Primary reinforcement with rectus abdominis muscle flap-a salvage technique for a tenuous post traumatic duodenal perforation- a case report

INTRODUCTION: The conventional techniques for management of complex duodenal injuries are duodenal diverticularisation, pyloric exclusion or triple tube decompression. We here present a salvage technique of primary reinforcement with pedicled rectus abdominis muscle flap (RAMF) for a tenuous post traumatic duodenal perforation (PTDP). The majority of the studies in the literature are on the use RAMF for the secondary repair of peptic duodenal perforations. PRESENTATION OF CASE: A 38 year old male presented with an acute abdomen, three days after sustaining a blunt abdominal trauma. The clinical and radiological findings in the abdomen were subtle and not contributory. An emergency laparotomy with a high index of suspicion revealed a large perforation in the anterolateral wall of the second portion of the duodenum with a friable unhealthy wall and shearing of the serosa around the perforation site. The entire omentum was unhealthy, contused with areas of gangrene and omentectomy done. The perforation site was closed using 3.0 vicryl and reinforced with a pedicled right RAMF based on the superior epigastric artery. The patient recovered uneventfully and was discharged. DISCUSSION: The addition of conventional diversion techniques to primary duodenorrhaphy is sophisticated, time consuming and adds morbidity. CONCLUSION: RAMF is a good tissue substitute to buttress tenuous duodenal injuries presenting late with inflamed, friable perforation sites and associated tissue loss, where duodenorrhaphy alone may not be successful. RAMF is a valuable salvage technique when the omentum is not available and the local tissue condition negates the effectiveness of other simpler techniques.