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TECNICA
TECNICA
TECNICA
ORIGINAL ARTICLE
Department of Plastic and Reconstructive Surgery and Maxillofacial Surgery, Kurume University School of Medicine,
Fukuoka, Japan
Abstract
Some patients develop an intrapelvic infection and fistula caused by the presence of intrapelvic dead space after the
resection of rectal cancer, and the treatment is sometimes quite difficult. We have developed a new surgical technique for the
treatment and prevention of such fistulas that uses a fasciocutaneous flap from the medial thigh. A V-shaped fasciocutaneous
flap with a pedicle on the anterior side of the thigh is designed on the medial thigh and gluteal region. After raising the
fasciocutaneous flap that contains the long saphenous vein, the gluteal section including a thick layer of fatty tissue is
de-epithelialised, and the flap is rotated and advanced towards the dead space to fill it. Four patients were operated on using
our technique. One was a secondary reconstruction: the patient had developed a small fistula after reconstructive surgery,
but it healed with conservative treatment. As a result, all four patients achieved satisfactory outcomes. The advantages of
our technique include: no change in the position of the body is required for reconstruction; operations are simple; sufficient
volume of tissue is obtained from the thick fatty tissues of the gluteal region; and the fasciocutaneous flap contains the long
saphenous vein and has good venous circulation. We consider this technique useful for the reconstruction of intrapelvic
dead space.
Key Words: Intrapelvic dead space, reconstruction, V-Y fasciocutaneous flap, long saphenous vein
Correspondence: Kensuke Kiyokawa, MD, PhD, Department of Plastic and Reconstructive Surgery and Maxillofacial Surgery, Kurume University School of
Medicine, 67 Asahi-machi, Kurume-shi, Fukuoka, 830-0011, Japan. Tel: 81-942-31-7569. Fax: 81-942-34-0834. E-mail: prsmf@med.kurume-u.ac.jp
fasciocutaneous flap is then slightly rotated and developed after total pelvic exenteration, which had
advanced towards the dead space. The donor site been done for recurrent rectal cancer (Table I).
of the flap is sutured in the same manner as the The three patients having primary reconstruction
preparation of a V-Y advancement flap (Figure 1c). were cured without complications, and there was no
After the dead space has been filled, two or three scar contracture on the thigh and gluteal regions. In
drains are left in the filled space, the donor sites of the case of secondary closure, a portion of the suture
the fasciocutaneous flap, and that of the gracilis on the thigh opened and a small fistula developed in
muscle flap. the filled area, but the wound healed after about two
months with maintenance treatment and split-thick-
ness skin grafting.
Patients and Results
From March 1991 to April 2001 four patients had
Two representative cases
their intrapelvic dead space reconstructed after
excision of rectal cancer using our technique. The Case 3 (Table I). A 51-year-old man had a rectal
patients, three men and one woman, were aged cancer that invaded the anal area and created an
between 39 and 68 years. Three had had primary abscess. He had an abdominoperineal resection of
reconstruction after abdominoperineal resection of the rectum and simultaneous resection of the skin
the rectum and extended perianal skin resection, and around the anus (about 10 cm in diameter). Bilateral
the other case was secondary closure of a fistula that fasciocutaneous flaps were designed on the medial
side of the thighs (Figure 2a) and raised with the was treated by retraction and debridement. He was
long saphenous vein. Bilateral gracilis flaps were then referred to us to have the dead space filled. On
raised (Figure 2b), and were placed into the back of examination, there was a fist-sized space in the
the pubic bone. The gluteal areas of the fasciocu- perineal region (Figure 3a). The space was filled
taneous flaps, which have thick fatty tissues, were de- using the flap that we designed (Figure 3b, c).
epithelialised (Figure 2c), rotated and advanced, and Postoperatively he developed a small fistula. It was
closed with sutures in a way that would fill the dead retracted, and after waiting for thickening of the flesh,
space (Figure 2d). The wound healed without we applied split-thickness skin grafts two months
complications. The scar did not contract and there after the reconstruction. The lesion then healed.
were no related problems (Figure 2e). Contracture of the gluteal region was released, and
he had good functional improvement.
