Distally Based Rectus Abdominis Flap for Reconstruction in Radical Gynecologic Procedures STEVEN *Division
H. PURSELL, M.D. ,* THOMAS G. DAY, JR., M.D.,*
R. TOBIN, M.D.?
Oncology, Department of Obstetrics and Gynecology, and TDivision of Plastic Surgery, Department University of Louisville School of Medicine, Louisville, Kentucky 40292
Received June 13, 1989
vagina or can be used as a “patch”
to provide coverage
The distally based rectus abdominis myocutaneous flap is an important adjunct to radical pelvic surgery. It can be used to for the perineal defect created by the exenterative profashion a functional neovagina or to create a patch to cover cedure. It is the purpose of this study to examine our perineal defects created by exenterative surgery. This report re- experience with this relatively new procedure. views the technical aspects of the creation of this flap and our MATERIALS AND METHODS experience with 22 patients who have undergone this procedure. The flap has been found to be technically easy to create. It is A retrospective chart review of gynecologic oncology reliable with little tissue loss, and donor site complications are acceptable. Healing is aided by filling the pelvic dead space, patients undergoing distally based rectus abdominis mythereby decreasing bowel complications, and by bringing a new ocutaneous flaps was undertaken. This form of reconblood supply into the operative site which has often been heavily struction has been used almost exclusively for the last h-radiated. Operative time is minimized since the procedure re- 3 years. The study includes patients who underwent varquires only unilateral mobilization. Subsequentabdominal surgery ious forms of exenterative surgery from 1985 to the preshas been performed without fascial complications. D IWOhdemic ent, providing a mean follow-up of 16.3 months with a Pres,
Reconstructive procedures have become an important part of radical gynecologic surgery in an attempt to lessen the sometmes devastating results of the aggressive surgery necessary to control the malignancy. A variety of techniques intended to reconstruct the pelvis following radical surgery have been described [l]. These various procedures represent a wide range of technical difficulty and reliability. The primary goals of these procedures are (1) creation of a functional neovagina; (2) provision of a pliable and durable vaginal surface; (3) use in conjunction with radical pelvic surgery; (4) aid in the recovery from radical pelvic surgery; (5) minimization of technical difficulty and operating time; and 6) minimization of injury to the donor site. It has been our aim to develop a technically simple procedure which can consistently and reliably be used to fashion a functional neovagina when used in conjunction with exenterative surgery for gynecologic malignancies. To accomplish this, we have used a distally based rectus abdominis myocutaneous flap for pelvic reconstruction . This flap can be used to create a neo-
range of 3 to 36 months. The flap procedure was performed by either the Division of Gynecologic Oncology or the Division of Plastic Surgery at the University of Louisville School of Medicine. FLAP DESIGN The distally based rectus abdominis myocutaneous flap has been previously described [3-51. The flap has usually been fashioned from the left rectus abdominis muscle for exenterative surgery, with the colostomy exiting this side of the abdomen. The urostomy has been brought through the right side of the abdomen, away from the flap. This has been done to preserve the right side of the abdomen, in its “normal” state, to minimize any anatomic changes which might adversely affect the support for the urostomy and its appliance. The flap construction is begun at the completion of the extirpative portion of the exenterative procedure. The initial step must be the examination and confirmation of an intact blood supply to the proposed flap via the inferior epigastric vessels. An outline of the skin paddle is then drawn with a sterile marking pen on the abdominal skin
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RECTUS FLAP RECONSTRUCTION
FIG. 2. Flap mobilized on its vascular pedicle. FIG. 1. Flap template for distally based rectus abdominis myocutaneous reconstruction.
