Reconstruction of Perineum and Abdominal Wall

Introduction

Since the turn of the century, managing severe abdominal walls and perineal anomalies has been a problem for general and reconstructive surgeons. The complexity of abdominal and perineal wall deformities and the development of procedures involving the manipulation and mobility of muscles and myocutaneous flaps, which drew general surgeons' attention, have necessitated the use of plastic surgeons' skills.

Regardless of the surgeon's training, the objectives of the reconstructive surgeon in treating complex abdominal and perineal wall abnormalities are to provide stable and long-lasting wound coverage. The main aim of the surgeon is to reestablish the structure and function of the musculofascial system.

What Is Reconstruction of Perineum?

• Rebuilding of injured or malformed tissue between the genitalia and the anus is referred to as perineal reconstruction.

• In the genital and urinary regions of the body, perineal reconstruction is frequently performed for inherited and congenital abnormalities or reconstruction after cancer surgery.

• One of the more difficult flaws to reconstruct in plastic surgery is perineal wounds.

• The sizes of resections in the perineum vary; apart from that, radiation, chemotherapy, and infection are frequent complications.

• The difficult positioning and the requirement to preserve the anus, urethra, vaginal function, and abdomen tissues and to enable comfortable sitting all add to the complexity of these repairs. Given this complexity, there are numerous possibilities for flap coverage.

Where Is Reconstruction of Perineum Indicated?

Perineal reconstruction is indicated in the following cases:

• Malignancies of the perineum.

• Radiation damage.

• Iatrogenic causes.

• Infections.

• Gangrene of perineal area.

• Trauma.

How Is Reconstruction of Perineum Done?

1. VRAM (Vertical Rectus Abdominis Myocutaneous) flap:

• Extensive surgery must be performed to achieve an oncologically safe scenario, and several pelvic tissues must be removed "en bloc" (removing totally) during pelvic exenteration.

• Even with radiation, when a significant intrapelvic cavity often persists, perineal wound problems such as wound dehiscence and prolonged secretion can happen after abdominoperineal extirpation.

• Studies have revealed that the VRAM flap, with its relatively low risk of donor and recipient site complications, is a safe and reliable approach for pelvic reconstruction in patients with novel diseases needing pelvic exenteration and radiation.

2. ALT (Anterolateral Thigh) Flap:

• A line is drawn between the anterior superior iliac spine (ASIS) and the lateral patella's midpoint to indicate the location of the ALT flap. The septum between the vastus lateralis and the rectus femoris is shown by this line.

• The main benefits of this flap are that it offers a lot of skin for harvesting and that the pedicle is near the perineum while being far enough away from the perineum's region and radioactively damaged regions.

• The lateral circumflex profunda femoral artery descending branch perforators are necessary for the ALT flap's blood supply. In general, a wide skin flap can be raised, but only one with a diameter of up to eight centimeter could be closed without a skin graft.

• Reconstruction timing might be exceedingly tricky. A multidisciplinary approach is essential to examine the patient and his clinical results comprehensively. The radiologic conclusions must be addressed multidisciplinary to achieve a long-lasting treatment. There should be no compromise of the diagnosis and treatment resection level.

3. Gracilis Flap:

• The gracilis flap continues to be one of the most popular flaps used for perineal repair.

• The medial femoral circumflex artery is the major blood vessel supplying the gracilis myocutaneous or muscle flap.

• A short gracilis may be provided by additional small perforators (vessels perforating the adjacent tissue) that originate medially from the obturator artery.

• If necessary, the flaps could be de-epithelialized to eliminate pelvic dead space (void caused due to tissue loss caused by infection, trauma, or surgery). After APR (abdominal perineal resection) for inflammatory bowel disease, this flap has demonstrated promising results in the delayed rebuilding of consistent perineal sinus tracts.

• The gracilis flap's benefits in the context of APR (abdominal perineal resection) are primarily associated with its ability to prevent interference with establishing a colostomy site.

• The flap is most useful in small, moderately narrow, distant lesions in the hip region.

What Is Reconstruction of the Abdominal Wall?

• The stomach, kidneys, and small intestine are among the organs that are protected by the numerous layers of tissue, fat, and muscle that make up the abdomen.

• Critical bodily processes like respiration and urination are aided by the abdominal wall muscles, which stabilize the torso.

• The creation of complicated hernias and the reappearance of a hernia that has been previously treated can occasionally cause the wall to deteriorate.

• The abdominal wall tissues in these situations need to be rebuilt. This surgical treatment is employed to reestablish the morphological and physiological stability of the abdominal muscles.

Where Is Surgical Reconstruction of Abdominal Wall Indicated?

Patients who have the following conditions may have this surgery advised to them:

• Repeated hernias.

• Surgical hernia.

• Infection that appears following surgery.

• Wound that occurs following a hernia surgery.

How Is Abdominal Wall Reconstruction Done?

1. Myocutaneous Flap:

Musculocutaneous flaps are widely used to repair the pelvic floor and perineum and to fill the intra-abdominal space left over after the exenteration. VRAM flaps damage the abdominal wall, however, mesh reinforcement is an option. Insertion of foreign material in the abdominal wall has been the subject of heated controversy because of the risk of surgical field contamination.

2. Extralevator Abdominoperineal Excision (ELAPE), Biological Mesh Reconstruction of the Pelvic Floor:

• Despite some reservations, the use of ELAPE over regular APER (abdominoperineal excision of the rectum) is becoming increasingly widespread, and the best way to close perineal wounds is still debatable.

• The reported outcomes of the perineal defect's primary closure are subpar, and most surgeons doing ELAPE choose an auxiliary approach.

• According to the research, myocutaneous flaps and other reconstruction procedures, such as perineal closure with biologic mesh, have injury, infection, and complications associated that are comparable.

• However, using a vertical rectus abdominis (VRAM), gracilis, or gluteus maximus for myocutaneous flap reconstruction has short-term disadvantages, including longer operating times and the need for plastic surgery expertise, which increases operative costs, flap necrosis, wound issues at the donor site, and long bed rest.

All of these potential problems are avoided through biological mesh rebuilding.

The mesh is often positioned as an inlay or bridge across the pelvic floor defect close to the bony structures and stitched at one centimeter intervals to close the defect.

Conclusion

Flap reconstruction for pelvic wounds and abdominal flaws is subject to decisions that the patient, the operation, the size, and the characteristics of the imperfection influence. Preoperative planning in a multidisciplinary context is crucial to achieving the best results.