|
1
|
Zaussinger M, Pommer G, Freller K, Schmidt M, Huemer GM. Bilateral Superior Gluteal Artery Perforator (SGAP) Flap: Modified Concept in Perineal Reconstruction. J Clin Med 2024; 13:3825. [PMID: 38999391 PMCID: PMC11242694 DOI: 10.3390/jcm13133825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Revised: 06/24/2024] [Accepted: 06/28/2024] [Indexed: 07/14/2024] Open
Abstract
Background/Objectives: Perineal reconstruction after abdominoperineal excision often requires complex closures and is fraught with wound healing complications. Flap-based approaches introduce non-irradiated vascularized tissue to the area of resection to fill a large soft-tissue defect and dead space, reduce the risk of infection, and facilitate wound healing. Employing perforator flaps with their beneficial donor site properties, the authors have developed a concept of bilateral superior gluteal artery perforator (SGAP) flaps to restore extensive perineal defects. Methods: This retrospective case series was conducted between September 2015 and December 2019. We included three patients who received bilateral SGAP flap reconstruction after oncological resection. One deepithelialized SGAP flap was used for obliteration of dead space, combined with the contralateral SGAP flap for superficial defect reconstruction and wound closure. Results: Within this patient population, two male and one female patient, with a median age of 62 years (range, 52-76 years), were included. Six pedicled SGAP flaps were performed with average flap dimensions of 9 × 20 cm (range 7-9 × 19 × 21). No flap loss or no local recurrence were documented. In one case, partial tip necrosis with prolonged serous drainage was observed, which was managed by surgical debridement. No further complications were detected. Conclusions: The combination of two SGAP flaps provides maximal soft tissue for defect reconstruction and obliteration of dead space, while maintaining a very inconspicuous donor site, even with bilateral harvesting. Given these advantages, the authors recommend this promising approach for successful reconstruction of perineal defects.
Collapse
Affiliation(s)
- Maximilian Zaussinger
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital, Krankenhausstrasse 9, 4020 Linz, Austria; (M.Z.); (G.P.); (K.F.)
- Medical Faculty, Johannes Kepler University Linz, Altenbergerstr. 69, 4040 Linz, Austria;
- Doctoral Degree Program in Medical Science, Paracelsus Medical University, Strubergasse 21, 5020 Salzburg, Austria
| | - Gabriele Pommer
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital, Krankenhausstrasse 9, 4020 Linz, Austria; (M.Z.); (G.P.); (K.F.)
| | - Katrin Freller
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital, Krankenhausstrasse 9, 4020 Linz, Austria; (M.Z.); (G.P.); (K.F.)
| | - Manfred Schmidt
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital, Krankenhausstrasse 9, 4020 Linz, Austria; (M.Z.); (G.P.); (K.F.)
- Medical Faculty, Johannes Kepler University Linz, Altenbergerstr. 69, 4040 Linz, Austria;
| | - Georg M. Huemer
- Medical Faculty, Johannes Kepler University Linz, Altenbergerstr. 69, 4040 Linz, Austria;
| |
Collapse
|
|
2
|
Reducing Complications and Expanding Use of Robotic Rectus Abdominis Muscle Harvest for Pelvic Reconstruction. Plast Reconstr Surg 2022; 150:190-195. [PMID: 35583937 DOI: 10.1097/prs.0000000000009233] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
SUMMARY The rectus abdominis flap has long been a workhorse in perineal reconstruction. Although traditionally approached though an external incision, the morbid nature of the incision and subsequent violation of the anterior rectus sheath has encouraged innovation of minimally invasive approaches for harvest. In this study, we present our experience, evolution, and comparative outcomes of robotic rectus abdominis muscle harvest. A retrospective review of perineal reconstruction was performed for a 6-year period (2014 to 2019). Robotic rectus abdominis muscle flaps were compared to nonrobotic techniques performed during this time. Descriptive statistics and complication profiles were computed. The details of our surgical technique are also described. Thirty-six patients underwent perineal reconstruction. Sixteen were performed using the robotic rectus abdominis muscle and 20 with traditional repairs (12 vertical rectus abdominis myocutaneous flaps and eight gracilis flaps). Demographic profiles were similar between cohorts, including age, body mass index, smoking, diabetes, neoadjuvant radiation therapy, and need for vaginal wall repair. Six robotic patients underwent abdominal wall reinforcement with biological mesh. Length of stay, surgical times, and incidence of major complications were similar between cohorts with a trend toward increased minor complications in traditional reconstructions (55 percent versus 31 percent; p = 0.15). Robotic rectus abdominis muscle harvest is a powerful tool that continues to evolve the potential to mitigate common morbidities and complications of traditional repair and further enhance cosmetic outcomes. This study suggests that greater flexibility for reconstruction can be afforded with harvest of the posterior rectus sheath and complications avoided with prophylactic mesh reinforcement. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
Collapse
|
|
3
|
Chen K, Lan YZ, Li J, Xiang YY, Zeng DZ. Mine disaster survivor’s pelvic floor hernia treated with laparoscopic surgery and a perineal approach: A case report. World J Clin Cases 2020; 8:4228-4233. [PMID: 33024783 PMCID: PMC7520773 DOI: 10.12998/wjcc.v8.i18.4228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/28/2020] [Accepted: 08/19/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND A pelvic floor hernia is defined as a pelvic floor defect through which the intraabdominal viscera may protrude. It is an infrequent complication following abdominoperineal surgeries. This type of hernia requires surgical repair by conventional or reconstructive techniques. The main treatments could be transabdominal, transperineal or a combination.
CASE SUMMARY In this article, we present the case of a recurrent perineal incisional hernia, postresection of the left side of the pelvis, testis and lower limbs resulting from a mine disaster 18 years ago. Combined laparoscopic surgery with a perineal approach was performed. The pelvic floor defect was repaired by a biological mesh and one pedicle skin flap. No signs of recurrence were indicated during the 2 years of follow-up.
CONCLUSION The combination of laparoscopic surgery with a perineal approach was effective. The use of the biological mesh and pedicle skin flap to restructure the pelvic floor was effective.