(Fig. 1). It is an ellipse whose vertical axis lies along the midclavicular line. It consists of skin, subcutaneous fat, and anterior rectus fascia all of which lie on the anterior surface of the rectus abdominis muscle. The superior pole of the ellipse is just below the costal margin. Extension of the flap onto the skin overlying the ribs may result in excessive tissue loss. The lateral margins of the skin paddle are placed about 2 cm lateral to the palpable borders of the rectus abdominis muscle,, creating a horizontal axis width of 10 to 14 cm. The inferior pole of the ellipse is located at a point created by the intersection of the left midclavicular line with the inter-tubercular plane, resulting in a vertical axis of 14 to 20 cm. The paddle is then raised by sharply incising along the inscribed template. First skin, then subcutaneous fat, and then anterior rectus fascia are incised. Care is taken not to create any shearing forces which might separate the delicate paddle structures from the rectus muscle and its sustaining vascular pedicle. This manuever is often facilitated by suturing the skin and subcutaneous tissues to the underlying fascia at several points around the periphery of the paddle. Next the rectus muscle itself is transected superiorly near the costal margin. It is then freed from its bed, ligating any minor segmental vessels which may be present, until the inferior border of the dissection is reached (Fig. 2). This point is identified by the lateral entrance of the inferior epigastric vessels into
the body of the muscle. The anterior rectus fascia below the arcuate line is preserved. This fascia will later be approximated to close the inferior portion of the wound. An elongated tube is formed from the myocutaneous paddle by rolling up the lateral edges of the flap with the skin on the interior surface. Skin staples are placed along the skin-to-skin junctions to hold the paddle in the tubular configuration. Then subdermal sutures are placed as the staples are serially removed to hold the paddle in this configuration (Fig. 3). The distal end of the tube is closed and then the entire structure is rotated into the pelvis. The open end of the tube is sutured to the skin edges of the perineal defect, creating a neovagina (Fig. 4). The internal parameters of this tube measure nearly 10 cm along the longitudinal axis and 4 cm along the transverse axis. Alternately, the paddle may be left flat, rotated into the pelvis, and sutured into place, creating a patch capable of filling a large perineal defect. The defect is closed by reapproximating the external rectus fascia using an interrupted Smead-Jones-type closure (Fig. 5). This requires bridging of the flap defect but can be done without significant difficulty or excessive tension. The wound is closed to the level of the arcuate line. At this time the intestinal and urinary stomas are brought through the left and right sides of the abdominal wall, respectively (Fig. 6). An active drain is placed above the fascia but below the skin, and brought out through a separate stab incision. Finally the skin is reapproximated. Often a “dog ear” will be present at the
FIG. 3. Neovaginal tube formed by inverting the lateral and distal margins.
superior and inferior poles of the paddle defect once the fascia is reapproximated. This can be easily remedied by excising the excess skin and subcutaneous tissue prior to reapproximation of the skin. The entire procedure will require around 45 min to complete after experience has been gained with this tech-
FIG. 4. Neovagina sutured into place.
FIG. 5. Upper abdominal wall closure begun by approximating the anterior rectus fascia.
nique. Importantly, after the myocutaneous paddle has been raised and the neovaginal tube formed, the reconstructive team can begin work in the abdominal operative field while the tube is being sutured into place in the pelvis. This approach allows for a minimal delay of about 30 min.
FIG. 6. Urostomy and colostomy placed with abdominal wall closure complete.
