Filling and reconstruction

Hans de Wilt, MD, PhD.

Department of Surgical Oncology Erasmus MC / Daniel den Hoed Cancer Center Rotterdam

Theo Wiggers, MD, PhD.

UMCG, Groningen the Netherlands

Perineal wound
Introduction Surgical options Surgical techniques Take Home Message

Woundinfections after APR

Radical resection (wide excision vs coning, exenteration) Preoperative (chemo)radiation therapy IORT

Abdominoperineal resection

Holm et al. Br J Surg 2007

Abdominoperineal resection

Sometimes things go wrong

Woundinfections

Healing time > 3 months

Woundinfections

Percentage of woundinfections after APR ?

Wondinfection after rectal surgery

Author Marijnen et al Vallero et al. Bullard et al.

Journal
J Clin Oncol 2002 Int J Colorectal Dis 2003 Dis Colon Rectum 2005

APR 18% 26% 23%

APR + Rtx 29% 45% 47%

p-value 0.008 0.005

Preoperative radiotherapy increases perineal morbidity

Preoperative Radiotherapy Indications

Radiotherapy (5x5Gy) : T2/3 Rectal cancer Chemoradiation (25x2Gy + 5-FU): Locally advanced rectal cancer (large T3/4 or N+ or APR) Recurrent rectal cancer Anal cancer

Perineal wond

closure

What are the options ? What is your experience ?

Perineal wond

options

Leave wound open/packing with gauzes

infection & delayed healing

Temporary VAC system, secundary closure (Oxford trial)

Primary closure with/without drainage

inadequate for large defects infection percentage 30-50%

Closure with tissue transfer

Tissue transfer

Advantages ?

Tissue transfer reasons

Hemostasis Filling dead space Sexual rehabilitation Stimulation of healing due to Capillary ingrowth Absorption of fluids Control of infection rehabilitation

Tissue transfer options

Free: Latissimus dorsi flap Pedicled: Local transposition Omental flap Gracilis flap Rectus Abdominis flap

Local transposition

Gluteus maximus transposition

Holm et al. Br J Surg 2007

Local transposition

80 min unilateral; 120 min bilateral flap 4/ 28 pts local woundinfection (14%)

Holm et al. Br J Surg 2007

Omentumplasty
Advantages: Well vascularised Haemostatic Non irradiated tissue Length and volume Easy take of split skin graft Vaginal reconstruction Disadvantages: Previously used Complications (stomach dilatation) Laparotomy No skin island

Surgery (I)
Omentum Plasty Dissection of right or left GEA

Surgery (II)

TME resection with en bloc posterior vaginal wall and left lateral pelvic wall

Surgery (III)

Anterior TME specimen

Posterior TME specimen

Surgery (IV)
Mobilization through transverse mesocolon Left or right paracolic gutter

Surgery (V)
Posterior vaginal wall removed

Surgery (VI)
Omentum sutured to vaginal sidewalls

Surgery (VII)
Close perineal subcutaneous fat and skin Leave gauze in reconstructed vagina

Omentumplasty after APR

Perineal infections
Author Poston et al. John et al. Wang et al. Journal
Ann R Coll Surg Engl 1991 Int J Colorectal Dis 1991 Kaohsiung J Med Sci 1994 Eur J Surg 1997

Patients 53 74 41

APR 28% 47% 55%

APR + Omentum 4% 18% 23%

Hay et al.

165

22%

20%

Omentumplasty after APR

Review Safe Simple

P. Nilsson

Dis Colon Rectum 2006

Might be benifitial RCT needed

Myo-(cutaneous) transposition
pro well vascularised outside radiation field additional subcutus and skin available in the absence of omentum neovagina

con

loss of muscle function scar tissue infection/complication M. Gracilis M. Rectus Abdominus (VRAM)

Musculus Gracilis
Advantages:

Disadvantages:

Musculus Gracilis
Advantages: Bilateral Possible in narrow pelvic inlet No laparotomy necessary Low morbidity Leg function not impaired Disadvantages: Small volume Vascularisation fragile Skin island unreliable
Vermaas et al., Eur J Surg Oncol 2005

Musculus gracilis transposition

Musculus gracilis transposition

Musculus gracilis transposition

Peroperative result

One month postoperative

Gracilis reconstruction after rectalsurgery

Perineale infecties
Author Shibata et al. Burke et al. Vermaas et al. Journal
Ann Surg Oncol 1999 Gynaecol Oncol 1999 Eur J Surg Oncol 2005

APR 46% -

APR + gracilis 12% 16% 28%

p-value 0.03

Potential use for postoperative woundinfections

Vertical Rectus Abdominus Muscle

pro:

con:

Vertical Rectus Abdominus Muscle

pro:

Large volume + skin Neovagina

con:

Functional impairment Laparotomy Complication (necrosis, hernia) Stoma at site of flap Impossible after groin / transverse abdominal wall surgery

VRAM-plasty (I)

VRAM-plasty (II)

Large rectal and anal cancers

VRAM-plasty (III)

Preparation of Vertical Rectus Abdominus Muscle (VRAM)

VRAM-plasty (IV)

Preparation of skin island

VRAM-plasty (V)
Closure of vagina with peritoneum of rectus abdominus Rectus abdominus muscle to fill the pelvis

VRAM-plasty (VI)
Closure of subcutaneous fat Closure of skin

VRAM-plasty (VII)
Closure of perineum Reconstruction of vagina

VRAM reconstruction after rectal surgery

Perineal infecties
Author Kapoor et al Chessin et al. Ferenschild et al. Journal
Am Surg 2005 Ann Surg Oncol 2005 World J Surg 2005

APR 40% 44% 36%

APR + VRAM 59% 16% 0%

p-value 0.1 0.03 -

Potential decrease of postoperative woundinfections

Take Home Messages

APR Reconstructie vagina, perineum Perineal wondinfection Omentumplasty, transposition VRAM Debridement VAC Gracilis

Questions ?