Decisional Algorithms for the Reconstruction of Pelviperineal Defects After Total Pelvic Exenteration: A Review

Dan Cristian Moraru,Viorel Scripcariu

doi:10.7438/1584-9341-14-1-3

Abstract

Abdominoperineal resection remains the “gold standard” for cancers of the lower rectum and of the anal canal as a result of the failure of the primary conservative care. Total pelvic exenteration leaves an important pelviperineal defect which requires reconstruction techniques to be applied when primary closure cannot be performed. Pelvic floor reconstruction is required and various complications, especially infectious, may occur in this area. The pelvis can be reconstructed using flaps. The perineal reconstruction that uses the numerous perforator flaps described lately raises the following question: which flap should be chosen? Each flap and its variants have their own advantages and disadvantages, and the choice of the appropriate reconstructive technique involves a collaboration between the gastrointestinal oncology surgeon, the radiologist, the anaesthesiologist and the plastic surgeon in order to identify when and which surgical reconstruction is to be preferred, using reconstruction algorithms to choose the appropriate technique. Various studies are presented describing the experience of one or more centers regarding reconstruction options and the decisional tree adopted in the form of an algorithm both in relation to neoadjuvant irradiation therapy and without irradiation.

Highlights

The main indicators for major perineal resection are vulvar cancer, anal cancer and low rectal cancer
Abdominoperineal resection leaves an important pelviperineal defect and local tissue can be compromised by preoperative radiotherapy that alters tissue vascularization and delays the healing process [1]
If the pelvic exenteration is anticipated, the VRAM flap is recommended, and for all other defects, the authors find plenty of soft tissue and epithelium that can be harvested by suggesting the gluteal flap

Summary

Introduction

The main indicators for major perineal resection are vulvar cancer, anal cancer and low rectal cancer. The use of pedicled muscular flaps provides a successful solution for defects that oncologic surgeons could not perform primary closure in the past. Improvements in resection techniques in general and especially in regard to the abdominoperineal cylindrical excision [8-11], with the use of laparoscopy in the first phase and abdominal perineal resection in the ventral decubitus position have led surgeons to review their reconstructive strategy. When abdominal incision is unnecessary, when cylindrical abdominoperineal excision is performed in ventral decubitus, the authors prefer the use of the gluteal donor site and especially the flaps based on the internal pudendal artery. This flap is not recommended in patients with radiotherapy history. Sinna R et al [15] elaborates an algorithm for the reconstructive technique of choice that depends on the initial situation: amputation in the position of dorsal decubitus, cylindrical amputation in ventral decubitus or secondary perineal sinus (Figure 2)

SGAP IGAP IGAM

Conclusion