despite advances in plastic surgery , reconstruction of soft tissue defects with exposed tendons on the hand and foot remains a challenge . there are several reconstruction options , including skin grafts , local flaps , distant flaps and free flaps.1 , 2 , 3 however , the experience over the past 20 years has demonstrated that tissue reconstruction with flap would lead to adhesion of tendon and functional impairment at the recipient site.4 , 5 , 6 the posterior rectus sheath - peritoneal free flap , developed by salgado et  al . they proposed that the peritoneum interposition might reduce adhesion formation in surgery of exposed extensor tendons of the hand and foot . traditionally , the peritoneal free flap was retrieved by making a paramedian incision under direct vision . considering underlying tendon excursion this flap was supplied by the peritoneal branches of the deep inferior epigastric artery . here , a 30-year - old woman was involved in a machine accident , with extensive soft tissue defects . after debridement and repair of tendons , the patient received vacuum sealing drainage ( vsd ) treatment . extensor tendons , metacarpal bones and carpus were exposed ( fig .  1 ) . the existing defect of the dorsal hand was 17  cm    12  cm . the peritoneal flap measuring 22  cm    15  cm retrieved by laparoscopic surgery was transplanted to cover the defect ( fig .  2 , fig .  3 ) . the peritoneal flap survived two weeks postoperatively and no postoperative complications were observed ( fig . the remaining wound received a skin graft and the abdominal wall demonstrated a satisfying appearance ( fig . the function of the injured hand recovered partially within the first year follow - up ( fig . after radical debridement , repair of extensor tendons and vsd treatment , the size of the defect measured 17  cm    12  cm ( fig .  1 ) . by using the laparoscopic system , pneumoperitoneum was created through an optiview trocar placed in the subumbilical position . a laparoscope was introduced through this port and two other trocars were placed in the right and left lower abdominal wall . the bilateral pedicles of the flap were divided through laparoscopic procedures using the ultrasonic - activated scissors . the bilateral deep inferior epigastric artery was carefully isolated , double clipped and then transected at its origin to maximize pedicle length and diameter . the peritoneal free flap was transplanted to cover the defect with exposed tendons , metacarpal bones and carpus . the deep inferior epigastric artery and its accompanying veins , as pedicles of the peritoneal free flap , were anastomosed to the radial artery and cephalic vein . after survival of the peritoneal flap , the skin defect was covered by a split - thickness skin graft . reconstruction of extensive soft tissue defects accompanied by exposed tendons and/or skeleton on the hand and foot continues to be a challenging issue for plastic surgeons . the skin grafts , local flaps , distant flaps and free flaps have become the most popular procedures to cover soft tissue defects . these above mentioned treatment regimens will inevitably involve severe tendon adhesion.2 , 5 , 8 although various biochemical and physical methods have been adopted to decrease adhesion formation , most of the results are unsatisfactory.9 , 10 , 11 a thin flap that easily supports a skin graft and provides a gliding surface for tendon coverage represents an ideal option . the peritoneum acts as a physiological barrier in prevention of abdominal adhesion , and thus , a similar mechanism may apply to tendon coverage . salgado et  al firstly introduced the posterior rectus sheath - peritoneal free flap for reconstruction of hand and foot . the totally laparoscopic peritoneal flap with bilateral pedicles allows a larger size , across median line . a more cosmetically acceptable result was obtained in both the donor site and the recipient site . creating one - stage reconstruction without following skin grafting might be achieved by introducing the concept of a chimeric flap , which can resurface the exposed tendons and provide cutaneous wound coverage simultaneously . in conclusion , the totally laparoscopic peritoneal free flap is a good choice for reconstruction of the hand and foot with exposed tendons . however , larger clinical trials and long - term follow - up are required to support the recommendation of this flap . this work was supported by grants from the foundation of science & technology department of zhejiang province , p.r.china ( no . 2012c13020 - 3 ) and from the foundation of health & family planning commission of zhejiang province , p.r.china ( no .