Morbidity associated with the immediate vertical rectus abdominus myocutaneous flap reconstruction after radical pelvic surgery

Proctor, Matthew; Westwood, David A.; Donahoe, Simon; Chauhan, Aakash; Lynch, A. C.; Heriot, Alexander G.; Sent-Doux, Kimberley N; Creagh, Terry; Frizelle, Frank; Wakeman, Chris

doi:10.1111/codi.14909

Cited by 14 publications

(16 citation statements)

References 33 publications

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“…For nonrestorative procedures, the combination of MIS and perineal reconstruction techniques avoiding the rectus abdominis muscle could theoretically yield the best results. In this setting, the inferior gluteal artery myocutaneous (IGAM) flap represents an attractive option to the vertical rectus abdominus myocutaneous (VRAM) flaps which are associated with complex reoperative scenarios [23].…”

Section: Discussionmentioning

confidence: 99%

Robotic beyond total mesorectal excision surgery for primary and recurrent pelvic malignancy: Feasibility and short‐term outcomes

et al. 2022

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Aim: To explore the feasibility and safety of robotic beyond total mesorectal excision (TME) surgery for primary and recurrent pelvic malignancy.Methods: Patients undergoing robotic beyond TME resections for primary or recurrent pelvic malignancy between July 2015 and July 2021 in a public quaternary and a private tertiary centre were included. Demographic and clinical data were recorded and outcomes analysed.Results: Twenty-four patients (50% males) were included, with a median age of 58 (45-70.8) years, and a BMI of 26 (24.3-28.1) kg/m 2 . Indication for surgery was rectal adenocarcinoma in nineteen, leiomyosarcoma in two, anal squamous cell carcinoma in one and combined rectal and prostatic adenocarcinoma in two patients. All patients required resection of at least one adjacent pelvic organ including genitourinary structures (n = 23), internal iliac vessels (n = 3) and/or bone (n = 2). Eleven patients had a restorative procedure. Of the 13 nonrestorative cases, nine needed perineal reconstruction with a flap.There was one conversion due to bleeding. The mean operating time was 370 (285-424) min, and the median blood loss was 400 (200-2,000) ml. The median length of stay was 16 (9.3-23.8) days. Fourteen patients (58.3%) had postoperative complications; eight of them (33.3%) were Clavien-Dindo III or more complication. Twenty-three (95.8%) patients had an R0 resection. During a median follow-up of 10 (7-23.5) months, five patients (20.8%) had systemic recurrences. No local recurrences were identified during the study period. Conclusion:Implementation of robotic beyond TME surgery for primary and recurrent pelvic malignancy is feasible within a highly specialised setting.

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Section: Discussionmentioning

confidence: 99%

Robotic beyond total mesorectal excision surgery for primary and recurrent pelvic malignancy: Feasibility and short‐term outcomes

et al. 2022

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“…Although the use of myocutaneous flaps reduces perineal morbidity following abdominoperineal resection or pelvic exenteration, the overall complication rate remains high, ranging from 36% to 65% in the literature, 7,[10][11][12][13][14] which is associated with a reoperation rate between 14% and 32%. 3,10,13,15,16 Perineal wound dehiscence is very common in these patients, being the reported incidence by different authors around 30% of the cases. 10,11,17 This is especially important in previously irradiated patients, due to the poor healing potential of the recipient bed.…”

Section: Discussionmentioning

confidence: 99%

“…Comparing to other series using traditional VRAM flap for pelvic reconstruction, perineal wound complications were neither more frequent nor more severe. Although the use of myocutaneous flaps reduces perineal morbidity following abdominoperineal resection or pelvic exenteration, the overall complication rate remains high, ranging from 36% to 65% in the literature, 7,10–14 which is associated with a reoperation rate between 14% and 32% 3,10,13,15,16 . Perineal wound dehiscence is very common in these patients, being the reported incidence by different authors around 30% of the cases 10,11,17 .…”

Section: Discussionmentioning

confidence: 99%

“…10,11,17 This is especially important in previously irradiated patients, due to the poor healing potential of the recipient bed. 2 Major necrosis or total flap loss mean varies between studies (1.8% to 8%), 10,11,[16][17][18] as some authors considered flap loss as significant flap necrosis requiring debridement in the operating room 11,17 while others described it as complete necrosis of the flap, 16 what is less frequent than the previous. Reported minor necrosis ranges between 5% and 8%.…”

Section: Discussionmentioning

confidence: 99%

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Extended vertical rectus abdominis myocutaneous flap for reconstruction of large pelviperineal defects following oncologic resection

