RECONSTRUCTIVE SURGERY

Contralateral Component Separation Technique for Abdominal Wall Closure in Patients Undergoing Vertical Rectus Abdominis Myocutaneous Flap Transposition for Pelvic Exenteration Reconstruction Antonio Espinosa-de-los-Monteros, MD,* Lilian Arista-de la Torre, MD,* Omar Vergara-Fernandez, MD,Þ and Noel Salgado-Nesme, MDÞ Abstract: Pelvic f loor reconstruction with pedicled vertical rectus abdominis myocutaneous f lap has been popularized in patients undergoing pelvic exenteration due to locally advanced rectal carcinoma. Abdominal wall fascial dehiscence and incisional hernia may occur as a result of large skin and fascia islands as well as muscle required to close these large defects. The purpose of this paper was to describe a novel technique, consisting of VRAM f lap donorsite closure with component separation technique, performed on the contralateral side as the flap harvest, allowing for a lower tension closure between ipsilateral external oblique/internal oblique/transverse abdominis muscles complex and contralateral rectus abdominis muscle. In 10 patients undergoing this technique, no abdominal fascial dehiscence, incisional hernia, or parastomal hernia occurred during a mean follow-up of 15 months. Overall 3-year patient survival rate was 80% with abdominal hernia free-survival rate of 100%. The addition of this technique represents an advance in overall patient care to provide a more successful outcomes in this complex scenario. Key Words: pelvic exenteration, VRAM, vertical rectus abdominis myocutaneous flap, pelvic floor reconstruction, component separation, abdominal wall reconstruction (Ann Plast Surg 2016;77: 90Y92)

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ectal carcinoma incidence has increased in the past years. Surgical treatment of distal rectal cancer with local invasion to gynecologic, urologic, and/or sacral structures is best accomplished by en-block removal of all involved organs.1 This pelvic exenteration is mostly performed in irradiated surgical fields since patients with this advanced-stage disease usually undergo neoadjuvant therapy. The external defect resulting from a pelvic exenteration may include as much as the posterior wall of the vagina in women as well as the perineum and the perirectal skin in both female and male patients. There are a number of methods available to reconstruct such defects. The most popular is the vertical-oriented rectus abdominis musculocutaneous flap (VRAM), which is transferred based on its deep inferior epigastric pedicle to provide well-vascularized skin to the area to be reconstructed.2 It also provides bulk to the pelvic floor so that proper obliteration of dead spaces may be accomplished. Donor site closure may be achieved primarily between ipsilateral external oblique muscle and contralateral rectus abdominis muscle, although

Received April 24, 2014, and accepted for publication, after revision, July 12, 2014. From the *Plastic Surgery Division and †Colorectal Surgery Division, Departamento de Cirugia, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga, Mexico City, Mexico. Conflicts of interest and sources of funding: none declared. Reprints: Antonio Espinosa-de-los-Monteros, MD, Departamento de Cirugia, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Vasco de Quiroga 15, Mexico City, CP 14000, Mexico. E-mail: [email protected]. Copyright * 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/16/7701-0090 DOI: 10.1097/SAP.0000000000000327

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variable degrees of tension result from lack of abdominal muscle and fascia. To overcome this adverse scenario, performance of component separation technique on the same donor muscle side has been described by Baumann and Butler.3 With this technique, separation of the external oblique muscle from the underlying internal oblique muscle at the same side as the transferred rectus muscle allows for a lower tension closure between ipsilateral internal oblique/transverse abdominis muscles complex and contralateral rectus abdominis muscle. The purpose of this paper was to describe a novel technique, consisting of VRAM f lap donor-site closure, with component separation technique performed on the contralateral side as the f lap harvest, allowing for a lower tension closure between ipsilateral external oblique/internal oblique/transverse abdominis muscles complex and contralateral rectus abdominis muscle.

