermans L, Klitsie PJ, Maat APW, et al: Abdominal wall bulging after thoracic surgery, an underdiagnosed wound complication. Hernia 2013;17:89Y94 4. Rogers ML, Henderson L, Mahajan RP, et al: Preliminary findings in the neurophysiological assessment of intercostal nerve injury during thoracotomy. Eur J Cardiothorac Surg 2002;21:298Y301
Am. J. Phys. Med. Rehabil. & Vol. 94, No. 5, May 2015 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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