Simultaneous posterior vaginal and perineal reconstruction using gluteal fasciocutaneous flaps following pelvic exenteration with sacrectomy

Herein we describe a novel surgical technique for simultaneous reconstruction of the perineum and posterior vaginal wall following exenteration with sacrectomy and posterior vaginectomy in a patient with recurrent rectal cancer. Bilateral V-Y gluteal flaps were used for perineal reconstruction, and an orthogonal gluteal fasciocutaneous rotation-advancement flap for posterior vaginal wall reconstruction.

Pelvic exenteration (PE) is a potentially curative treatment for locally recurrent rectal cancer. Technical and surgical advancements have led to more complex PE resections being regularly performed, with R0 and mortality rates improving globally^1,2. Vaginal reconstruction following pelvic exenteration may provide physical and psychological benefits. This letter describes the technique for simultaneous perineal and vaginal reconstruction.

A 74-year-old woman with locally recurrent rectal cancer underwent pelvic exenteration including resection of the sacrum below the level of S1/S2, posterior wall of the vagina, an involved loop of terminal ileum, right piriformis and coccygeus muscles. Bilateral V-Y gluteal flap and posterior vaginal wall reconstruction were performed at the time of surgery, as the patient strongly wished to undergo vaginal reconstruction. After completion of the abdominal portion of the exenteration, the abdomen was closed and the patient placed prone. Sacrectomy, resection of the specimen and reconstruction were performed in the prone position (Fig. 1a). The perineum and posterior wall of the vagina were reconstructed using the following technique. An orthogonal gluteal fasciocutaneous flap was designed and carried in the left lateral aspect of the gluteal region (Fig. 1b). A designated gluteal skin paddle measuring 12 cm × 4 cm was left intact for reconstruction of the posterior vaginal wall, while a gluteal skin strip 4 cm lateral and 15 cm superior to the designed flap was de-epithelialized, with the underlying fat used to fill the perineal cavity (Fig. 1c). After mobilization of the subcutaneous tissue, the orthogonal gluteal fasciocutaneous flap could be turned over into the vaginal cavity. The flap was ultimately inverted to the vagina and was fashioned to match the posterior vaginal wall defect. The gluteal skin was reapproximated to the anterior and lateral walls of the vagina using interrupted 2-0 Vicryl sutures without tension (Figs 1d, e). Bilateral gluteal V-Y advancement skin flaps were carried out as previously described to fill the perineal defect, the perineal wound was closed without tension (Fig. 1f). Post-surgery, the reconstructed vagina healed well and remained patent.

Fig. 1.

a Perineal defect following pelvic exenteration with en bloc sacrectomy and vaginectomy. Patient in prone position. b Design of the left gluteal skin flap measuring 12 cm × 4 cm. c De-epithelialized gluteal skin 4 cm lateral and 15 cm superior to the designed flap, with the underlying fat used to fill the perineal cavity. d Orthogonal gluteal fasciocutaneous flap turned over into the vaginal cavity and fashioned to match the posterior vaginal wall defect. e Gluteal skin reapproximated to the anterior and lateral walls of the vagina. Clamp delineating neovaginal introitus. f Bilateral gluteal V-Y advancement skin flaps to fill the perineal defect

A few techniques for vaginal reconstruction following pelvic exenteration have been described in the literature, suggesting that no single procedure is ideal. The most commonly used procedures include vertical/oblique/transverse rectus abdominis myocutaneous, gracilis and modified Singapore (pudendal thigh) flaps. However, all myocutaneous flap procedures are associated with prolonged operative times, and varying degrees of both intraoperative and postoperative morbidity^2,3. Donor site morbidity remains a major concern for all abdominal wall-based myocutaneous flaps, with complications such as fascial dehiscence, evisceration or later development of incisional hernias described in 10–20% of cases^4–6.

The flap described in this letter may be an ideal method for closure of major sacral/perineal defects with simultaneous posterior vaginal reconstruction. It provides non-irradiated, well-vascularized gluteal fat tissue that fills the pelvic dead space, allows for optimal stomal placement, and provides a chance for sexual function. The principle of this technique lies in preservation of the gluteal arteries supplying the subcutaneous tissue, and the use of the overlying skin as new posterior vaginal wall. This technique provides bulky tissue that is suitable for filling the pelvic defect with use of bilateral gluteal V-Y advancement fasciocutaneous flaps, while at the same time providing the ability to form a versatile skin flap for posterior vaginal reconstruction of adequate length and width, with the surface of the new vaginal tissue being pliable for function.

Funding

E.P., A.B.-Y., R.M.J.-R.: no financial disclosures. Dr. Julio Garcia Aguilar receives honoraria from Johnson and Johnson, Medtronic and Intuitive Surgical, and owns stock in Intuitive Surgical.

Disclosure

The authors declare no conflict of interest.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article.

Author contributions

Emmanouil Pappou (CRediT contribution not specified), Almog Ben-Yaacov (Writing—review & editing), Rosa M. Jimenez Rodriguez (CRediT contribution not specified) and Julio Garcia-Aguilar (CRediT contribution not specified)