2025/08/01 by Zoe Li, Alethea Tang, Peter Drew · 1 voice
Medicine · #Anorectal Disease Treatments and Outcomes #Colorectal Cancer Surgical Treatments #Colorectal and Anal Carcinomas
paper · pdf · doi:10.1093/bjs/znaf164
openalex publication_date 2025/08/01 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/30
Perineal reconstruction aims to mitigate the complications of radical pelvic cancer resection by filling pelvic dead space, restoring perineal skin continuity, and reconstructing the pelvic floor and vagina The reconstructive strategy can be influenced by factors relating to the patient, the defect, previous treatment, and surgeon experience There is no consensus on optimal reconstructive technique, which can be broadly categorized into direct closure, mesh repair, and tissue flaps Flaps have different advantages and complication profiles. It remains crucial to tailor reconstruction according to the specific needs and wishes of each patient Curative treatment of locally advanced and recurrent malignant pelvic tumours requires radical surgical excision. The goal of potentially curative surgery is complete resection with pathologically clear (R0) margins1. The proximity of organs within the pelvis means that surgery for advanced tumours frequently requires a tailored multidisciplinary approach. Radical surgery often results in large and complex defects that necessitate specialist reconstruction. Radicality of oncological resection will depend on the pathology and extent of malignancy. When disease involves one or more pelvic organs some form of pelvic exenteration (PE) is usually required. Pelvic exenteration can be classified anatomically as anterior, posterior, or total, depending on the organs excised (Fig. 1). A recent attempt to standardise nomenclature defined PE procedures as Conventional (‘a major surgical procedure where all or most organs in the pelvic cavity are removed’) or Highly Complex (‘conventional PE with the extension of surgery to remove bony structures or structures in the pelvic sidewall’)2. Varieties of pelvic exenteration. Pelvic exenteration is a curative treatment strategy for appropriately selected patients. Five-year survival rates of over 60% are reported for patients with locally advanced primary rectal cancers after pelvic exenteration, with the possibility of quality-of-life outcomes returning to preoperative levels 6 months after surgery3. However, major complications—for example, wound dehiscence, pelvic abscess—are relatively common (up to 40%)4. Recently, ‘Empty Pelvis Syndrome’ (EPS) has been identified as a consequence of PE and is defined as encompassing ‘a spectrum of post-exenteration complications including infected fluid collections, bowel obstruction, perineal sinus, and fistulas—severity is multifactorial, likely due to radicality of resection and migration of bowel into the void generated’5. Perineal reconstruction aims to mitigate the risks of complications and promote rapid wound healing, restoring form and function where possible. In this context, reconstruction may include procedures designed to achieve one or more of the following: fill pelvic dead space replace or repair the pelvic floor restore perineal skin continuity vaginal reconstruction Patient-related factors that influence reconstructive strategy include co-morbidity, body habitus, and previous treatment, the most significant being preoperative pelvic radiotherapy and surgery. Radiotherapy impairs wound healing, increasing the risk of perineal wound complications6, whereas previous or current stomas and scars from other procedures may preclude the availability of some flap options. Surgical factors include patient positioning (supine or prone), intended operative approach (open or laparoscopic), likely defect size and complexity, and the availability of flap donor sites. The preference and expertise of the pelvic surgeon and the availability of assistance from a specialist reconstructive surgeon may also have a role. Factors influencing reconstructive strategy Factors influencing reconstructive strategy Three broad categories of reconstructive technique are commonly used—direct closure, mesh repair, and closure using tissue flaps. The indications and risks of each are summarized in Table 2. These techniques can be used alone or in combination; for example, mesh repair to reduce risk of perineal herniation with flap reconstruction to provide robust soft tissue cover. Techniques in perineal reconstruction Techniques in perineal reconstruction There is currently no consensus on the optimal reconstructive technique. In a 2018 position statement on perineal closure following abdominoperineal excision (APE) for rectal adenocarcinoma, the Association of Coloproctology of Great Britain and Ireland (ACPGBI) concluded that there is insufficient evidence to demonstrate the optimal reconstructive choice, although primary perineal closure is likely to have a higher risk of perineal herniation7. This uncertainty is largely due to a paucity of high-quality research. Significant confounding factors in published series to date