Br. J. Surg. 1990, Vol. 77, June,
A. 1. Skene*, D. T. Gaultt, C. R. J. Woodhouse$, N. M. Breach? and J. M. Thomas87 Department of Surgeryy, Westminster Hospital, London and Department of Surgery*$, Plastic Surgery? and Urology$, Royal Marsden Hospital, London. UK Correspondence to: Mr J. M. Th o m as , Westminster Hospital, Horseferry Road, London SW1 P 2AP, UK
Perineal, vulval and vaginoperineal reconstruction using the rectus abdominis myocutaneous flap Poor perineal healing is a major complication of total or partial pelvic exenteration especially when the pelvis and perineum have previously been irradiated. Perineal, vulval or vaginoperineal reconstruction was performed in five women using the inferiorly based rectus abdominis myocutaneous flap. Primary perineal wound healing occurred in all patients and no flap-related complications developed. Primary healing of abdominal wall wounds occurred in all patients without incisional hernia. Three of the patients had an anterior or total pelvic exenteration with continent urinary diversion by the Mitrofanoff technique. Two of the patients had complete vaginal reconstruction and one patient had after-loading catheters insertedfor postoperative interstitial irradiation. The patients were in hospital for 42,28,21,17 and 15 days respectively. The longest stays were associated with training for self-catheterization of the continent urinary diversion. Median follow-up was 9 months. One patient developed two perineal recurrences at I 6 months which were resected, and she remains disease-free 6 months later. Keywords: Perineum, vagina, vulva, reconstruction
Various pelvic exenterations a r e commonly performed to treat a variety of malignant conditions, mostly persistent or recurrent tumours of the pelvic organs, collectively referred t o as cloacogenic malignancies'. Less common indications for pelvic exenteration include extensive perineal radiation damage2, extensive perineal fistulae a n d certain post-traumatic injuries3. Following such extensive surgery, particularly when radiotherapy has been p ar t of the initial management, delayed wound healing is a problem that can result in considerable morbidity and a protracted hospital stay. Primary wound healing is often not achievedk6 and a persistent perineal sinus may prove t o be a p r ~ b l e r n ' . ~ . The rectus abdominis myocutaneous flap has previously been used, when superiorly based, for the repair of chest wall defects and breast r e c o n s t r u c t i ~ n ~a~n'd~, when inferiorly based, for the repair of groin" a n d perineal defects", a n d for the treatment of persistent perineal sinuses". This paper describes the use of a n inferiorly based myocutaneous flap t o establish primary healing of large perineal wounds following excision of diseased and irradiated tissues. The skin pedicle was used to reconstruct the perineum and posterior vaginal wall of two patients, the perineum alone in t w o patients, a n d the vulva and perineum of one patient. T h e bulk of the muscle an d subcutaneous fat was used to reduce the dead space of the pelvic cavity.
Patients and methods Two patients aged 59 and 60 years respectively had been treated for carcinoma of the anus by extensive irradiation. One of them was referred with recurrent adenocarcinoma in the anus and rectovaginal septum following external beam radiotherapy. The other had no recurrence of squamous carcinoma following external beam and interstitial radiotherapy, but was referred with severe perineal pain controlled only by diamorphine. A defunctioning pelvic colostomy had been performed for incontinence resulting from radiation damage to the sphincter and perineum. Both patients were treated by extended abdominoperineal resection of rectum and anus including perineal skin and posterior vaginal wall up to the posterior fornix. The rectus abdominis myocutaneous flap was used to reconstruct the vagina and perineum. Two patients aged 58 and 63 years respectively were referred,
following abdominoperineal resection and radiotherapy, with recurrent adenocarcinoma of the rectum invading the vagina and bladder (Figure I ) . They were treated by total pelvic exenteration. Both had continent MitrofanoB urinary diversions. One of these patients had, in addition, total vaginal reconstruction with pedicled ileum and the other required peroperative placement of after-loading catheters to the pelvic side wall, where clearance of disease was considered to have been inadequate. The perineum was reconstructed using the rectus abdominis myocutaneous flap. One patient aged 56 years was referred with extensive postirradiation recurrent squamous carcinoma of the anterior vaginal wall invading the bladder base, vulvae and clitoris. She was treated by anterior exenteration and simple vulvectomy. Reconstruction was by MitrofanoB urinary diversion, pedicled loop of colon for vagina and rectus abdominis myocutaneous flap for perineum and vulva. After mechanical bowel preparation and under systemic antibiotic cover the patients were put in the Lloyd-Davies position. The abdomen was explored through an infraumbilical midline incision. Following the surgical resection an inferiorly based rectus abdominis myocutaneous flap was raised taking care to preserve the inferior epigastric vessels which lie on its deep surface14. The length and breadth of the skin pedicle varied according to the size of the perineal, vulval or vaginoperineal defect. Primary closure of the abdominal wall was achieved in all cases. The rectus muscle was transected at the level of the costal margin and the superior epigastric vessels were ligated. The myocutaneous flap was then rotated through 180" on its inferior vascular pedicle and transferred through the pelvis into the perineum and the cutaneous island inset. In the one patient where the myocutaneous flap was used for vulval reconstruction, the pedicle was transposed suprapubically. Care was taken during the handling of the flap to avoid shearing the small perforating vessel between the muscle and the overlying skin. Viability of the flap was verified by palpating the pulsatile vascular pedicle and by observing capillary refill after blanching. Patients requiring continent urinary diversion had a Mitrofanofftype reconstruction. A urinary reservoir was formed from an isolated segment of caecum and ascending colon. Intestinal continuity was re-established by ileotransverse anastomosis. The isolated colon was detubularized to reduce intrinsic peristaltic contractions. The appendix, mobilized on its pedicle and with the distal tip resected, was implanted into the reservoir in a 4-cm submucosal tunnel. The other end of the appendix was brought to the skin and formed a continent catheterizable stoma. The ureters were implanted in submucosal tunnels at a suitable site in the pouch15.