Collapse
Affiliation(s)
- Kai Chen
- Department of General Surgery, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 401120, China
| | - Yuan-Zhi Lan
- Department of General Surgery, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 401120, China
| | - Jing Li
- Department of General Surgery, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 401120, China
| | - Yuan-Yuan Xiang
- Department of General Surgery, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 401120, China
| | - Dong-Zhu Zeng
- Department of General Surgery, The Third Affiliated Hospital of Chongqing Medical University, Chongqing 401120, China
| |
Collapse
|
|
4
|
Moucharafieh RC, Nehme AH, Badra MI, Rahal MJH. Rectus abdominis free tissue transfer in lower extremity reconstruction: Long term follow up in 58 cases. Injury 2019; 50 Suppl 5:S25-S28. [PMID: 31699350 DOI: 10.1016/j.injury.2019.10.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
UNLABELLED This study evaluates the long-term results of rectus abdominis free-tissue transfer performed for lower extremity reconstruction. METHODS Over a period of 8 years 58 were available for long term follow-up. Indications for reconstruction included acute wounds with soft tissue defects, diabetic foot ulcers, and chronic osteomyelitis. RESULTS At a mean follow-up of 18 years, there were no major complications in the soft tissue defect coverage group except for one patient who continued to have recurrent folliculitis over the weight bearing heel area, which was treated by repeated debridement. Among the diabetic patients, two patients had recurrent ulcerations of the forefoot which were detected early and treated conservatively. In the osteomyelitis group, however, there were no recurrences of the foot infection. CONCLUSIONS The rectus abdominis free-tissue transfer provided an excellent method of soft tissue reconstruction with a very minimal long-term complication rate, and a very high rate of success in the treatment of diabetic foot ulcers and chronic osteomyelitis.
Collapse
Affiliation(s)
- Ramzi C Moucharafieh
- Department of Orthopedic Surgery and Traumatology, Saint Georges University Medical Center, Balamand University, P.O. Box 166378, Achrafieh, Beirut 1100 2807, Lebanon; Department of Orthopedic Surgery and Traumatology, Clemenceau Medical Center affiliated with Johns Hopkins International, Clemenceau Beirut, Lebanon.
| | - Alexandre H Nehme
- Department of Orthopedic Surgery and Traumatology, Saint Georges University Medical Center, Balamand University, P.O. Box 166378, Achrafieh, Beirut 1100 2807, Lebanon
| | - Mohammad I Badra
- Department of Orthopedic Surgery and Traumatology, Clemenceau Medical Center affiliated with Johns Hopkins International, Clemenceau Beirut, Lebanon
| | - Mohammad Jawad H Rahal
- Department of Orthopedic Surgery and Traumatology, Clemenceau Medical Center affiliated with Johns Hopkins International, Clemenceau Beirut, Lebanon
| |
Collapse
|
|
5
|
Zelken JA, AlDeek NF, Hsu CC, Chang NJ, Lin CH, Lin CH. Algorithmic approach to lower abdominal, perineal, and groin reconstruction using anterolateral thigh flaps. Microsurgery 2014; 36:104-14. [DOI: 10.1002/micr.22354] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 10/25/2014] [Accepted: 11/07/2014] [Indexed: 01/13/2023]
Affiliation(s)
- Jonathan A. Zelken
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Nidal F. AlDeek
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Chung-Chen Hsu
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Nai-Jen Chang
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Chih-Hung Lin
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| | - Cheng-Hung Lin
- Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University; Taipei Taiwan
| |
Collapse
|
|
6
|
Horch RE, Hohenberger W, Eweida A, Kneser U, Weber K, Arkudas A, Merkel S, Göhl J, Beier JP. A hundred patients with vertical rectus abdominis myocutaneous (VRAM) flap for pelvic reconstruction after total pelvic exenteration. Int J Colorectal Dis 2014; 29:813-23. [PMID: 24752738 DOI: 10.1007/s00384-014-1868-0] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2014] [Indexed: 02/04/2023]
Abstract
PURPOSE We analysed the outcomes of a series of 100 consecutive patients with anorectal cancer with neoadjuvant radiochemotherapy and abdominoperineal exstirpation or total pelvic exenteration, who received a transpelvic vertical rectus abdominis myocutaneous (VRAM) flap for pelvic, vaginal and/or perineal reconstruction and compare a cohort to patients without VRAM flaps. METHODS Within a 10-year period (2003-2013) in our institution 924 patients with rectal cancer stage y0 to y IV were surgically treated. Data of those 100 consecutive patients who received a transpelvic VRAM flap were collected and compared to patients without flaps. RESULTS In 100 consecutive patients with transpelvic VRAM flaps, major donor site complications occurred in 6 %, VRAM-specific perineal wound complications were observed in 11 % of the patients and overall 30-day mortality was 2 %. CONCLUSIONS The VRAM flap is a reliable and safe method for pelvic reconstruction in patients with advanced disease requiring pelvic exenteration and irradiation, with a relatively low rate of donor and recipient site complications. In this first study, to compare a large number of patients with VRAM flap reconstruction to patients without pelvic VRAM flap reconstruction, a clear advantage of simultaneous pelvic reconstruction is demonstrated.
Collapse
Affiliation(s)
- R E Horch
- Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich Alexander University Erlangen-Nuernberg, Krankenhausstrasse 12, 91054, Erlangen, Germany,
| | | | | | | | | | | | | | | | | |
Collapse
|
|
7
|
Sexual dysfunction after colpectomy and vaginal reconstruction with a vertical rectus abdominis myocutaneous flap. Dis Colon Rectum 2013; 56:186-90. [PMID: 23303146 DOI: 10.1097/dcr.0b013e31826e4bd5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The use of the vertical rectus abdominis myocutaneous flap in reconstruction after abdominoperineal resection or pelvic exenteration for neoplasia is well documented. However, functional outcomes after vaginal reconstruction, including sexual function, are poorly described. OBJECTIVE This study aimed to examine sexual function in women following extensive pelvic surgery with colpectomy and vaginal reconstruction with the use of a vertical rectus abdominis myocutaneous flap. DESIGN This study is a retrospective review of medical records in combination with patient questionnaires. Nonresponders were followed up with a second contact. SETTINGS This study was performed at a tertiary care university medical center (Colorectal Section, Department of Surgery P, Aarhus University Hospital, Denmark) PATIENTS All women undergoing pelvic surgery and simultaneous vaginal reconstruction with the use of a vertical rectus abdominis myocutaneous flap between 2004 and 2010 at our department were identified from a patient database. Thirty women who were alive at the time of identification were included in the study. MAIN OUTCOME MEASURES Sexual function before and after surgery was evaluated by the use of the Sexual function Vaginal changes Questionnaire. The main outcome end point was whether the patient was sexually active after vaginal reconstruction. RESULTS Twenty-six participants (87%) answered the questionnaire. Fifty percent of patients reported an active sex life before surgery. In general, patients reported an unchanged desire for both physical and sexual contact after surgery. However, only 2 patients (14%) reported being sexually active after surgery. LIMITATIONS This was a retrospective study with a heterogeneous cohort involving several types of cancers and surgical procedures. Factors other than vertical rectus abdominis myocutaneous flap reconstruction itself may interfere with the sexual function. CONCLUSION Extensive pelvic surgery with colpectomy leads to sexual dysfunction even when the vagina is reconstructed with a vertical rectus abdominis myocutaneous flap. This knowledge may improve the quality of information given to this group of patients before surgery.
