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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 26  |  Issue : 2  |  Page : 227-229

Bilateral gluteal fasciocutaneous flap for perineal reconstruction following abdominoperineal resection


Department of Surgical Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala, India

Date of Submission13-Aug-2020
Date of Decision14-Aug-2020
Date of Acceptance14-Oct-2020
Date of Web Publication07-Nov-2020

Correspondence Address:
Dr. K Chandramohan
Department of Surgical Oncology, Regional Cancer Centre, Thiruvananthapuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_32_20

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  Abstract 


Local flap reconstruction of the perineum and anal canal is an excellent method of managing large perineal defects. Benefits of V-Y flaps compared with other methods such as vertical rectus abdominis myocutaneous include reduced donor-site morbidity and increased ease of harvest and inset. This is a case report of bilateral gluteal V-Y fasciocutaneous reconstruction of perineal defect, in a post-irradiated anorectal carcinoma patient, with excellent outcome.

Keywords: Bilateral V-Y advancement flap, gluteal fasciocutaneous flap, perineal reconstruction


How to cite this article:
Naga Srinivas M V, Mathew AP, Rao AV, Muralee M, Wagh MS, Vijayasarathy S, Chandramohan K. Bilateral gluteal fasciocutaneous flap for perineal reconstruction following abdominoperineal resection. Kerala Surg J 2020;26:227-9

How to cite this URL:
Naga Srinivas M V, Mathew AP, Rao AV, Muralee M, Wagh MS, Vijayasarathy S, Chandramohan K. Bilateral gluteal fasciocutaneous flap for perineal reconstruction following abdominoperineal resection. Kerala Surg J [serial online] 2020 [cited 2020 Dec 5];26:227-9. Available from: http://www.keralasurgj.com/text.asp?2020/26/2/227/300246



A 56-year-old female with a past history of treated carcinoma breast was evaluated for bleeding per rectum. Sigmoidoscopy showed an ulceroproliferative growth just above the anal verge, and biopsy showed moderately differentiated adenocarcinoma. Serum carcinoembryonic antigen was 6.3 ng/ml. Contrast-enhanced computed tomography abdomen showed locally advanced growth in the rectum, close to the anal verge, with enlarged perirectal lymphnodes. Metastatic work-up was negative. The patient received neoadjuvant chemoradiotherapy. Post-neoadjuvant therapy magnetic resonance imaging showed anorectal thickening infiltrating the mesorectal fascia and levator ani. In addition, there was a perianal fistula, coursing through the right levator ani and opening into the gluteal cleft. There was a focal loss of a fat plane with the posterior vaginal wall. On examination, her performance status was PS-1. Abdominal examination was normal. The growth was palpable through the posterior vaginal wall, and the vaginal mucosa appeared free. On rectal examination, the growth was felt at 1 cm from the anal verge, with the external fistula opening at 9'o clock position.

Extra levator abdomino perineal excision with bilateral gluteal V-Y advancement fasciocutaneous flap reconstruction was done. Initially, rectosigmoid mobilisation was done through lower midline laparotomy, and a proximal bowel cut was made. The end stoma was fashioned in the left iliac region and the omentum was packed into the pelvis. In prone jack-knife position, perineal dissection was done, removing the bilateral levator muscles at origins, coccyx and adherent posterior vaginal wall. The vaginal defect was closed primarily. The perineal defect was reconstructed with a bilateral gluteal V-Y advancement fasciocutaneous flap. The medial 2-cm wide portions of the flaps were de-epithelialised and filled into the pelvic cavity. Post-operatively, the patient convalesced well [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7].
Figure 1: Prone jack-knife position. Note the external opening of the fistula

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Figure 2: Incision for perineal dissection, including the fistula

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Figure 3: Defect after perineal dissection

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Figure 4: Primarily closed vaginal defect (arrow) and omentum (arrowhead) packed into the pelvic cavity

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Figure 5: Marking of the flaps

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Figure 6: Raised flaps with de-epithelialised medial portions

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Figure 7: After the closure of the flaps over the defect

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  Discussion Top


Extensive perineal defect following abdominoperineal resection (APR) is traditionally managed via a primary closure strategy. Reported complications related to primary perineal closure after APR include seroma, abscess formation and wound dehiscence; these complications are prevalent in 30%–66% of patients.[1] Local flap reconstruction of the perineum and anal canal is an excellent method of managing large perineal defects.[2] Although several techniques such as musculocutaneous flaps and free tissue transfers have been described, they are much complicated. The benefits of V-Y flaps compared with other methods such as vertical rectus abdominis myocutaneous include reduced donor-site morbidity and increased ease of harvest and inset.[3] In small institutional series, V-Y flap closures were associated with higher primary healing rates, even in the setting of neoadjuvant radiotherapy. Arnold et al. reported outcomes from V-Y fasciocutaneous flaps based on the inferior gluteal artery perforators to reconstruct the perineal defect after APR in 18 patients.[4] The median hospital length of stay was 12 days, and the reported rate of minor wound complications (including abscesses and drainage) occurred at 39% and major complications (including flap dehiscence) occurred in 11% of patients. The perineal complication rate (including abscess, dehiscence and delayed healing) is 17%. Additional advantages of the V-Y flaps include the additional bulk created by the bilateral flaps; symmetric scarring; ability to recreate the vertical gluteal cleft and also, not associated with weakness or problems with balance, sitting or walking. This is a report of one such bilateral gluteal V-Y fasciocutaneous reconstruction of perineal defect, after extensive perineal resection, in a post-irradiated patient, with very good outcome.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Wiatrek RL, Thomas JS, Papaconstantinou HT. Perineal wound complications after abdominoperineal resection. Clin Colon Rectal Surg 2008;21:76-85.  Back to cited text no. 1
    
2.
Orkin BA. Perineal reconstruction with local flaps: Technique and results. Tech Coloproctol 2013;17:663-70.  Back to cited text no. 2
    
3.
Tashiro J, Yamaguchi S, Ishii T, Suwa H, Kondo H, Suzuki A, et al. Salvage total pelvic exenteration with bilateral V-Y advancement flap reconstruction for locally recurrent rectal cancer. Case Rep Gastroenterol 2013;7:175-81.  Back to cited text no. 3
    
4.
Arnold PB, Lahr CJ, Mitchell ME, Griffith JL, Salloum N, Walker MR, et al. Predictable closure of the abdominoperineal resection defect: A novel two-team approach. J Am Coll Surg 2012;214:726-32.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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