0 1990 Butterworth-Heinemann
Reconstruction with the rectus abdominis flap: A. I. Skene et al.
practise intermittent clean self-catheterization every 4-6 h by day and occasionally at night. There have been no urinary tract complications.
Discussion Securing primary healing of perineal wounds remains a challenging surgical problem, particularly after radiotherapy16. Healing difficulties are compounded by haematoma and sepsis within the unobliterated pelvic cavity. Initial techniques of abdominoperineal resection resulted in granulating cavities and protracted healing' '. In an attempt to improve this situation Crile and Robnett described closure of the pelvic peritoneum and perineal skin with efficient drainage of the dead spaceI8 and Papaionnou described closure of the perineal skin only, allowing small bowel freely to enter the pelvis'g. Despite these measures Irvin and Goligher found that 17-35 per cent of perineal wounds were not healed at 6 months6. The transfer of pedicled omentum to obliterate the pelvic cavity has contributed to healing4 but this useful organ varies considerably in size and previous surgery or secondary deposits can render it unusable. The intrinsic benefits of a myocutaneous flap are considerable. The transfer of a muscle with its own blood supply facilitates wound healingg. This improvement may be the result of improved delivery of nutrients, oxygen, inflammatory cells
b Figure 1 Computed tomogram. a, and line drawing, b, showing recurrent carcinoma oj rectum (after abdominoperineal resection of rectum) at level of vaginal vault invading right side of bladder base. 1. Bladder; 2, iiaginal vaultlcervix uteri: 3, recurrent carcinoma When patients were having simultaneous posterior vaginal wall reconstruction, the anterior lip of the flap was reflected into the pelvis and sutured to the posterior vaginal wall remnant (Figures 2 and 3 ) . Closure of the large perineal defects was thus achieved. The bulk of the myocutaneous flap contributes to the filling of the pelvic cavity. Corrugated drains were placed in the pelvis and brought out through the perineal wound.
Results Primary healing of both donor and perineal wounds was achieved in all cases. One patient required 6 days' ventilation after operation due to chest complications but this did not prejudice flap healing. The abdominal defects closed primarily in all patients and none has incisional hernia. Hospital stay was 42, 28, 21, 17 and 15 days respectively, the longer admissions being related to Mitrofanoff training. One patient treated for recurrent carcinoma of the rectum developed two perineal wound recurrences at 16 months. These were excised following uneventful mobilization of one edge of the flap and she remains well and disease-free 6 months later. The three patients who had internal urinary diversions are continent and
Figure 2 Sagittal section of pelvis and abdomen shoning the raising of the rectus abdominis myocutaneou.s,flup. , Volume to be resected
Br. J. Surg., Vol. 77, No. 6. June 1990
Reconstruction w i t h the rectus abdominis flap: A. 1. Skene et al.
The rectus abdominis flap for perineal, vulva1 and vaginoperineal reconstruction following radical resection of tumours from heavily irradiated beds has been described. When anterior or total pelvic exenteration is necessary, further refinement by continent urinary diversion and vaginal reconstruction may be added. Primary healing may be expected and flap-related complications are rare.
2. 3. 4. 5.
6. 7. 8. 9. 10.
11. Figure 3 Sagittal section of the pelvis showing the reflection of the myocutaneous flap to reconstruct the vagina and perineum
and antibiotics to the woundz0,which is particularly important in the healing of heavily irradiated tissues. The gracilis myocutaneous flap has been well described for reconstruction of perineal defect^^^^^^'*^^. Its disadvantages include a limited skin paddle size and a variable blood supply. Occasionally the dominant blood vessels enter the muscle as low as the mid thigh, limiting the length of the pedicle and its access to the perineal defectI4. For large perineal defects, bilateral gracilis flaps may have to be raised. In contrast, the inferior epigastric vessels provide the rectus abdominis myocutaneous flap with a consistent and excellent blood ~ u p p l y ' ~ Furthermore, . a large skin paddle is available for reconstruction. A long pedicle allows the flap to be transposed with little risk of tension or kinking of the feeding vessels. The skin island is therefore capable of filling large defects in the perineum and is particularly useful for reconstruction when wide excision of radiation-damaged perineal tissues has been performed. When the bladder is removed it is conventional to form an ileal conduit. A continent internal diversion adds considerably to the length of surgery and may potentially cause major complications, but it is offered to all patients having anterior or pelvic exenteration who are physically and emotionally fit enough. Many methods are available which differ only in detail. In the patients described, available viscera were used to form a reservoir. The Mitrofanoff technique of submucosal tunnelling of a narrow tube, such as the appendix, into the pouch to give continence was used as the Kock nipple has been found to be rather unreliable' 5 , 2 3 .
Br. J. Surg., Vol. 77, No. 6, June 1990
18. 19. 20. 21. 22. 23.
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