PATIENTS AND METHODS Since January 2007, all patients undergoing posterior pelvic exenteration for locally advanced rectal cancer at our institution are reconstructed with a VRAM f lap. Donor-site closure of the abdomen is performed identically in all cases, as follows. After en-block removal of all organs involved with the rectal carcinoma, a right-sided VRAM f lap is transferred to the pelvic area (Fig. 1). In addition, the colonic segment to be used as colostomy is exteriorized through the left-sided abdominal wall, and intra-abdominal drains are placed with care taken to have them exit at the level between the left rectus abdominis muscle and the left external oblique muscle to avoid injury of abdominal wall vessels. Then, a subcutaneous tunnel along the middle third of the left-sided abdomen is created. This tunnel extends from the midline incision laterally to the semilunaris line and provides a "surgical window" for further incision of the interface between left rectus abdominis muscle and left external oblique muscle along its entire length. No skin undermining is performed on the upper and lower thirds of the left-sided abdomen to preserve myocutaneous perforators to the wound. Once the semilunaris fascia has been incised, the left external oblique muscle is separated from the left internal oblique muscle extending far laterally to the level of the midaxillary line. These maneuvers allow for a lower tension abdominal wall closure between the left rectus abdominis muscle and the right external oblique/internal oblique/transversus abdominis muscles complex. This is performed with a running number 0 polypropylene suture (Prolene, Ethicon) (Fig. 2). No meshes are used to aid in abdominal wall closure. One drain is placed along the leftsided intermuscular space before closing superficial fascia and skin with 3 layers of 3Y0 polyglecaprone sutures (Monocryl, Ethicon). Patients are seen on a daily basis while at the hospital. After discharge, follow-up is performed at the office once a week for the first month, once a month for the following 5 months, and once every 6 months thereafter. Follow-up includes physical examination and review of computed tomographic scans obtained serially for oncologic surveillance. Analysis of all cases performed includes sex, age, Annals of Plastic Surgery

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Contralateral Component Separation for VRAM Flap

FIGURE 1. Left, Pelvic f loor defect including anal canal, perianal and perineal skin, as well as uterus and posterior wall of vagina. Right, External view of defect reconstructed with VRAM f lap.

body mass index, cancer stage, serum albumin, pelvic organs included in exenteration, abdominal wall donor area postoperative complications, total follow-up, abdominal fascial dehiscence occurrence, abdominal wall incisional and parastomal hernia occurrences, overall patient survival, and abdominal hernia-free survival.

RESULTS From January 2007 to March 2014, a total of 10 patients undergoing VRAM f lap transposition to the pelvic f loor for pelvic exenteration reconstruction have had abdominal wall closure by means of contralateral component separation technique. All of them had a diagnosis of invasive rectal carcinoma. There were 7 female and 3 male patients. Mean age was 53 years (range, 34Y64 years old). All patients had neoadjuvant combined chemotherapy and radiation therapy. Mean body mass index was 23 kg/m2 (range, 18Y32 kg/m2). Mean preoperative albumin level was 3.2 g/dL (range, 1.5Y4.1 g/dL).

Rectal cancer stages II, III, and IV were present in 2, 5, and 3 patients, respectively. During surgery, all patients underwent removal of the anal canal, perianal soft tissue, perineum, and rectum. Concomitant organs removed during pelvic exenteration were posterior wall of vagina (5 patients), uterus (3 patients), bladder (2 patients), ovaries (1 patient), and sacrum (1 patient). Mean VRAM f lap skin island size was 30  7 cm (range, 25Y33  6Y8 cm). One patient with stage III rectal cancer and preoperative albumin level of 1.5 g/dL died on the 31st postoperative day owing to septic shock secondary to osteomyelitis. No other immediate postoperative deaths occurred. Another patient with stage III rectal cancer died 16 months after surgery owing to locoregional recurrence causing bowel perforation. Mean follow-up was 15 months (range, 1Y46 months). During the early postoperative period, there were no abdominal wall donor area complications. No abdominal fascial dehiscence, incisional hernia, or parastomal hernia occurred during follow-up. Overall 3-year patient survival rate was 80% with abdominal hernia free-survival rate of 100%.

