Hostile Fields and Limited Options: Autologous Peritoneal Grafting as a Salvage Strategy for Complex Perineal Defects

Pelvic surgery for malignancy or infection can result in large pelvic floor defects. Standard reconstruction options may not be feasible in patients with prior radiation, significant comorbidities, and/or malnutrition. We present a low-morbidity salvage approach using an autologous peritoneal graft as a biologic pelvic partition, followed by vacuum-assisted closure, for a large contaminated perineal defect in a patient with a colocutaneous fistula following robotic abdominoperineal resection. An autologous peritoneal graft was harvested from the parietal peritoneum, including tissue from a previous incisional hernia sac, tailored to the required size, and sutured circumferentially to the margins of the defect to partition the pelvic inlet from the peritoneal cavity. A vacuum-assisted closure system was placed on postoperative day (POD) 4 and maintained until POD 43, resulting in marked wound size reduction. This technique offers a tension-free, mesh-free salvage option for selected complex perineal defects, particularly in hostile, irradiated, and contaminated fields where conventional reconstructive strategies may not be feasible.