Collapse
|
|
8
|
Washiro M, Shimizu H, Katakura T, Kumagai S, Miyazaki M. Using the uterus to close a pelvic defect after primary perineal posterior hernia repair: report of a case. Surg Today 2010; 40:277-80. [PMID: 20180085 DOI: 10.1007/s00595-008-4036-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2007] [Accepted: 07/28/2008] [Indexed: 11/26/2022]
Abstract
Perineal hernias rarely develop spontaneously, and their treatment is controversial. We report a case of a primary perineal posterior hernia in an 81-year-old woman, who presented with progressive bulging in the perineal area, preventing comfortable excretion. The diagnosis was established by herniography. We operated via an abdominal approach and repaired the hernia by reconstructing the pelvic floor using the uterus. To our knowledge, reconstruction using the uterus to repair a pelvic defect has not been reported before.
Collapse
Affiliation(s)
- Mitsutsune Washiro
- Department of Surgery, Suzaka Hospital, 1332 Ooaza Suzaka, Suzaka, Nagano, 382-0091, Japan
| | | | | | | | | |
Collapse
|
|
9
|
Yamauchi T, Kiyokawa K, Inoue Y, Rikimaru H. V-Y fasciocutaneous flap of the medial thigh including the long saphenous vein for reconstruction of intrapelvic dead space. ACTA ACUST UNITED AC 2009; 43:142-7. [PMID: 19401944 DOI: 10.1080/02844310902771657] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Some patients develop an intrapelvic infection and fistula caused by the presence of intrapelvic dead space after the resection of rectal cancer, and the treatment is sometimes quite difficult. We have developed a new surgical technique for the treatment and prevention of such fistulas that uses a fasciocutaneous flap from the medial thigh. A V-shaped fasciocutaneous flap with a pedicle on the anterior side of the thigh is designed on the medial thigh and gluteal region. After raising the fasciocutaneous flap that contains the long saphenous vein, the gluteal section including a thick layer of fatty tissue is de-epithelialised, and the flap is rotated and advanced towards the dead space to fill it. Four patients were operated on using our technique. One was a secondary reconstruction: the patient had developed a small fistula after reconstructive surgery, but it healed with conservative treatment. As a result, all four patients achieved satisfactory outcomes. The advantages of our technique include: no change in the position of the body is required for reconstruction; operations are simple; sufficient volume of tissue is obtained from the thick fatty tissues of the gluteal region; and the fasciocutaneous flap contains the long saphenous vein and has good venous circulation. We consider this technique useful for the reconstruction of intrapelvic dead space.
Collapse
Affiliation(s)
- Toshihiko Yamauchi
- Department of Plastic and Reconstructive Surgery and Maxillofacial Surgery, Kurume University School of Medicine, Kurume-shi, Fukuoka, Japan
| | | | | | | |
Collapse
|
|
10
|
Abdominoperineal resection for anal cancer. Dis Colon Rectum 2008; 51:1495-501. [PMID: 18521675 DOI: 10.1007/s10350-008-9361-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2007] [Revised: 02/06/2008] [Accepted: 03/18/2008] [Indexed: 02/08/2023]
Abstract
PURPOSE Following initial radiotherapy or chemoradiotherapy for the treatment of anal cancer, patients who present with either persistent or locally recurrent disease are treated by abdominoperineal resection. The aim of this retrospective study was to review the long-term survival and prognostic factors after such surgery in a single institution. METHODS Over a 34-year period (1969-2003), 422 patients with nonmetastatic anal cancer were treated with a curative intent. Of these, 83 (median age 61 years; 74 women) underwent abdominoperineal resection. RESULTS Forty-one patients underwent abdominoperineal resection for persistent disease and 42 for locally recurrent disease. Postoperative mortality was 4.8 percent and morbidity was 35 percent with 18 percent having perineal wound infections. Median follow-up was 104 months (range, 3-299). The 3-year and 5-year actuarial survival was 62.8 and 56.5 percent respectively. Using univariate analysis, patients below 55 years, females, T1-2 tumors, N0-N1 lymphadenopathy and the absence of locally advanced tumor were associated with significantly improved survival. Surgery, whether for persistent or locally recurrent disease, did not affect the 5-year survival rate. CONCLUSIONS Abdominoperineal resection for nonmetastatic anal cancer is associated with a high morbidity rate but may result in long-term survival regardless of the indication.
Collapse
|
|
11
|
Schaden D, Schauer G, Haas F, Berger A. Myocutaneous flaps and proctocolectomy in severe perianal Crohn's disease--a single stage procedure. Int J Colorectal Dis 2007; 22:1453-7. [PMID: 17583818 DOI: 10.1007/s00384-007-0337-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND Complex perianal wounds can be extremely difficult to treat and primary closure of these defects can be a challenge even for experienced surgeons. So far, myocutaneous flaps for wound closure after removal of malignant tumors are a well-accepted option, but there are only a few reports focusing on the primary closure of the perineal wound after proctocolectomy for Crohn's disease. We describe our experience with wide excision of the diseased perineum using a combined abdominoperineal two-team approach. MATERIALS AND METHODS We performed proctocolectomy with permanent ileostomy in five patients with longstanding extensive Crohn's disease. All five patients had fistulizing perineal Crohn's disease combined with Crohn's colitis. Each patient received at least one flap for primary wound closure, either a rectus abdominis myocutaneous flap or a gracilis flap. RESULTS Indication for surgical intervention included anal or bowel stenosis, septic condition, fecal incontinence, or a combination of these features. One patient had a simultaneous adenocarcinoma of the sigmoid colon. Five patients underwent a total of seven flaps. Three months after surgery, complete healing was achieved in all patients; one patient suffered recurrence in the region of his right thigh. Mean follow up was 19.6 months (range-12-43 months). CONCLUSIONS Myocutaneous flaps are a promising therapeutic option in patients with chronic perianal disease. With the transposition of well-vascularized tissue into the perineal defect, complete healing and control of sepsis can be achieved in the majority of patients.
