Research Article| Volume 65, ISSUE 11, P1537-1543, November 2012

Reconstruction of the irradiated perineum following extended abdomino-perineal excision for cancer: An algorithmic approach


      Our unit has implemented an algorithm for irradiated perineal reconstruction incorporating current evidence and a new technique in line with the advent of laparoscopic tumour excision. Our approach attempts to maintain the benefits patients derive from minimally invasive oncological surgery.
      Four consecutive patients had uterine retroversion to obturate pelvic deadspace and reconstruct the posterior vaginal wall. Age range was 41–84 years and mean follow-up of 21 months with mean in-patient stay of 7 days. All patients had neoadjuvant radiotherapy or chemoradiation for low rectal/anorectal adenocarcinoma. All patients had laparoscopic Extended APER and contiguous posterior vaginal wall excision and reconstruction with uterine retroversion and z-plasty skin closure. One patient required ultrasound aspiration of a pre-sacral seroma at two months. No patients returned to theatre for major complications. We highlight one minor and no major complications associated with an algorithmic approach incorporating our method of uterine retroversion and z-plasty parallel to traditional flap reconstruction methods.


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        • Chessin D.B.
        • Hartley J.
        • Cohen A.M.
        • et al.
        Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study.
        Ann Surg Oncol. 2005; 12: 104-110
        • Butler C.E.
        • Rodriguez-Bigas M.A.
        Pelvic reconstruction after abdominoperineal resection: is it worthwhile?.
        Ann Surg Oncol. 2005; 12: 91-94
        • Tham L.Y.E.
        • Pan W.R.
        • Rozen W.M.
        • et al.
        The pudendal thigh flap for vaginal reconstruction: optimising flap survival.
        J Plast Reconstr Aesthet Surg. 2010; 63: 826-831
        • Glancy D.G.
        • Corfield A.P.
        • Thomas M.G.
        Expression of Muc2 in normal colonic mucosa is decreased following pre-operative radiotherapy for rectal cancer: implications for anastomotic healing.
        Colorectal Dis. 2008; 10: 25
        • Tibbs M.K.
        Wound healing following radiation therapy: a review.
        Radiother Oncol. 1997; 42: 99-106
        • Nisar P.J.
        • Scott H.J.
        Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision.
        Colorectal Dis. 2009; 11: 806-816
        • D’Souza D.N.
        • Pera M.
        • Nelson H.
        • Finical S.
        • Tran N.V.
        Vaginal reconstruction following resection of primary locally advanced and recurrent colorectal malignancies.
        Arch Surg. 2003; 138: 1340-1343
        • Smith H.O.
        • Genesen M.C.
        • Runowicz C.D.
        • Goldberg G.L.
        The rectus abdominus myocutaneous flap; modifications, complications and sexual function.
        Cancer. 1998; 83: 510-520
        • Wang X.
        • Qiao Q.
        • Burd A.
        • et al.
        Perineum reconstruction with pedicled antero-lateral thigh fasciocutaneous flap.
        Ann Plast Surg. 2006; 56: 151-155
        • Woods J.E.
        • Alter G.
        • Meland B.
        • Podratz K.
        Experience with vaginal reconstruction utilising the modified Singapore flap.
        Plast Reconst Surg. 1992; 90: 270-274
        • Holm T.
        • Ljung A.
        • Haggmark T.
        • Jurrell G.
        • Lagergren J.
        Extended abdominoperineal resection with gluteus maximus flap reconstruction for the pelvic floor for rectal cancer.
        Br J Surg. 2007; 94: 232-238
        • Houvenaeghel G.
        • Ghouti L.
        • Moutardier V.
        • et al.
        Rectus abdominus myocutaneous flap in radical oncopelvic surgery: a safe and useful procedure.
        Eur J Surg Oncol. 2005; 31: 1185-1190
        • Buchel E.W.
        • Fincal S.
        • Johnson C.
        Pelvic reconstruction using vertical rectus abdominus musculocutaneous flaps.
        Ann Plast Surg. 2004; 52: 22-26
