Single centre experience of bilateral gracilis flap perineal reconstruction following extra‐levator abdominoperineal excision

Abstract

Aim A variety of tissue flaps have been described for the closure of perineal wounds following abdominoperineal excision of the rectum (APE) or exenteration for locally advanced/recurrent rectal cancer and salvage surgery for anal cancer. The aim of this study was to demonstrate the utility of the bilateral pedicled gracilis muscle flaps (BPGMFs) as a reconstruction option in these patients. This is of particular benefit when using a laparoscopic approach for the abdominal component of the operation, avoiding disruption of the abdominal wall and risk of herniation with other reconstruction options, e.g. vertical rectus abdominis myocutaneous flaps. Method This is a retrospective single centre case series of patients who underwent reconstruction of perineal defects using BPGMFs using a novel weave technique, from January 2008 to August 2017. Results There were 25 patients (16 female), with a median follow‐up of 19 months (3–102). The indications for BPGMFs were cancer resection (21) and perineal hernia (4). The median length of stay was 14 days (6–60). All‐cause mortality was 36% within the follow‐up period. A healed perineal wound was achieved in 72% of patients within 30 days (84% of patients received neoadjuvant chemoradiotherapy). The overall donor site complication rate was 20% (including infection, dehiscence, numbness, haematoma and seroma) and 28% for the perineal site (including infection, dehiscence and prolapse). Conclusions BPGMFs provide an important option for reconstruction of the perineum particularly with a minimally invasive approach or with two stomas.

Surgical Outcomes of VRAM vs. Gracilis Flaps in Vulvo-Perineal Reconstruction Following Oncologic Resection: A Proportional Meta-Analysis

“…The pooled rate of recipient site dehiscence with the gracilis (0.276 [95% CI 0.134, 0.443]) was higher than that of the VRAM (0.158 [95% CI 0.086, 0.246]) [ 11 , 12 , 21 , 26 , 27 , 28 , 29 , 30 , 31 , 33 , 34 , 38 ] ( Figure 5 A,B). Concerning donor site infection rate, the pooled analysis was similar for both flaps: VRAM (0.091 [95% CI 0.035, 0.168]) vs. gracilis (0.078 [95% CI 0.016, 0.170]) [ 12 , 21 , 26 , 27 , 28 , 29 , 30 , 31 , 34 , 36 , 38 ] ( Figure 6 A,B). Recipient site infection rate was similar between gracilis (0.135 [95% CI 0.065, 0.223]) and VRAM (0.104 [95% CI 0.049, 0.176]) [ 11 , 21 , 26 , 27 , 29 , 30 , 31 , 34 , 35 , 36 ] ( Figure 7 A,B).…”

“…Concerning donor site infection rate, the pooled analysis was similar for both flaps: VRAM (0.091 [95% CI 0.035, 0.168]) vs. gracilis (0.078 [95% CI 0.016, 0.170]) [ 12 , 21 , 26 , 27 , 28 , 29 , 30 , 31 , 34 , 36 , 38 ] ( Figure 6 A,B). Recipient site infection rate was similar between gracilis (0.135 [95% CI 0.065, 0.223]) and VRAM (0.104 [95% CI 0.049, 0.176]) [ 11 , 21 , 26 , 27 , 29 , 30 , 31 , 34 , 35 , 36 ] ( Figure 7 A,B). Partial flap necrosis was similar with gracilis (0.087 [95% CI 0.027, 0.170]) and VRAM (0.061 [95% CI 0.040, 0.085]) [ 11 , 12 , 21 , 26 , 27 , 28 , 29 , 34 , 36 , 38 ] ( Figure 8 A,B).…”

“…Recipient site infection rate was similar between gracilis (0.135 [95% CI 0.065, 0.223]) and VRAM (0.104 [95% CI 0.049, 0.176]) [ 11 , 21 , 26 , 27 , 29 , 30 , 31 , 34 , 35 , 36 ] ( Figure 7 A,B). Partial flap necrosis was similar with gracilis (0.087 [95% CI 0.027, 0.170]) and VRAM (0.061 [95% CI 0.040, 0.085]) [ 11 , 12 , 21 , 26 , 27 , 28 , 29 , 34 , 36 , 38 ] ( Figure 8 A,B). No statistical difference in terms of total flap necrosis was seen between gracilis reconstruction (0.064 [95% CI 0.003, 0.171]) and VRAM (0.025 [95% CI 0.012, 0.042]) [ 12 , 26 , 27 , 28 , 29 , 30 , 33 , 34 , 37 ] ( Figure 9 A,B).…”

“…Sixteen studies were identified, one of which, from Stein et al, separately reported surgical outcomes for VRAM and gracilis [ 26 ]. There were 5 prospective studies and 11 retrospective studies [ 11 , 12 , 21 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ] ( Figure 1 ).…”

“…The 16 studies were conducted in Europe ( n = 6), the United States ( n = 7), Australia ( n = 1), Africa ( n = 1), and Canada ( n = 1) and were published between 1994 to 2020 [ 11 , 12 , 21 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 ]. One study was multicentric and 15 were monocentric.…”