Collapse
Affiliation(s)
- Dagmar Schaden
- Department of Surgery, Hospital of Barmherzige Brüder, Marschallgasse 12, 8020, Graz, Austria.
| | | | | | | |
Collapse
|
|
12
|
Miranda EP, Anderson AL, Dosanjh AS, Lee CK. Successful management of recurrent coccygeal hernia with the de-epithelialised rectus abdominis musculocutaneous flap. J Plast Reconstr Aesthet Surg 2007; 62:98-101. [PMID: 17889632 DOI: 10.1016/j.bjps.2007.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2006] [Revised: 10/30/2006] [Accepted: 08/07/2007] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Little data exist about the optimal management of the rare coccygeal hernia. A novel method of repair is reported. METHODS A 46-year-old woman presented with a symptomatic coccygeal hernia after resection of the coccyx for a tumour. She had previously been reconstructed with an on-lay polytetrafluorethylene (PTFE) mesh but subsequently developed a hernia. A de-epithelialised vertical rectus abdominis musculocutaneous flap was elevated and passed through the hernia defect. The de-epithelialised dermis was secured to the levator ani and to the periosteum of the sacrum via access through a posterior approach. The gluteal skin was closed primarily over the inset flap. RESULTS The de-epithelialised rectus abdominis musculocutaneous flap is a viable option for the treatment of coccygeal hernia. RELEVANCE The de-epithelialised rectus abdominis flap has several advantages over other techniques including mesh repair and anterior or posterior flap repairs of the coccygeal hernia. The transposed muscle blocks herniation through the pelvic floor and does not create the dead space that is associated with posterior flap repairs such as the bilateral gluteal advancements. It also has the advantages of the posterior approach mesh repair, as the de-epithelialised dermis provides significant strength when secured like mesh to healthy local tissue.
Collapse
Affiliation(s)
- E P Miranda
- Department of Surgery, University of California San Francisco, CA 94143, USA.
| | | | | | | |
Collapse
|
|
13
|
Preiss A, Herbig B, Dörner A. Primary perineal hernia: a case report and review of the literature. Hernia 2006; 10:430-3. [PMID: 16858521 DOI: 10.1007/s10029-006-0114-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2005] [Accepted: 06/26/2006] [Indexed: 12/25/2022]
Abstract
UNLABELLED Pelvic floor hernias are extremely rare. This study presents a successfully treated case of primary perineal hernia and takes a look at the existing literature. CASE The case of a 75-year-old female patient with a great perineal hernia is presented. Diagnosis was secured by magnetic resonance tomography. The pelvic defect was successfully treated by primary suture with Prolene. DISCUSSION The literature shows many different approaches for treatment of perineal hernia, such as open or laparoscopic mesh repair, and perineal, abdominal or combined access. Our case confirms that primary closure of the hernial orifice through an abdominal approach is also feasible.
Collapse
Affiliation(s)
- A Preiss
- Department of Surgery, Diakonie Hospital Alten Eichen, Jütländer Alle 48, 22527, Hamburg, Germany.
| | | | | |
Collapse
|
|
14
|
Bell SW, Dehni N, Chaouat M, Lifante JC, Parc R, Tiret E. Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection. Br J Surg 2005; 92:482-6. [PMID: 15736219 DOI: 10.1002/bjs.4857] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Significant morbidity can result from perineal wounds, particularly after radiotherapy and extensive resection for cancer. Myocutaneous flaps have been used to improve healing. The purpose of this study was to evaluate the morbidity and results of primary rectus abdominis myocutaneous flap reconstruction of the vagina and perineum after extended abdominoperineal resection. METHODS Thirty-one consecutive patients undergoing one-stage rectus abdominis myocutaneous flap reconstruction of extensive perineal wounds were studied prospectively. Twenty-six patients had surgery for recurrent or persistent epidermoid anal cancer or low rectal cancer, and 21 had high-dose preoperative radiotherapy. RESULTS Three weeks after the operation, complete healing of the perineal wound was seen in 27 of the 31 patients. There were nine flap-related complications including three patients with partial flap necrosis, two with vaginal stenosis, one with vaginal scarring, one with small flap disunion and two with weakness of the anterior abdominal wall. There were no unhealed wounds at the completion of follow-up (median 9 months). CONCLUSION The transpelvic rectus abdominis myocutaneous flap for the reconstruction of large perineal and vaginal wounds achieves wound healing with only moderate morbidity in the majority of patients after extensive abdominoperineal resection with or without radiotherapy.