FIGURE 2. Left, Abdominal wall defect resulting from harvest of left VRAM myocutaneous f lap. Center, Subcutaneous undermining has been performed along the middle third on the left side until reaching the semilunaris line. Note that external oblique muscle is handled with Allis clamps. Incision of the semilunaris fascia and separation between external and internal oblique muscles are performed along the entire length of the left side. Right, Abdominal wall reconstruction with contralateral component separation allows for closure between right external oblique/internal oblique/transversus abdominis muscles unit and left rectus abdominis muscle. * 2014 Wolters Kluwer Health, Inc. All rights reserved.

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Espinosa-de-los-Monteros et al

DISCUSSION Many improvements have been achieved in the treatment of patients with low rectal cancer. Some of these include the removal of all tissues involved by the tumor. For patients with advanced disease, this concept implies performance of not only an abdominoperineal resection of the rectum but also a pelvic exenteration involving uterus, bladder, ovaries, sacrum, the posterior wall of the vagina, and larger segments of perineal and perianal skin. Postoperative morbidity of these procedures is high, and resulting cutaneous defects tend to be large.1 In addition, most of these patients have received radiation therapy to the pelvic floor. Therefore, a bulky well-vascularized tissue including a large skin island is desirable for adequate reconstruction. Positive clinical outcomes have been reported in this scenario with the use of VRAM flaps for pelvic floor reconstruction. Nonetheless, information regarding abdominal wall outcomes in this subset of patients has occasionally been reported. In 2000, Jurado et al4 reported fascial dehiscence in 6% and an incisional hernia rate of 6% after a median follow-up of 16 months in 31 patients undergoing VRAM f laps with nearly half of them having absorbable or nonabsorbable mesh as part of their donor-site closure. Three years later, D’Souza et al5 reported an 8% ventral hernia rate among 12 patients undergoing primary fascial closure without the aid of synthetic mesh on VRAM f laps donor sites. Soper et al6 published that there were no hernia occurrences and 3% acute fascial dehiscence after 28 months of median follow-up in 32 patients undergoing pelvic reconstruction with VRAM f laps. In 2008, Butler et al7 analyzed 35 patients undergoing pelvic reconstruction with VRAM f laps having donor sites closed primarily and without added mesh and reported acute fascial dehiscence in 6%, incisional hernias in 6%, and parastomal hernias in 11% of patients at a mean follow-up of 38 months. One year later, Nelson and Butler8 updated those series and reported 3.5% and 7% incisional and parastomal hernia rates, respectively, after 24 months of mean follow-up in 114 patients undergoing either abdominoperineal resection or pelvic exanteration and reconstruction with VRAM f laps. Two years later, Campbell and Butler9 reported on 185 patients having their VRAM f lap donor sites closed either primarily or with component separation, some of which were reinforced with synthetic or biologic mesh, and reported an overall 5% hernia occurrence rate at a mean follow-up of 25 months. Finally, Creagh et al10 reported 8% parastomal hernia rate in a subset of 37 patients undergoing pelvic reconstruction with VRAM flaps at a mean follow-up of 54 months. Ramirez et al11 introduced the component separation technique with the intention of providing closure of large midline incisional hernias. We have also shown it to be helpful in reconstruction of other types of defects such as lateral transverse hernias of small to moderate size.12 Improved results of lower morbidity rates are now possible with limited subcutaneous dissection and preservation of some myocutaneous perforators to the wound, as originally described by Saulis and Dumanian.13 Late in 2010, Bauman and Butler3 described the use of ipsilateral component separation to aid in donor-site closure after transferring VRAM flaps for pelvic reconstruction. Their technique involves separation of the external oblique muscle from the underlying internal oblique muscle on the same side as the rectus muscle f lap harvest. This maneuver allows for medial approximation of the ipsilateral abdominal wall and therefore a lower tension closure between the ipsilateral internal oblique/transversus abdominis muscles unit and the contralateral rectus abdominis muscle. Reported incisional hernia occurrence for this technique has been 6% after a mean follow-up of 22 months, which compares favorably with 24% incisional hernia rate in patients undergoing donor-site primary closure without component separation, although the authors noted a lack of statistical significance between both groups.3 Perforator preservation leaves intact skin stuck