RESULTS Twenty-two patients underwent rectus abdominis myocutaneous flap reconstruction following various types of exenterative surgery. A total pelvic exenteration was performed on 18 patients. Three patients underwent an anterior exenteration and an additional patient underwent a posterior exenteration. The mean age of the patients undergoing surgery was 49.9 years (range 24-82 years). Recurrent cervical cancer was the indication for surgery in 17 women. Three women had recurrent vaginal cancer. One patient had recurrent vulvar cancer and one had recurrent colon cancer. The cell type most frequently seen was squamous cell carcinoma (20/22), whereas adenocarcinoma was seen twice (2/22). One patient underwent a primary exenterative procedure for stage IV cervical cancer, whereas the remaining 21 had recurrent disease preceded by pelvic radiotherapy. A neovagina was created in 20 patients from the distally based rectus abdominis myocutaneous flap; the paddle was left flat in the remaining two patients to serve as a patch for the perineal defect. Special note should be made of one particular patient who had significant peripheral vascular disease with severe claudication. After an uneventful operation, she developed an ischemic left leg which required amputation. She also had total loss of her neovagina due to the ileofemoral thrombosis and a complete abdominal wound separation with evisceration requiring repeat closure with a synthetic mesh. The patient did not recover and died postoperatively with adult respiratory distress syndrome. Flap complications were evaluated in the immediate postoperative period for wound infection and flap loss. Long-term evaluation included evaluation for prolapse of the neovagina and return to sexual function. Infectious complications at the flap site were noted in three (14%) patients. Significantly, one of these infectious complications resulted in an enteroneovaginal fistula which required surgical closure. Flap loss was generally acceptable. Eighteen patients (82%) had no flap loss. Two patients (9 ) lost less than 20% of their flaps. A 38-yearold woman lost one-third of the neovagina and required subsequent intraoperative debridement and a split-thickness skin graft for repair. One patient, as mentioned before, had complete flap loss. Neovaginal prolapse has been uncommon, with only one (5%) patient demonstrating mild prolapse. Return to sexual activity has also been relatively uncommon in this group with the exception of the 7 patients who were 40 years old or younger at the time of their surgery. Five (5/7) of these women have attempted intercourse and four (4/5) have been successful. None of the older women have attempted to return to sexual activity.
Donor site complications were evaluated by noting the presence of a wound infection, a superficial wound separation, or a fascial dehiscence during the immediate postoperative period. The subsequent development of an incisional hernia or stomal prolapse was evaluated in the late postoperative period. A wound infection occurred in 3 (14%) abdominal incisions. A partial superficial wound separation occurred in 9 patients (41%). These wounds were allowed to close uneventfully by secondary intention. One patient, as mentioned previously, suffered a fascial dehiscence with evisceration. None of these patients developed either an incisional hernia or prolapse of an excretory stoma. Further abdominal surgery was required in 2 patients. Each underwent two successive laparotomies utilizing the previous abdominal exenterative/myocutaneous flap incision for access to the peritoneal cavity. No subsequent abdominal wall defect has been detected since the second procedure in either patient now at 17 and 21 months follow-up. Currently, 14 (64%) of these patients are alive. Thirteen (59%) are free of disease and one (5%), although alive, has demonstrated a clinical recurrence. Eight patients died during the follow-up period. Four (18%) of them demonstrated clinical evidence of disease and four (18%) were disease free. DISCUSSION The distally based rectus abdominis myocutaneous flap has proven technically simple to perform. It can be used to fashion a neovagina or to “patch” a perineal defect. The flap is pliable and provides an adequate surface for sexual function. There is little loss of tissue from the skin paddle and infectious complication rates are low. Donor sites are prone to superificial separation but heal uneventfully without fascial complications such as incisional hernias. Healing is enhanced by bringing a new blood supply into the often heavily radiated and denuded pelvis . The “dead space” created by the extirpative portion of the exenterative procedure is filled comfortably by the mass of the flap and, in conjunction with an omental “J” flap, intestinal herniation into the pelvis is controlled. This decreases intestinal fistulization and small bowel obstruction. Operative time is minimized with this procedure since it requires unilateral mobilization and is incorporated into the primary abdominal incision. There is no second operative procedure or delay required in this reconstruction. It is difficult to determine a single cause of the one postoperative death. Other studies have demonstrated an operative mortality rate of 5.3 to 10% [7-91. The operative mortality in our series was 5% (l/22). The one