Collapse
Affiliation(s)
- S W Bell
- Centre de Chirurgie Digestive, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, 75571 Paris, France
| | | | | | | | | | | |
Collapse
|
|
15
|
Chessin DB, Hartley J, Cohen AM, Mazumdar M, Cordeiro P, Disa J, Mehrara B, Minsky BD, Paty P, Weiser M, Wong WD, Guillem JG. Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study. Ann Surg Oncol 2005; 12:104-10. [PMID: 15827789 DOI: 10.1245/aso.2005.03.100] [Citation(s) in RCA: 210] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2004] [Accepted: 09/29/2004] [Indexed: 12/12/2022]
Abstract
BACKGROUND A major source of morbidity after abdominoperineal resection (APR) after external beam pelvic radiation is perineal wound complications, seen in up to 66% of cases. Our purpose was to determine the effect of rectus abdominus myocutaneous (RAM) flap reconstruction on perineal wound morbidity in this population. METHODS The study group consisted of 19 patients with anorectal cancer treated with external beam pelvic radiation followed by APR and RAM flap reconstruction of the perineum. A prospectively collected database was queried to identify a control group (n = 59) with anorectal cancer treated with similar radiation doses that subsequently underwent an APR without a RAM flap during the same time period. Comparison of percentages was performed with a two-sided Fisher's exact test, and comparison of means was performed with Wilcoxon's test. RESULTS Perineal wound complications occurred in 3 (15.8%) of the RAM flap patients and 26 (44.1%) of the control patients (P = .03). The incidence of other complications was not different between groups (42.1% vs. 42.4%; P = .8). Despite an increased number of anal squamous tumors, an increased vaginectomy rate, increased use of intraoperative radiotherapy, and an increased proportion of cases with recurrent disease, the flap group had a significantly lower rate of perineal wound complications relative to the control group. CONCLUSIONS Perineal closure with a RAM flap significantly decreases the incidence of perineal wound complications in patients undergoing external beam pelvic radiation and APR for anorectal neoplasia. Because other complications are not increased, RAM flap closure of the perineal wound should be strongly considered in this patient population.
Collapse
Affiliation(s)
- David B Chessin
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
16
|
|
|
17
|
Abstract
AIM: To evaluate the results of salvage resection in the management of persistent or locally recurrent anal canal cancer.
METHODS: Details of all patients with anal canal cancer treated from 1978 to 1994 at Cancer Hospital of Chinese Academy of Medical Sciences (CAMS) were reviewed retrospectively. Sixteen patients who presented with persistent or locally recurrent anal canal cancer received salvage surgery. Before surgery all of the patients had received radiotherapy alone as their primary treatments.
RESULTS: Of the 16 patients, 14 received salvage abdominoperineal resection (APR) and two had transanal local excision. There were no deaths attributable to operation. Delayed healing of the perineal wound occurred in eight patients. Complications unrelated to the perineal wound were found in five patients. The median follow-up time was 120 (range 5 - 245) months after salvage surgery. Nine patients died of disease progression, with a median survival time of 16 (range 5 - 27) months. Six patients had a long-term survival.
CONCLUSION: Salvage resection after radiotherapy can yield a long-time survival in selected patients with anal canal cancer. However it offers little hope to patients with T4 and/or N2-3 tumors.
Collapse
Affiliation(s)
- Yue-Kui Bai
- Department of General Surgical Oncology, Cancer Hospital of Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing 100021, China.
| | | | | | | | | |
Collapse
|
|
18
|
Nilsson PJ, Svensson C, Goldman S, Glimelius B. Salvage abdominoperineal resection in anal epidermoid cancer. Br J Surg 2002; 89:1425-9. [PMID: 12390386 DOI: 10.1046/j.1365-2168.2002.02231.x] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND In the management of isolated locoregional failure after (chemo)radiation therapy for anal epidermoid cancer, salvage abdominoperineal resection (APR) is the treatment of choice. The results of a 15-year consecutive population-based series are reviewed. METHODS Details of all patients with anal epidermoid cancer treated from 1985 to 2000 in the Stockholm Health Care Region were recorded prospectively. Among 308 patients with biopsy-proven anal epidermoid cancer, there have been 39 isolated locoregional failures after sphincter-preserving therapy. Thirty-five patients have undergone salvage APR. The medical records of these 35 patients were reviewed retrospectively with regard to surgical and oncological results. RESULTS There were no postoperative deaths. There was considerable morbidity related to the perineal wound, with postoperative perineal infections in 13 patients and delayed healing beyond 3 months in 23 patients. Complications unrelated to the perineal wound were found in 13 patients. The crude 5-year survival rate for the 35 patients was 52 per cent (median follow-up 33 months). Patients with persistent disease fared significantly worse than those with locoregional recurrence (crude 5-year survival rate 33 versus 82 per cent; P < 0.05, log rank test). CONCLUSION Salvage APR in anal epidermoid cancer is associated with a high complication rate but may result in long-term survival.
Collapse
Affiliation(s)
- P J Nilsson
- Centre of Gastrointestinal Disease, Ersta Hospital, Stockholm, Sweden.
| | | | | | | |
Collapse
|
|
19
|
Smith AJ, Whelan P, Cummings BJ, Stern HS. Management of persistent or locally recurrent epidermoid cancer of the anal canal with abdominoperineal resection. Acta Oncol 2001; 40:34-6. [PMID: 11321657 DOI: 10.1080/028418601750071028] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
We retrospectively evaluated the outcome of 22 patients with epidermoid cancer of the anal canal who underwent surgical salvage after failure of primary chemoradiotherapy. Patients who required surgery had significantly more advanced T-stage than those who did not fail chemoradiotherapy. Eighteen patients failed surgical salvage. Invasion through the muscle wall of the bowel was present in 16 of 18 patients compared with two of four patients who have no evidence of disease (follow-up 5-10 years). Failure occurred only in the pelvis in 13 of the patients who died of disease. The mean time to death after surgery was 19 months. We confirm the overall poor results of conventional abdominoperineal resection in those patients who have failed previous therapy. Most failures occur in the pelvis. Transanorectal ultrasound and magnetic resonance imaging (MRI) may allow better selection of patients for exenterative procedures and identify those not amenable to successful salvage.
Collapse
Affiliation(s)
- A J Smith
- Division of Surgical Oncology, Toronto-Sunnybrook Regional Cancer Centre, Ontario, Canada.
| | | | | | | |
Collapse
|
|
20
|
de Bree E, Zoetmulder FA, Christodoulakis M, Aleman BM, Tsiftsis DD. Treatment of malignancy arising in pilonidal disease. Ann Surg Oncol 2001; 8:60-4. [PMID: 11206226 DOI: 10.1007/s10434-001-0011-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Malignant degeneration is a rare complication of pilonidal disease and is associated with a high recurrence rate and poor prognosis compared with regular nonmelanoma skin cancer. Treatment in our departments and in the international literature was evaluated. METHODS We analyzed the data from three patients with malignant degeneration who were treated in our departments and an additional 56 patients who were found after an extensive literature search. RESULTS A total of 47 males and 12 females, with a mean age of 52 years, were most frequently primarily treated with surgery. After a mean follow-up time of 28 months, 20% of all patients died with evidence of disease and an additional 10% died of unrelated causes. The overall recurrence rate was 39%, with a median time to recurrence of only 9 months. The local recurrence rate was lower when radiotherapy was added to surgical treatment alone (30% vs. 44%). Re-excision of local recurrence resulted in some long-term survivals. CONCLUSIONS Early diagnosis and treatment may lead to improvement of the relative poor prognosis. Surgical treatment should be tailored according to the locoregional extent. The high recurrence rate after surgical treatment can be reduced by the addition of radiotherapy. Although repeat surgery for recurrent disease may involve extensive resection and morbidity, this may result in prolonged survival.
