Gluteal transposition flap without donor site scar for closing a perineal defect after abdominoperineal resection
Gluteal transposition flap without donor site scar for closing a perineal defect after abdominoperineal resection
R. D. Blok 0 1 2
O. Lapid 0 1 2
W. A. Bemelman 0 1 2
P. J. Tanis 0 1 2
0 Department of Plastic and Reconstructive Surgery, University of Amsterdam , Amsterdam , The Netherlands
1 Department of Surgery, Academic Medical Center, University of Amsterdam , Post box 22660, 1100 DD Amsterdam , The Netherlands
2 Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam , Amsterdam , The Netherlands
Fig. 1 Protrusion of a small bowel loop through a granulating perineal wound after abdominoperineal resection reconstructed by stitching an acellular biological mesh (StratticeTM, 6 9 10 cm) to the sacrococcygeal ligaments, remnants of the levator muscle and transverse perineal muscles with interrupted Monoplus 2/0 sutures. A silicone drain was inserted in the pelvic cavity behind the mesh, because there was still a purulent discharge from the perineal wound. Next, a shallow semicircular incision was made in the right gluteal skin with a maximum distance of about 3 cm from the adjacent perineal defect, including at least one perforator of the gluteal artery as identified by Doppler imaging (Fig. 2). The Luna-shaped skin island was deepithelialized. The subcutaneous fat was transected lateral from the perforator down to the gluteal fascia. Afterward, the subcutaneous flap was placed onto the biomesh and fixed with Novosyn 3/0 sutures, completely obliterating the remaining dead space. A vacuum drain was placed between the mesh and the flap. The subcutaneous tissue on both sides of the wound was slightly mobilized from the gluteal fascia and closed in the midline over a
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Abdominoperineal resection (APR) is still associated with
substantial morbidity related to the perineal wound [1].
Perineal wound problems are observed in up to 47% of
patients, with secondary hernia formation in up to 26% [2, 3].
Obliterating the perineal dead space with
well-vascularized tissues can promote wound healing after primary
APR or can be used to treat secondary complications.
We present a case of emergency surgery in a patient
presenting with small bowel herniation through an unhealed
perineal wound (Fig. 1) 2 months after APR for pT3N0M0
rectal cancer. Following pelvic floor reconstruction with a
biological mesh, the perineal soft tissue defect was closed
using a unilateral semicircular gluteal perforator flap, which
we named Luna flap, followed by midline closure of the skin.
Surgical technique
The patient was placed in the prone position. Granulation
and fibrotic tissue was excised with detachment and
repositioning of the small bowel loop. The pelvic floor was
Fig. 2 a Pelvic floor
reconstruction with Strattice
6 9 10 cm with intra pelvic
silicone drain, b incision of
Luna flap, c deepithelialization,
d transection of subcutaneous
fat e deep fixation of the flap
over a CH10 Redon drain,
f closure of the midline over a
second CH10 Redon drain
second vacuum drain, followed by intracutaneous closure
of the skin in the midline.
Postoperatively, continuous purulent discharge from the
silicone drain in the pelvic cavity required twice-daily
irrigation with saline solutions. After 7 days, the patient
was discharged with the silicone and deep vacuum drains
still in situ. The patient was fully mobilized after 2 days
and was allowed to sit after 10 days. The silicone drain fell
out after 2 weeks, but clinical examination at the outpatient
clinic at 3 weeks showed a well-healed perineal wound
(Fig. 3) and the remaining vacuum drain was removed.
Follow-up after 6 weeks is still uneventful.
A small bowel herniation in an unhealed perineal defect
after APR demanded emergency surgery. A biomesh was
used to reconstruct the pelvic floor. The dead space above
this mesh was covered with a gluteal perforator flap. No
additional scars were required.
Because a subcutaneous transposition flap probably does
not add any strength to the pelvic floor, a biological mesh
was chosen for reconstruction in a contaminated
environment. It is of great importance to sufficiently cover the
mesh with soft tissue to prevent seroma and abscess
Fig. 3 Healed perineal wound at 3 weeks
formation below the mesh and to promote mesh ingrowth.
Currently, there are several options for filling a perineal
defect, but all are associated with the risks of donor- and
recipient-site morbidity [4, 5]. The Luna flap as described
in the present report seems to be a promising modification
of the VY fasciocutaneous gluteal transposition flap for
complete filling of the dead space in relatively small
perineal defects, without additional scars, with an early return
to normal activity and only limited increase in operative
time.
Compliance with ethical standards
Ethical approval This modification of a routinely applied surgical
technique was not performed in the context of a study that needs
ethical approval.
Informed consent Consent from (...truncated)