Reconstruction of pelvic exenterative wounds with transpelvic rectus abdominis flaps: a case series

Exenterative pelvic surgery is commonly performed for advanced carcinoma of the cervix and selected cases of locally advanced colorectal cancers. Low-lying lesions that are locally invasive in contiguous organs require resection of the perineal body en bloc with the resected specimen. The resulting defect, both in the pelvis and the perineum, creates a difficult management problem. Dead space in the pelvis, especially with adjunctive irradiation, leads to delayed wound healing and prolapse of small bowel into the pelvis. Small bowel obstruction and/or fistula formation are the greatest sources of morbidity in the operative group. Fifteen patients underwent exenterative pelvic procedures (total exenteration, 1 patient; posterior exenteration, 8 patients; abdominoperineal resection, 6 patients). All patients were reconstructed by transpelvic placement of the rectus abdominis muscle (muscle only, 4 patients; muscle with skin grafting, 8 patients; musculocutaneous, 3 patients). Eighty-seven percent received radiation therapy. One patient had Crohn's disease and all others had carcinoma. Healing was complete in 12 of 15 patients at discharge. There were no complications related to pelvic dead space (i.e., bowel obstruction, perineal fistula), with a mean follow-up time of 24.3 months. Small bowel was effectively excluded from the pelvis to the level of the acetabular roof by computerized axial tomography scan. The transpelvic rectus abdominis muscle flap is effective in preventing major morbidity after exenterative pelvic surgery.