Collapse
Affiliation(s)
- E de Bree
- Department of Surgical Oncology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Huis, Amsterdam
| | | | | | | | | |
Collapse
|
|
21
|
Abstract
BACKGROUND Vaginal, perineal, and pelvic floor reconstruction is being performed with increasing frequency in conjunction with radical pelvic surgery. Although the vertical rectus abdominis myocutaneous flap is ideally suited to such procedures, little information exists regarding risks or complications associated with it. METHODS A chart review of all patients who underwent this procedure at two institutions was performed, and the results were compared with existing series. Surviving patients were asked to describe their satisfaction with the procedure and their sexual function. RESULTS Between 1990 and 1997, 22 patients underwent placement of a rectus abdominis myocutaneous flap for vaginal/pelvic floor reconstruction, 21 (95.5%) at the time of pelvic exenteration. Attachment of the graft was complete in 20 patients (90.9%) and partial in 1 (4.5%), and 1 patient experienced complete loss that resulted in total vaginal stenosis. Four patients (18.2%) developed mild vaginal stenosis that was corrected with dilators. Donor site complications included wound separation (above the fascia) in three patients and one delayed abdominal closure. There were no cases of bowel obstruction, dehiscence, hernia, or death. The only statistically significant identifiable risk factors for graft necrosis included prior abdominal surgery and operative time. Thirteen of 22 (59.1%) of the patients are cancer free (median progression free interval, 42.2 months), 11 (84.6%) of whom reported having had vaginal intercourse since surgery. CONCLUSIONS The rectus abdominis myocutaneous flap can be safely used with excellent results and acceptable morbidity, and in this series it restored sexual function in the majority of cancer survivors. Because previous abdominal surgery (transverse incisions or colostomy) may compromise blood supply to the flap, alternative sites should be considered in such cases.
Collapse
Affiliation(s)
- H O Smith
- Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center, Albuquerque 87131-5286, USA
| | | | | | | |
Collapse
|
|
22
|
Kierney PC, Cardenas DD, Engrav LH, Grant JH, Rand RP. Limb-salvage in reconstruction of recalcitrant pressure sores using the inferiorly based rectus abdominis myocutaneous flap. Plast Reconstr Surg 1998; 102:111-6. [PMID: 9655415 DOI: 10.1097/00006534-199807000-00017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Pressure sore closure is frequently a reconstructive challenge. This challenge is particularly evident in cases of multiply recurrent sores. In such settings, there are often opportunities to manage the recurrent wounds either by repeated advancement of previous flaps or by design of alternative ones. However, these interventions are not always feasible, and limb amputation with total thigh flap closure must be considered. A review of operative experience with seven such complex pressure sores in seven patients is presented. Each patient had previously suffered a permanent thoracic-level spinal cord injury. Prior attempts at wound closure were unsuccessful. Despite consideration of all described locoregional flaps, no limb-sparing procedure could be designed satisfactorily. As an alternative to either hip disarticulation and total thigh flap coverage or distant free-tissue transfer, we reconstructed the debrided ulcer beds with inferiorly based rectus abdominis myocutaneous flaps. Six of the seven wounds healed primarily, whereas one required repeated debridement and the addition of a gracilis muscle flap to achieve complete closure. Postoperative follow-up has ranged from 6 to 45 months. Each patient has returned to his baseline preoperative activity level with no clinical compromise of abdominal wall function. All wounds have healed. Successful application of the inferiorly based vertical rectus abdominis myocutaneous flap for cases of both recalcitrant ischial and trochanteric pressure sores is demonstrated and its consideration is advocated if no reconstructive options short of extremity amputation and total thigh flap coverage exist for such challenging sores.
Collapse
Affiliation(s)
- P C Kierney
- University of Washington Medical Center, Department of Surgery, Seattle, USA
| | | | | | | | | |
Collapse
|
|
23
|
Kind GM, Rademaker AW, Mustoe TA. Abdominal-wall recovery following TRAM flap: a functional outcome study. Plast Reconstr Surg 1997; 99:417-28. [PMID: 9030149 DOI: 10.1097/00006534-199702000-00016] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Abdominal-wall function was evaluated preoperatively and at intervals postoperatively in 25 consecutive patients undergoing breast reconstruction with transverse rectus abdominis myocutaneous (TRAM) flaps (single-pedicled TRAM flap, 14 patients; free TRAM flap, 9 patients; and bilateral free TRAM flaps, 2 patients). Objective measures of abdominal-wall function were performed with the B200 Isostation, a triaxial dynamometer. In addition, the patients were assessed by a physical therapist and filled out an activity questionnaire at each postoperative examination. Tests of abdominal-wall function demonstrated the greatest decrease in performance at the 6-week postoperative tests of flexion. The maximum isometric flexion torque of the pedicled TRAM flap group decreased to 58 +/- 10 percent, while the unilateral free TRAM flap group average was 87 +/- 11 percent of baseline. For the pedicled TRAM flap group this difference was significant (p = 0.004). By the 6-month evaluation, the maximum isometric flexion torque increased for both the pedicled and the free TRAM flap groups to 89 +/- 13 percent and 93 +/- 8 percent of baseline, respectively. The physical therapist evaluation of abdominal-wall strength and the activity questionnaire data showed no statistically significant differences between groups or over time. Rectus abdominis muscle harvest for pedicled TRAM flaps causes a greater insult to the abdominal wall than does free TRAM flap harvest. The ultimate clinical effect of the sacrifice of even an entire rectus abdominis muscle appears to be well tolerated by most patients. This is the first prospective outcome study of abdominal-wall function in TRAM flap patients. The clinical implications of this information will be discussed.