Figure 3. A 39-year-old male patient. (a) A fistula developed as a result of inflammation in the intrapelvic dead space after
abdominoperineal resection of the rectum. (b) The design of the flap. (c) Immediately postoperatively.
but complete cure is rarely achieved. Even when therefore often used for reconstruction of the pelvic
complete cure is achieved, it is only after a long cavity. However, a muscular flap alone cannot
period of treatment during which the QOL of the provide sufficient volume of tissue, and only the tip
patient is affected because of difficulty in sitting on a of the muscular flap can be used for filling the dead
chair because of contracture of the gluteal region. To space because of the location of nutrient vessels. If
prevent inflammation of the pelvic dead space, it is the flap is attached with a skin island and used as a
important to fill that space. Examples of fillers are a myocutaneous flap, blood circulation in the skin
gracilis muscle flap [1,2], a rectus abdominis island is unstable. Another method creates a skin
myocutaneous flap [36], an omental flap, an antero- flap including the sartorius muscle [8,9], but the
lateral thigh flap [7], and a free latissimus dorsi volume of tissue is still insufficient. The rectus
myocutaneous flap. Each one has advantages and abdominis myocutaneous flap has a stable blood
disadvantages (Table II), and the optimal flap should circulation, allows grafting of sufficient volume of
be chosen according to the size of the dead space and tissue without a change in the position of the body,
other factors. The gracilis muscle flap is relatively and is grafted intraperitoneally. However, the posi-
easy to raise and the procedure does not require a tion of the stoma must be planned before operation,
change in the position of the body of the patient; it is and this flap is difficult to apply to secondary
[2] McCraw JB, Massey FM, Shanklin KD, Horton CE. Vaginal
operation field; our fasciocutaneous flap can be
reconstruction with gracilis myocutaneous flaps. Plast Re-
advanced in the same manner as a V-Y flap, and constr Surg 1976;58:17683.
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this allows reconstruction of a dead space with a [3] Jain K, DeFranzo AJ, Marks MW, Loggie BW, Lentz S.
large resection of skin around the anus (Figure 2); Reconstruction of pelvic exenterative wounds with transpelvic
our flap rarely causes deformation or contracture of rectus abdominis flaps: a case series. Ann Plast Surg 1997;38: / /
11522.
the gluteal region; and the donor site does not need
[4] Tobin GR, Day TG. Vaginal and pelvic reconstruction with
skin grafting for closure. distally based rectus abdominis myocutaneous flaps. Plast
Our flap is basically a random pattern flap. Reconstr Surg 1988;81:6273. / /
However, it has good venous blood circulation [5] Giampapa V, Keller A, Shaw WW, Colen SR. Pelvic floor
because the long saphenous vein is included in the reconstruction using the rectus abdominis muscle flap. Ann
Plast Surg 1984;13:569.
flap. Blood circulation in our flap is the same as the
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visible, and it does not cause serious problems [7] Luo S, Raffoul W, Piaget F, Egloff DV. Anterolateral thigh
fasciocutaneous flap in the difficult perineogenital
because there are no functional disorders caused by reconstruction. Plast Reconstr Surg 2000;105:1713. / /
cases in which the defect is equal to, or slightly larger [10] Goi T, Koneri K, Katayama K, et al. Modified gluteus
than, the fist of the patient. When the dead space is maximus V-Y advancement flap for reconstruction of
Reconstruction of intrapelvic dead space 147
perineal defects after resection of intrapelvic recurrent rectal [13] Nakajima H, Imanishi N, Fukuzumi S, Minabe T, Aiso S,
cancer: report of a case. Surg Today 2003;33:6269.
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