1001

Vaginal Reconstruction with Rectus Abdominis Myocutaneous Flap: CT Findings

Steven

J. Willing1’2

American Journal of Roentgenology 1991.156:1001-1004.

Steven Scott Gordon

H. PurselI3 R. Koch1’4 R. Tobin5

The distally based rectus abdominis myocutaneous flap is used in a new technique for vaginal reconstruction after pelvic exenteration for malignant disease. We identified 27 patients who underwent this procedure, of whom eight had a total of 14 postoperative CT scans and two CT-directed biopsies. The myocutaneous flap appeared as a unilateral arcuate band of soft tissue extending from the linea alba to the rectal fascia or sacrum. Additional CT findings included asymmetric thinning of the ventral abdominal wall (7/8), fluid collections (2/8), vaginal breakdown (1/8), presacral soft-tissue thickening (6/8), and tumor recurrence (3/8). The postoperative CT scan reflects the altered anatomy produced by the surgery. Complications and recurrent disease can be recognized as deviations from the normal postoperative appearance. AJR

156:1001-1004, May 199i

Pelvic exenteration for locally advanced or recurrent malignant disease has been shown to improve survival and in some cases to effect a cure [1]. In order to decrease morbidity and improve patients’ acceptance and quality of life, numerous techniques for vaginal reconstruction were developed. One of the more successful techniques has been the bilateral gracilis myocutaneous flap reported by McCraw et al. [2] in i976. Its resultant CT findings were described by Epstein et al. [3] in 1987. In 1 988, Tobin and Day [4] reported their initial results with a distally based rectus abdominis myocutaneous flap for vaginal reconstruction. In this procedure,

a myocutaneous Received September 5, 1990; revision November 21 , 1990.

accepted

after

Presented as a scientific exhibit at the annual meeting of the American Roentgen Ray Society, Washington, DC, May 1990. 1 Department of Diagnostic Radiology, University of Louisville, 2 Present

Louisville, KY 40202. address: Department of Diagnostic

diology, University of Alabama mingham, AL 35233. Address S. J. Willing. 3 Department sity of Louisville,

of Gynecologic Oncology, Louisville, KY 40202.

Univer-

Present address: Department of Diagnostic diology, Emory University, Atlanta, GA 30322. 4

gery,

Department University

Ra-

at Birmingham, Birreprint requests to

of Plastic and Reconstructive Surof Louisville, Louisville, KY 40202.

0361 -803X/91/1 565-1001 © American Roentgen Ray Society

Materials

is constructed

from

the cephalic

portion

of the rectus

and

Methods

We identified 27 patients who had pelvic exenteration with rectus abdominis myocutaneous flap reconstruction in the past 6 years, of whom eight patients had a total of 14 postoperative CT scans and two CT-directed biopsies. The patients ranged in age from 23 to 82 years old (median

Ra-

flap

abdominis, the superior epigastric artery is ligated, and the flap is rotated around its inferior epigastric vascular pedicle and passed through a peritoneal incision into the pelvis (Figs. 1 -3). The advantages of this technique are shortened operative time, improved graft survival, and better obliteration of the pelvic dead space. Patients who have undergone this procedure have a unique postoperative CT appearance, which we describe here.

age,

of the cervix, vagina,

45 years)

at the

time

of the

one had adenocarcinoma

and one

had transitional

procedure.

Five

of the cervix,

cell carcinoma

patients

had

squamous

one had squamous

of the bladder.

The

time

from

carcinoma

carcinoma original

of the diagnosis

ranged from 1 month to 8 years. Six patients had complete exenteration with vaginal reconstruction, one had an anterior exenteration (sparing the rectum) with vaginal reconstruction, and one had exenteration with a rectus abdominis patch but no neovagina to exenteration

was

constructed.

Six patients

were

initially

treated

with

radiation,

and

one

patient

was

treated

i 002

WILLING

initially

with

both

initially

with

exenteration

Fourteen Four

and

were

One

One

in the

patients

and

from

2 to

ranging

patient

by postoperative first

treated

Results

were reviewed.

Normal

postoperative

six additional 17 months

was

month

\.

May 1991

patients after

Postoperative

had

follow-

surgery.

,

I

The muscular flap most often is seen as a unilateral arcuate band of soft tissue extending from the linea alba to the sacrum (Fig. 4) or, in the case of anterior exenteration, to the perirectal fascia (Fig. 5). It may be situated on either side of the pelvis. The flap may also lie in a more posterior position, anterior to the sacrum and nearly midline in position (Fig. 6). The cutagraft

forms

the

neovagina,

completely

encircled

by a

of fat (Fig. 5). As reported after gracilis reconstruction, air may be seen in the neovagina and is a normal finding. Intravaginal air, when present, permits visualization of both layer

I

!!