        • Nelson R.A.
        • Butler C.E.
        Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects.
        Plast Reconstr Surg. 2009; 123: 175-183
        • Butler C.E.
        • Gundeslioglu A.O.
        • Rodriguez-Bigas M.A.
        Outcomes of immediate VRAM flap reconstruction for irradiated abdomino-perineal resection defects.
        J Am Coll Surg. 2008; 206: 694-703
        • Suneson K.G.
        • Buntzen S.
        • Tei T.
        • Lindegaard J.C.
        • Norgaard M.
        • Laurberg S.
        Perineal healing and survival after anal cancer salvage surgery: 10-year experience with primary perineal reconstruction using the vertical rectus abdominus myocutaneous (VRAM) flap.
        Am Surg Oncol. 2009; 16: 68-77
        • Radice E.
        • Nelson H.
        • Mercill S.
        • et al.
        Primary myocutaneous flap closure following resection of locally advanced pelvic malignancies.
        Br J Surg. 1999; 86: 349-354
        • Tei T.
        • Stolzenburg T.
        • Bunten S.
        • Laurburg S.
        • Kjeldsen H.
        Use of trans-pelvic rectus abdominus flap for anal cancer salvage surgery.
        Br J Surg. 2003; 90: 575-580
        • Ratliff C.R.
        • Gershenson D.M.
        • Morris M.
        • et al.
        Sexual adjustment of patients undergoing gracilis myocutaneous flap vaginal reconstruction in conjunction with pelvic exenteration.
        Cancer. 1996; 78: 2229-2235
        • Shibata D.
        • Hyland W.
        • Busse P.
        • et al.
        Immediate reconstruction of the perineal wound with gracilis muscle flaps following abdominoperineal resection and intraoperative radiation therapy for recurrent carcinoma of the rectum.
        J Surg Oncol. 1999; 6: 33-37
        • Yeh K.A.
        • Hoffman J.P.
        • Kusiak J.E.
        • et al.
        Reconstruction with myocutaneous flaps following resection of locally advanced recurrent rectal cancer.
        Am Surg. 1995; 7: 581-589
        • Persichetti P.
        • Cogliandro A.
        • Marangi G.F.
        • et al.
        Pelvic and perineal reconstruction following abdominoperineal resection; The role of gracilis flap.
        Ann Plast Surg. 2007; 59: 168-172
        • Wagstaff M.J.D.
        • Rozen W.M.
        • Whitaker I.S.
        • et al.
        Perineal and posterior vaginal wall reconstruction with superior and inferior gluteal artery perforator flaps.
        Microsurgery. 2009; 29: 626-629
        • Boccola M.A.
        • Rozen W.M.
        • Ek E.W.
        • et al.
        Inferior gluteal myocutaneous island transposition flap reconstruction of irradiated perineal defects.
        J Plast Reconstr Aesthet Surg. 2010; 63: 1169-1175
        • Christensen H.K.
        • Nerstrom P.
        • Tei T.
        • Laurberg S.
        Perineal repair after extralevator abdominoperineal excision for low rectal cancer.
        Dis Colon Rectum. 2011; 54: 711-717
        • Gleeson N.C.
        • Baile W.
        • Roberts W.S.
        • et al.
        Pudendal thigh fascio-cutaneous flaps for vaginal reconstruction in gynaecologic oncology.
        Gynaecol Oncol. 1994; 54: 269-274
        • Tham N.L.Y.
        • Pan W.
        • Rozen W.
        • et al.
        The pudendal thigh flap for vaginal reconstruction: optimising flap survival.
        J Plast Reconstr Aesthet Surg. 2010; 63: 826-831
        • Seshadri R.A.
        • Srinivasan A.
        • Tapkire R.
        • Swaminathan
        Laparoscopic versus open surgery for rectal cancer after neoadjuvant chemoradiation: a matched case-control study of short-term outcomes.
        Surg Endosc. 2012; 26: 154-161
        • Castillo P.A.
        • Aguilar V.C.
        • Wexner S.
        • Davila G.W.
        Uterine retroversion for vaginoperineal reconstruction following resection of rectal tumours.
        Dis Colon Rectum. 2010; 53: 350-354
        • Carlson J.W.
        • Soisson A.P.
        • Fowler J.M.
        • et al.
        Rectus abdominus myocutaneous flap for primary vaginal reconstruction.
        Gynaecol Oncol. 1993; 51: 323-329