Collapse
Affiliation(s)
- G M Kind
- Microsurgical Replantation Transplantation Department, Davies Medical Center, San Francisco, Calif., USA
| | | | | |
Collapse
|
|
24
|
Wall LL, Copas P, Galloway NT. Use of a pedicled rectus abdominis muscle flap sling in the treatment of complicated stress urinary incontinence. Am J Obstet Gynecol 1996; 175:1460-4; discussion 1464-6. [PMID: 8987925 DOI: 10.1016/s0002-9378(96)70090-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE A pedicled rectus muscle flap sling in the treatment of complicated stress urinary incontinence was evaluated. STUDY DESIGN Thirty-two women underwent a combined vaginal and abdominal sling operation for stress incontinence with a pedicled muscle flap developed from the rectus abdominis muscle. All operations were performed jointly by the same two surgeons. The procedure involved transecting one rectus abdominis muscle just above its first tendinous intersection and isolating the muscle as a flap on its inferior vascular pedicle. The muscle flap was then swung beneath the urethra and bladder neck, pulled into the retropubic space on the contralateral side, and sewn to the obturator internus fascia or to Cooper's ligament. All patients undergoing the procedure had demonstrable stress incontinence on physical examination and underwent preoperative fluoroscopic video urodynamics. The diagnosis of complicated stress incontinence was based on the presence of one or more of the following factors: previous failed antiincontinence surgery (33 operations in 22 patients, average 1.5 operations), open vesical neck on fluoroscopy (14 patients), urethral closure pressure < or = 30 cm H2O by the Brown-Wickham technique (16 patients), or massive vaginal prolapse and demonstrable stress incontinence with the prolapse reduced and the urethra supported in a normal position (16 patients). Follow-up ranged from 2 to 13 months (average 6 months). Surgical outcome was assessed by physical examination and a detailed telephone interview conducted by a physician who was not involved in the operations. RESULTS Twenty-eight patients (87.5%) were satisfied with the results of the operation. There were four surgical failures (12.5%). Stress incontinence persisted in three patients after surgery, and one patient who had mixed incontinence before surgery was cured of stress incontinence but continued to have significant urinary leakage as a result of detrusor overactivity. There appears to be less voiding dysfunction with this technique than with other sling procedures for stress incontinence. CONCLUSIONS The sling procedure with a rectus abdominis muscle flap appears to be a viable surgical technique in the treatment of complicated stress incontinence. Further study is needed to assess the long-term results of this operation and to evaluate its proper place in reconstructive pelvic surgery.
Collapse
Affiliation(s)
- L L Wall
- Emory Continence Center, Atlanta, Georgia, USA
| | | | | |
Collapse
|
|
25
|
Schliephake H, Schmelzeisen R, Neukam FW. The free revascularized rectus abdominis myocutaneous flap for the repair of tumour related defects in the head and neck area. Br J Oral Maxillofac Surg 1996; 34:18-22. [PMID: 8645676 DOI: 10.1016/s0266-4356(96)90129-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The present work reviews a series of 11 consecutive patients who have received free revascularized rectus abdominis myocutaneous flaps for primary reconstruction of soft tissues after ablative tumour surgery in the head and neck area. In 10 patients, a total or subtotal glossectomy had been performed and the flap was used to replace the resected tongue volume. In 5 of these cases, extensive perforating defects had resulted after additional resection of large portions of the chin and the cheek. Mandibular continuity was restored by a metal plate and the flap was divided into an intraoral and extraoral portion in these patients. In one patient, the flap had been used for closure of a full thickness defect of the calvarium. 9 of the 11 flaps healed uneventfully. In one case, a partial flap loss was encountered after thrombosis of the venous pedicle due to compression as a result of an unfavourable defect anatomy and flap positioning. Primary closure of the abdominal wall was achieved in all cases. A subcutaneous hematoma occurred at the donor site in one patient. According to our present experience, the rectus abdominis free flap may serve as an alternative to the frequently employed latissimus dorsi flap in maxillofacial reconstructions while it offers the possibility for flap elevation simultaneously to the surgical procedures in the head and neck area.
Collapse
Affiliation(s)
- H Schliephake
- Department of Oral and Maxillofacial Surgery, University Medical School, Medizinishe Hochshule Hannover, Germany
| | | | | |
Collapse
|
|
26
|
Loessin SJ, Meland NB, Devine RM, Wolff BG, Nelson H, Zincke H. Management of sacral and perineal defects following abdominoperineal resection and radiation with transpelvic muscle flaps. Dis Colon Rectum 1995; 38:940-5. [PMID: 7656741 DOI: 10.1007/bf02049729] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
PURPOSES In this study we present our experience with treating persistent sacral and perineal defects secondary to radiation and abdominoperineal resection with or without sacrectomy. METHODS Fifteen consecutive patients were treated with an inferiorly based transpelvic rectus abdominis muscle or musculocutaneous flap. RESULTS Fourteen of the 15 patients achieved healing, and 7 patients had no complications. The remaining eight patients required one or more operative debridements and/or prolonged wound care to accomplish a healed wound. Our technique for the dissection and insetting of the transpelvic muscle flap is presented. CONCLUSION The difficult postirradiated perineal and sacral wounds can be healed with persistent surgical attention to adequate debridement, control of infections, and a well-vascularized muscle flap. The most satisfying aspects for patients are the discontinuance of foul-smelling discharge, discontinuation of multiple, daily dressing changes, and reduction in the degree of chronic pain.
Collapse
Affiliation(s)
- S J Loessin
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | | | | |
Collapse
|
|
27
|
Defektdeckung im Bereich der Leiste, der Hüfte sowie perineal unter besonderer Berücksichtigung des unteren M. rectus abdominis-, des M. tensor fasciae latae (TFL)- und des M. gracilis-Lappens. Eur Surg 1994. [DOI: 10.1007/bf02629716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
|
28
|
Wiederherstellung von Bauchwanddefekten. Eur Surg 1994. [DOI: 10.1007/bf02629714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
|
29
|
Iida F, Adachi W. Closure of a perineal sinus connected with the small bowel developing after radical surgery for rectal carcinoma: a report of the operative procedures used in two cases. Surg Today 1993; 23:455-7. [PMID: 8324340 DOI: 10.1007/bf00309506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
A technique for closure of a perineal sinus connected with the small bowel is described herein. One patient who underwent Miles' operation and another who underwent total pelvic exenteration for rectal carcinoma developed a perineal sinus through which a large amount of intestinal fluid was discharged. The pelvic orifice of the sinus was successfully closed in both patients using a right rectus abdominis muscle flap. In one patient, the muscle flap was reflected with the peritoneal surface inside and fixed to the pelvic floor covering the pelvic orifice of the sinus. In the other patient, the flap was isolated without the attached peritoneum and the peritoneal side of the flap covered with omentum.
