Neovaginal reconstruction after exenteration using an omental flap and split-thickness skin graft

The earliest efforts at neovaginal reconstruction used split-thickness skin grafts when bladder and rectum remained in place. In patients undergoing total pelvic exenteration, the pelvic organs are not available to accept the skin graft. By modifying the omental flap normally used to close off the pelvic inlet after total pelvic exenteration with or without lower coloproctostomy, a cylinder can be created that provides anterior, posterior, and lateral walls for the neovagina. When this omental cylinder is lined with a split-thickness skin graft and secured in the postoperative period using a soft vaginal form, a satisfactory neovagina can be created. This article presents the authors' experience with 20 patients who underwent radical pelvic exenteration for gynecological malignancy and neovaginal reconstruction using an omental cylinder flap lined with a split-thickness skin graft. In this series, all flaps and skin grafts have remained soft and completely viable with no pelvic infections, perineal fistulae, or hernias, and they offer the potential for sexual function in approximately 80 percent of patients. Average reconstruction operating time is less than 2 hours. In the properly selected patient, this method provides distinct advantages over reconstruction with myocutaneous flaps, which may be too bulky, too difficult to pass into the pelvis, and require additional donor-site incision with prolonged operative time. Myocutaneous flaps may have greater potential for partial or complete tissue loss. Neovaginal reconstruction using an omental cylinder flap lined with a split-thickness skin graft compares favorably with previously described methods by providing support for the pelvic floor with primary healing while restoring the potential for sexual function with minimal overall morbidity.