Appearance

in two

neous ‘

AJR:156,

irradiation.

CT scans

abdominopelvic

obtained

of these

up examinations

hysterectomy.

followed

postoperative

scans

patients.

radiation

ET AL.

‘I

inner

and

outer

walls.

and only the outer vagina is redundant,

Otherwise,

the inner

walls

are apposed

wall is visible. The skin forming the neoand tends to collapse into a linear or “V’

configuration. A

B

American Journal of Roentgenology 1991.156:1001-1004.

Fig. 1.-A,

Myocutaneous

C flap is created,

based on inferior

epigastric

vascular pedicle. B, Skin of flap is wrapped

C, Flap with neovagina laparotomy

and donor

to form neovagmna. is passed into pelvis and secured

to perineum;

site closed.

Seven of the eight patients exhibited asymmetric thinning of the ventral abdominal wall at the graft donor site (Fig. 7A). Here the posterior rectus fascia forms the remaining abdominal wall support. This area is at risk for hernia formation, but the reported prevalence is only about 3% [5]. No hernias were present in this select group of patients. Presacral soft-tissue thickening was seen in six patients (Fig. 6). This is usually attributable to the muscular flap. Only one of the six had recurrent tumor in the presacral space. In this

case,

smooth --q

:

“F

markedly

4 months

Abnormal

CT Findings

One

Fig. 2.-Cross

early

postoperative

of presacral

soft

scans

tissue,

showed

which

a thin,

had thickened

later.

‘-‘

R

wrapped abdominis

the

band

section

to form neovagina. muscle.

of flap illustrates how myocutaneous flap is S = skin, F = subcutaneous fat, R = rectus

obese

separation pelvic fluid resolved died

of

that

patient

had

healed

collection

during

spontaneously recurrent

a superficial

uneventfully. 8A);

however,

Breakdown

of

wound

patient

the first postoperative

(Fig. tumor.

abdominal

Another

had

month

a

that

she subsequently the

neovagina

oc-

Fig. 3.-A, Sagittal view of reconstructed pcIvis. I = neointroitus, S = pubic symphysis. B, Cut-away view of reconstructed pelvis, viewed from perineum. A = aorta, E = external

iliac artery, I = inferior epigastnc artery. R = rectus abdominis graft, F = subcutaneous fat, V = neovagina. A

B

AJR:156,

CT

May 1991

Fig. 4.-23-year-old cell carcinoma

of vagina.

first month after surgery

OF

VAGINAL

RECONSTRUCTION

1003

woman with squamous CT scan obtained in

shows curvilinear

of soft tissue from linea alba to sacrum due to muscular graft.

band

(arrows)

American Journal of Roentgenology 1991.156:1001-1004.

Fig. 5.-34-year-old woman with carcinoma of cervix, 6 months after anterior exenteration and reconstruction. CT scan shows rectus abdominis forming a soft-tissue band from linea alba to rectal fascia (arrows), surrounding neovagina. Neovagmna is formed by grafted skin (arrowheads) surrounded by subcutaneous fat (asterisk).

Fig. 6.-54-year-old

woman with squamous

car-

cinoma of cervix, 17 months after exenteration and reconstruction. CT scan shows presacral, midline band of soft-tissue density due to muscular patch.

in one patient, indirectly identifiable extraperitoneal collection of free air in the Postoperative abscess occurred in one had a postoperative course complicated struction and jejunal perforation leading curred

Fig. 7.-A, 32-year-old woman with adenocarcinoma of cervix. CT scan obtained 10 months after exenteration and reconstruction for carcinoma of cervix shows a normal graft donor site. There is asymmetric thinning of left abdominal wall due to removal of rectus abdominis. Left kidney is hydronephrotic. B, Biopsy-proved recurrent tumor (arrows) causes convex bulge on normally concave inner border of muscular flap. Note neovagina (arrowheads) surrounded by fat.

on CT as a large pelvis. patient. This patient by small-bowel obto a large abscess

containing air and fluid in the anterior perihepatic Pathologically confirmed tumor recurrence was

space.

identified in three patients. In the first case, follow-up scans showed omental tumor mass and a heterogeneous pelvic soft-tissue mass lateral and posterior to the flap extending to the piriformis muscles and sacrum (Fig. 8B). The second patient developed a focal soft-tissue mass altering the normal crescentic inner margin of the myocutaneous flap 1 0 months after reconstruction (Fig. 7B). A CT-guided needle biopsy was diagnostic for recurrent tumor. In the third case, recurrent pelvic tumor was visible as a soft-tissue mass with central low attenuation abutting the wall of the neovagina.