PURSELL, DAY, AND TOBIN
death occurred in a 39-year-old woman who had recurrent cervical cancer. She had been previously treated with radiation therapy for stage III cervical disease. This patient had significant peripheral vascular disease with claudication requiring medical therapy and she was a heavy smoker. It is doubtful that the flap reconstruction in and of itself was responsible for her significant complications. Gracilis myocutaneous flaps have also been used to create a neovagina in radical pelvic surgery [lo]. Certainly this technique has been successful in experienced hands. The rectus abdominis myocutaneous flap has proven to be just as effective as the gracilis flap in providing revascularization of radiated wounds, in filling endopelvic space, and in providing quality surface restoration. In addition, the rectus flap has several advantages. The frequency of flap loss from rectus abdominis reconstructions has ranked among the lowest, whereas loss from gracilis-based flaps has been the highest [l 11. The rectus flap requires only one additional incision; the bilateral gracilis flap requires two additional incisions. This allows for more rapid completion of the procedure, decreasing the operative time. When a supralevator exenteration is performed and the external genitalia are preserved, rectus abdominis flaps can be easily positioned into the pelvis and attached to the distal structures. Gracilis flaps, on the other hand, are often bulky and difficult to pass into the pelvis and position appropriately. Beemer ef al. have recently reported their experience with split-thickness skin grafting for vaginal reconstruction in radical pelvic surgery [ 121.Their procedure often requires a delay in reconstruction for 2-8 weeks while an adequate granulation bed forms. The rectus abdominis reconstruction is carried out at the time of the initial radical surgery. Therefore no delay of surgery is required nor is a second anesthesia needed. Active participation on the part of the patient to dilate the neovagina is required when using a split-thickness graft technique. Because of its large capacity and inherent resistance to contraction, routine dilation is not required for distally based rectus abdominis neovaginas. Reconstructive surgery is an important part of radical
pelvic procedures. Reconstruction utilizing the distally based rectus abdominis myocutaneous flap is an acceptable and desirable adjunct to radical gynecologic surgery. It is a technically simple procedure and is reliable for use in pelvic reconstruction for exenteration surgery. Further follow-up will be necessary to identify any longterm difficulties. REFERENCES 1. Magrina, J. F., and Masterson, B. J. Vaginal reconstruction in gynecological oncology: A review of techniques, Obstet. Gynecol. Surv. 36, 1 (1981). 2. Tobin, G. R., and Day, T. G., Jr. Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps, Plust. Reconstruct. Surg. 81, 1 (1988). 3. Tobin, G. R. Myocutaneous and muscle flap reconstruction of problem wounds, Surg. Clin. North Amer. 64, 667 (1984). 4. Taylor, G. I., Corlett, R. J., and Boyd, J. B. The versatile deep inferior epigastric (inferior rectus abdominis) flap, &it. J. Plust. Surg. 37, 330 (1984). 5. Logan, S. E., and Mathes, S. J. The use of a rectus abdominis myocutaneus flap to reconstruct a groin defect, Brit. J. Plast Surg. 37, 351 (1984). 6. Parkash, S., and Ramakrishnan, K. A myocutaneous island flap in the treatment of a chronic radionecrotic ulcer of the abdominal wall, Brit. J. Plust. Surg. 33, 138 (1980). 7. Roberts, W. S., Cavanagh, D., Bryson, S. C. P., Lyman, G. H., and Hewitt, R. N. Major morbidity after pelvic exenteration: A seven-year experience, Obstet. Gynecol. 69, 617 (1987). 8. Averette, H. E., et al. Pelvic exenteration: A 15year experience in a genera1 metropolitan hospital, Amer. J. Obstet. Gynecol. 150, 179 (1984). 9. Lawhead, R. A., Jr., Clark, D. G. C., Smith, D. H., Pierce, V. K., and Lewis, J. L., Jr. Pelvic exenteration for recurrent or persistent gynecologic malignancies: A IO-year review of the Memorial-Sloan Kettering Cancer Center experience (1972-1981), Gynecol. Oncol. 33, 279 (1989). 10. McGraw, J. B., Massey, F. M., Shanklin, K. D., and Horton, C. E. Vaginal reconstruction with gracilis myocutaneous flaps, Plust. Reconstruct. Surg. 58, 2 (1976). 11. Mathes, S. J., and Nahai, F. Muscle and myocutaneous flaps, in The unfavorable result in plastic surgery: Avoidance and treatment (R. M. Goldwyn, Ed.), 2d ed., Little, Brown, Boston, pp. lll115 (1984). 12. Beemer, W., Hopkins, M. P., and Morley, G. W. Vaginal reconstruction in gynecologic oncology, Obstet. Gynecol. 72, 6 (1988).