Collapse
Affiliation(s)
- F Iida
- Second Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | | |
Collapse
|
|
30
|
Piza H, Rath T, Hausmaniger C, Walzer RL. Wound closure at the trunk by microvascular free flap transfer. Microsurgery 1993; 14:260-5. [PMID: 8412636 DOI: 10.1002/micr.1920140409] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Defects of the thoracic or abdominal wall can be congenital or caused by trauma or tumour resection. There may be other problems, such as infection and irradiation effects. In most cases those defects can be closed by local cutaneous and fasciocutaneous or by muscle and myocutaneous flaps. In some rare instances, the use of pedicled flaps may be limited. The size of the defect, the impossibility of closing the donor site, an impaired blood supply, or poor quality of local tissues represent such limitations. In these cases microvascular flap transfer has enlarged our choice of alternative methods. Advantages of this method are the one-stage procedure and the wound coverage by well-vascularized tissue. This is especially beneficial in areas of infected or irradiated tissue. On the other hand microvascular flap transfer requires high technical skill and extensive perioperative and postoperative care.
Collapse
Affiliation(s)
- H Piza
- Department of Plastic and Reconstructive Surgery, Krankenhaus Lainz, Vienna, Austria
| | | | | | | |
Collapse
|
|
31
|
Cali RL, Pitsch RM, Blatchford GJ, Thorson A, Christensen MA. Rare pelvic floor hernias. Report of a case and review of the literature. Dis Colon Rectum 1992; 35:604-12. [PMID: 1587182 DOI: 10.1007/bf02050544] [Citation(s) in RCA: 76] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The case of a 64-year-old female who presented with difficult evacuation of stool is reported. A posterior perineal hernia was diagnosed by dynamic proctography. The patient had an unusual herniation of the upper rectum through the perineal defect. At surgery, there was no peritoneal sac, since the herniation occurred extraperitoneally. The patient was treated with repair of the pelvic floor using Marlex mesh and rectopexy. Pelvic floor hernias are rare and often difficult to diagnose. The three types, in order of decreasing frequency, are obturator, perineal, and sciatic. The etiology, diagnosis, and treatment of each is discussed.
Collapse
Affiliation(s)
- R L Cali
- Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska 68131-2197
| | | | | | | | | |
Collapse
|
|
32
|
Piza-Katzer H, Balogh B. Experience with 60 inferior rectus abdominis flaps. BRITISH JOURNAL OF PLASTIC SURGERY 1991; 44:438-43. [PMID: 1834293 DOI: 10.1016/0007-1226(91)90203-v] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We report on our experience with the inferior rectus abdominis flap. Since 1984, 60 patients have been operated on with this technique. The inferior rectus abdominis flap was used as a free flap, island flap or pedicle flap (inferiorly based). Pure muscle flaps served to fill bone defects in patients with chronic osteomyelitis or as a biologic cover of infected vascular prostheses following multiple vascular surgery in the groin. The myocutaneous and fasciocutaneous rectus flaps served to cover soft tissue defects of the upper and lower extremities after accidents, degloving and radical tumour surgery. We present data from our collective patients to document the benefits of the inferior rectus abdominis flap and recommend this technique as a safe surgical modality to manage large-surface soft tissue defects.
Collapse
Affiliation(s)
- H Piza-Katzer
- Department of Plastic and Reconstructive Surgery, University of Vienna Medical School, Austria
| | | |
Collapse
|
|
33
|
Frydman GM, Polglase AL. Perineal approach for polypropylene mesh repair of perineal hernia. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1989; 59:895-7. [PMID: 2818352 DOI: 10.1111/j.1445-2197.1989.tb07036.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
This is the first case report of a perineal hernia repair following abdominoperineal excision of rectum employing a purely perineal approach for interposition of a mesh graft.
Collapse
Affiliation(s)
- G M Frydman
- Department of Surgery, Monash University, Alfred Hospital, Prahran, Victoria, Australia
| | | |
Collapse
|
|
34
|
Fasching MC, Meland NB, Woods JE, Wolff BG. Recurrent squamous-cell carcinoma arising in pilonidal sinus tract--multiple flap reconstructions. Report of a case. Dis Colon Rectum 1989; 32:153-8. [PMID: 2914529 DOI: 10.1007/bf02553830] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Squamous-cell carcinoma arising from a pilonidal sinus tract is an unusual complication of a common condition. Approximately 36 cases of carcinoma related to pilonidal disease have been reported in the literature. Wide excision with tumor-free margins has yielded five-year disease-free states in 55 percent of patients. Recurrence rates have been 44 percent to 50 percent in several large series. Regional (inguinal) nodal metastasis occurs in 14 percent of patients, heralding a dismal prognosis. Radiation and chemotherapy are of minimal palliative value. Reconstruction of these patients has consisted of split-thickness skin grafts or local cutaneous and myocutaneous flaps. Some authors have allowed healing by secondary intention. A case of squamous-cell carcinoma arising in a chronic pilonidal sinus tract is reported. Local recurrence required an extensive resection resulting in a large sacral/perineal defect. A single-stage reconstruction of this defect with multiple muscle and musculocutaneous flaps is described.
Collapse
Affiliation(s)
- M C Fasching
- Section of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota 55905
| | | | | | | |
Collapse
|
|
35
|
Robertson CN, Riefkohl R, Webster GD. Use of the rectus abdominis muscle flap in urological reconstructive procedures. J Urol 1986; 135:963-5. [PMID: 2937934 DOI: 10.1016/s0022-5347(17)45938-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The rectus abdominis muscle flap has been used successfully in 4 reconstructive procedures complicated by tissue loss or urinary fistula. This simple procedure is advocated as an alternative to the use of omentum when prior abdominal surgery precludes omental mobilization. No adverse functional nor cosmetic result to the abdominal wall resulted.
Collapse
|