Discussion Although pelvic exenteration can significantly improve the survival rate (up to a SO% 2-year survival rate) for patients with gynecologic malignant tumors, it is not without morbidity. The

loss of pelvic soft tissue allows bowel herniation

into the

pelvis with the danger offistulization and obstruction. If further radiotherapy is required, bowel may be in the therapy field. The loss of sexual function affects the patient’s postoperative quality of life and acceptance of the procedure. In order to address these issues, pelvic soft-tissue packing and vaginal reconstruction have been performed by using a variety of techniques. The bilateral gracilis myocutaneous flap has commonly been used; however, the distally based rectus abdommis myocutaneous flap has certain advantages and is finding increasing acceptance. These advantages include improved graft survival and shortening of the operative time.

1004

WILLING

ET AL.

AJR:156,

May 1991

American Journal of Roentgenology 1991.156:1001-1004.

Fig. 8.-A, 50-year-old woman with squamous carcinoma of cervix. CT scan obtained in first postoperative month shows pelvic fluid collection surrounding graft. This resolved spontaneously. Note air in neovagmna (arrow), rectus abdominis (arrowheads), and layer of subcutaneous fat (asterisk). B, CT scan obtained 6 months later. Note marked increase in amount of presacral soft tissue.

The procedure begins with the design of a 1 0- to 1 2-cmwide ellipse of skin beginning below the costal margin and extending a few centimeters below the umbilicus. The caudal end is extended into the laparotomy incision to allow a single closure. After the skin incision, the cephalic margin of the rectus abdominis is transected and the superior epigastric artery is ligated. A tube is created with the cutaneous portion of the graft to form a neovagina. The cephalic end is left open, to form the new introitus. The completed pouch is passed through a peritoneal incision into the pelvis, and the rectus fascia

is closed

to prevent

hernia.

Care

is taken

in the

series.

activity vagina

reported successful orgasms even though the neois insensate. Our series of CT evaluations in this group

yielded

the

following

patients

observations.

who

(1)

resumed

The

unilateral

thinning

tissue thickening Recurrent tumor normal

configuration

fat with inner cutaneous lining. be seen in most patients as of the rectus sheath. (4) Presacral softcan be a normal postoperative finding. (5) appears as a soft-tissue mass altering the of the reconstructed

pelvis,

possibly

with

abnormal enhancement or tissue inhomogeneity. (6) Familiarity with the normal postoperative appearance is necessary both for the detection of recurrence and to avoid a falsely positive diagnosis.

throughout

to preserve the inferior epigastric vascular pedicle supplying the graft. In Tobin and Day’s series, there was complete graft survival in 1 8 of 20 patients. The remaining two had partial losses that were successfully revised. In these two, the paddles had been extended above the costal margin. Subsequently, the cephalic extent of the paddle was limited to just below the costal margin. No hernias or postoperative infections occurred Interestingly,

configuration of subcutaneous (3) The graft donor site can

muscular

sexual

flap

appears as a band of soft-tissue density abutting the pelvic side wall or sacrum. (2) The neovagina exhibits a doughnut

REFERENCES 1 . Morley nancy:

GW, Lindenauer SM. Exenterative therapy for gynecologic an analysis of 70 cases. Cancer 1976:38:581-586

malig-

2. McCraw JB, Massey FM, Shanklin KD, Horton CE. Vaginal reconstruction with gracilis

myocutaneous

flaps.

Plast Reconstr Surg 1976;58: 176-183 D, Mintz MC, Coleman BG. CT evaluation vaginal reconstruction after pelvic exenteration.

3. Epstein DM, Arger PH, LaRossa

of gracilis myocutaneous AJR 1987:148:1143-1146 4. Tobin GR, Day TG. Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps. Plast Reconstr Surg i988;81: 62-70 5. Kroll 55, Pollock R, Jessup JM, Ota D. Transpelvic rectus abdominis flap reconstruction of defects following abdominal-perineal resection. Am Surg

1989:55:632-637

Vaginal reconstruction with rectus abdominis myocutaneous flap: CT findings.

The distally based rectus abdominis myocutaneous flap is used in a new technique for vaginal reconstruction after pelvic exenteration for malignant di...
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