Pérez‐García

García-Granero

Thione

et al. 2022

Journal of Surgical Oncology

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Background and Objectives Extended vertical rectus abdominis myocutaneous (eVRAM) flap has been proposed for reconstruction of large pelviperineal defects where traditional VRAM flap is insufficient. We present our experience with eVRAM flap for pelviperineal reconstruction following oncologic resection. Methods A retrospective study was conducted, including all the patients who underwent reconstruction with eVRAM flap after complex pelvic resection, between 2012 and 2020. EVRAM flap was indicated when traditional VRAM was considered deficient to cover or reach the skin defect or to fill the dead space. Results Forty‐four patients were included in the study. Successful reconstruction with eVRAM flap was achieved in 40 patients. There were three flap failures, and one patient died in the second postoperative day because of multiple organ failure. Perineal wound complications occurred in 17 patients (38.6%), eight of them requiring surgical reoperation. Donor site problems were present in five patients (11.4%), and only one patient required surgical closure because of a major dehiscence. Conclusions The authors found the eVRAM flap to be a useful and reliable flap for reconstruction of complex pelviperineal wounds, with a low rate of donor site morbidity.

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“…Factors that warranted myocutaneous flap reconstruction included radiotherapy, previous APR, total PEx, and sacrectomy. In a review of 154 patients undergoing VRAM reconstruction post-APR by Proctor et al, 30 the authors caution that careful patient selection is the key to balance the risks versus benefits of VRAM flap reconstruction. A best evidence review by Howell et al 31 investigated whether irradiated perineal wounds following APR warranted myocutaneous flap closure.…”

Section: Discussionmentioning

confidence: 99%

Pelvic Reconstruction following Abdominoperineal Resection and Pelvic Exenteration: Management Practices among Plastic and Colorectal Surgeons

Stein

Karir

Hanson

et al. 2021

J Reconstr Microsurg

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Background Pelvic reconstruction with a muscle flap significantly improves postoperative outcomes following abdominoperineal resection (APR). Despite it being the gold standard, significant surgeon-selection bias remains with respect to the necessity of pelvic obliteration, flap choice, and ostomy placement. The objective of the study was to characterize management practices among colorectal surgeons (CSs) and plastic surgeons (PSs). Methods Specialty-specific surveys were distributed electronically to CSs and PSs via surgical societies. Surveys were designed to illustrate geographic and specialty-specific differences in management. Results Of 106 (54 CSs and 52 PSs) respondents (58% Canada, 21% Europe, 14% the United States, and 6% Asia/Africa), significant interdisciplinary differences in practices were observed. Most respondents indicated that multidisciplinary meetings were not performed (74% of CSs and 78% of PSs). For a nonradiated pelvic dead space with small perineal defect, 91% of CSs and 56% of PSs indicated that flap reconstruction was not required. For a radiated pelvic dead space with small perineal defect, only 54% of CSs and 6% of PSs indicated that there was no need for flap reconstruction. With respect to ostomy placement, 87% of CSs and 21% of PSs indicated that stoma placement through the rectus was superior. When two ostomies were required, most CSs preferred exteriorizing ostomies through bilateral recti and requesting thigh-based reconstruction. PSs favored the vertical rectus abdominis muscle (VRAM; 52%) over the gracilis (23%) and inferior gluteal artery perforator (IGAP; 23%) flaps. Among PSs, North Americans favor abdominally based flaps (VRAM 60%), while Europeans favor gluteal-based flaps (IGAP 78%). Conclusion A lack of standardization continues to exist with respect to the reconstruction of pelvic defects following APR and pelvic exenteration. Geographic and interdisciplinary biases with respect to ostomy placement, flap choice, and role for pelvic obliteration continues to influence reconstructive practices. These cases should continue to be approached on a case by case basis, driven by pathology, presence of radiation, comorbidities, and the size of the pelvic and perineal defect.

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Morbidity associated with the immediate vertical rectus abdominus myocutaneous flap reconstruction after radical pelvic surgery

Cited by 14 publications

References 33 publications

Robotic beyond total mesorectal excision surgery for primary and recurrent pelvic malignancy: Feasibility and short‐term outcomes

Robotic beyond total mesorectal excision surgery for primary and recurrent pelvic malignancy: Feasibility and short‐term outcomes

Extended vertical rectus abdominis myocutaneous flap for reconstruction of large pelviperineal defects following oncologic resection

Pelvic Reconstruction following Abdominoperineal Resection and Pelvic Exenteration: Management Practices among Plastic and Colorectal Surgeons

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