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to the abdominal wall where the ostomy comes out. This has been described by Butler in the Journal of American College of Surgeons. In this paper, we describe contralateral perforator-preserving component separation technique for donor-site closure in patients undergoing VRAM f lap transposition for pelvic reconstruction after pelvic exanteration. This technique involves the performance of component separation on the contralateral side as the rectus muscle flap harvest. Therefore, approximation of the left rectus muscle is performed to the more robust external oblique/internal oblique/transversus abdominis muscle unit on the right-sided abdominal wall. Perforator preservation on the component separation side leaves intact skin in continuity with subcutaneous fat, fascia, and muscle at the level of the ostomy exit. In all cases, a lower tension closure was achieved, and no acute fascial dehiscence or short- to mid-term abdominal wall hernia occurred during follow-up. For this complex subset of patients, often malnourished and undergoing a long surgical procedure, it is important to provide a successful reconstruction method exhibiting the lowest donor area complication rate possible. Since component separation technique is performed on one side of the abdomen through a middle third tunnel that allows preservation of upper and lower musculocutaneous perforators, a lower-tension donor-site closure is achieved without adding local wound morbidity. Such types of measures represent an advance in overall patient care to provide more successful outcomes in this complex scenario. REFERENCES 1. Speicher PJ, Turley RS, Sloane JL, et al. Pelvic exenteration for the treatment of locally advanced colorectal and bladder malignancies in the modern era. J Gastrointest Surg. 2014;18:782Y788. 2. Howell AM, Jarral OA, Faiz O, et al. How should perineal wounds be closed following abdominoperineal resection in patients post radiotherapy: primary closure or flap repair? Best evidence topic (BET). Int J Surg. 2013; 11:514Y517. 3. Baumann DP, Butler CE. Component separation improves outcomes in VRAM flap donor sites with excessive fascial tension. Plast Reconstr Surg. 2010; 126:1573Y1580. 4. Jurado M, Bazan A, Elejabeitia J, et al. Primary vaginal and pelvic floor reconstruction at the time of pelvic exenteration: a study of morbidity. Gynecol Oncol. 2000;77:293Y297. 5. D’Souza DN, Pera M, Nelson H, et al. Vaginal reconstruction following resection of primary locally advanced and recurrent colorectal malignancies. Arch Surg. 2003;138:1340Y1343. 6. Soper JT, Secord AA, Havrilesky LJ, et al. Comparison of gracilis and rectus abdominis myocutaneous flap neovaginal reconstruction performed during radical pelvic surgery: flap-specific morbidity. Int J Gynecol Cancer. 2007; 17:298Y303. 7. Butler CE, Gu¨ndeslioglu O, Rodriguez-Bigas MA. Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg. 2008;206:694Y703. 8. Nelson RA, Butler E. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg. 2009;123:175Y183. 9. Campbell CA, Butler CE. Use of adjuvant techniques improves surgical outcomes of complex vertical rectus abdominis myocutaneous flap reconstructions of pelvic cancer defects. Plast Reconstr Surg. 2011;128:447Y458. 10. Creagh TA, Dixon L, Frizelle FA. Reconstruction with vertical rectus abdominis myocutaneous flap in advanced pelvic malignancy. J Plast Reconstr Aesthet Surg. 2012;65:791Y799. 11. Ramirez OM, Ruas E, Dellon AL. ‘‘Component separation’’ method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990;86:519Y526. 12. Espinosa-de-los-Monteros A, Franssen B, Orozco V, et al. Componentsseparation technique for closure of transverse non-midline abdominal wall incisional hernia. J Plast Reconstr Aesthet Surg. 2011;64:264Y267. 13. Saulis AS, Dumanian GA. Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in ‘‘separation of parts’’ hernia repairs. Plast Reconstr Surg. 2002;109:2275Y2280.

* 2014 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Contralateral Component Separation Technique for Abdominal Wall Closure in Patients Undergoing Vertical Rectus Abdominis Myocutaneous Flap Transposition for Pelvic Exenteration Reconstruction.

Pelvic floor reconstruction with pedicled vertical rectus abdominis myocutaneous flap has been popularized in patients undergoing pelvic exenteration ...
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