include the heterogeneity of patients and post-resection defect size. The term ‘flap’ describes a segment of tissue transferred with its own blood supply. Most flaps used in perineal reconstruction are pedicled, that is they remain attached to the patient by their vascular pedicle. The pedicle of a perforator flap includes one or more perforating branches of a named artery. Flaps vary in their composition: fasciocutaneous flaps consist of skin, subcutaneous tissue and deep fascia; myocutaneous or muscle flaps consist of muscle, fat and skin, or muscle alone respectively (Fig. 2). Donor sites are usually in neighbouring areas, such as buttock, upper thigh, or abdominal wall (Table 3). In the UK, the most used (‘work horse’) flaps include the inferior and superior gluteal artery perforator flaps (IGAP and SGAP), gracilis flap, and vertical rectus abdominus myocutaneous flap (VRAM), although others are described8–10 . Components of fasciocutaneous and myocutaneous flaps. Flap advantages and disadvantages Flap advantages and disadvantages These fasciocutaneous flaps are based on perforating branches of the inferior or superior gluteal artery which pierce the gluteus maximus muscle in the buttock (Fig. 3a). They are applicable when the abdominal part of an APE is performed laparoscopically, and the patient is then turned prone to access the perineum11. a,b. IGAP flaps. IGAP flaps (uni- or bilateral) are usually advanced medially into a post-exenteration defect, in a V to Y fashion (Fig. 3b). The medial edge of one flap is de-epithelialized and secured within the pelvic outlet, filling perineal dead space, while the other overlaps it. Simultaneous perineal and vaginal reconstruction is possible using IGAP flaps, although mesh may be required to reduce the risk of perineal hernias12. The complication rate for IGAP and gluteal flaps appears to be comparable to flaps from other donor sites, although they may be associated with a higher risk for perineal hernias13. SGAP flaps are indicated for sacral defects and may be used bilaterally or in combination with a contralateral IGAP flap. They are usually raised on a single perforating vessel and transposed into the defect, while the flap donor site is closed directly14. The gracilis muscle is a hip adductor and knee flexor in the medial thigh, supplied by vascular pedicles from the medial circumflex femoral artery. When isolated on the most proximal of these, the muscle can be rotated through 180° and the distal end brought into the perineum via a subcutaneous tunnel (Figs 4a,b). If required, the skin and fat overlying the proximal half can be reliably transferred with it. The muscle-only pedicled gracilis flap can be used to repair rectovaginal fistulae, as bilateral flaps, and the pelvic floor, although its limited bulk and reach make it less applicable in filling pelvic dead space15,16. As a myocutaneous flap, gracilis has a role in vaginal and vulval–perineal reconstruction. It can be combined with a pedicled profunda artery perforator flap, which can be inset independently to enable reconstruction of the pelvic floor and vaginal canal separately10. a,b. Muscle-only pedicled gracilis flap. The VRAM flap is probably the most widely used flap in post-exenteration perineal reconstruction due to its robust blood supply, significant reach, and bulk17. Transabdominal transfer of the flap was first described in 198418. The flap is raised on its inferior pedicle (deep inferior epigastric artery) with or without a skin paddle and passed internally. Flap bulk fills both pelvic and perineal dead space, and skin is available to be used in vaginal and perineal reconstruction (Figs 5a–e). Donor site hernia is a risk, although studies indicate that the incidence of incisional hernias in VRAM flaps is comparable to a standard laparotomy, particularly when fascia-sparing techniques are used in flap harvesting19,20. The total flap loss rate is reported at around 2%, with a partial flap loss rate of 4%13,17. a–e. VRAM flap harvest and inset. Meta-analyses comparing primary closure versus flap closure have validated the use of myocutaneous flaps for reducing perineal morbidity rates following abdominoperineal resection or pelvic exenteration21,22. Studies comparing different flap reconstructions have illustrated the profiles of the different flaps—the varying indications that influence their use, as well as their different advantages and complication profiles13,23. The factors that influence the success of perineal reconstruction following advanced pelvic malignancy are complex and multiple. While further studies are underway evaluating outcomes of different reconstructive methods, the guiding principle of tailoring each reconstruction according to the specific needs and wishes of the patient remains crucial. The authors have no funding to declare. Zoe Li (Writing—original draft, Writing—review & editing), Alethea Tang (Writing—original draft, Writing—review & editing), and Peter Drew (Conceptualization, Supervision, Writing—original draft, Writing—review & editing) The authors declare no conflict of interest.