Partial myocutaneous gluteal flap for perineal reconstruction of extralevator abdominoperineal defects. A single surgeon series of 49 cases in eight years, and a modification of the technique.

Introduction: Extralevator abdominoperineal excision (ELAPE) for low rectal tumours necessitates a reliable method of reconstructing the perineum. The senior author developed the partial myocutaneous gluteal (PMG) flap. We present 49 consecutive reconstructions with refinement of the original procedure.

Methods: We conducted a retrospective observational review of patients undergoing ELAPE and PMG reconstruction from 2012 to 2019, with at least 1 year follow-up. The procedure was modified iteratively following our original series, to minimise perineal herniation, specifically by greater mobilisation of the inferior gluteus maximus muscle and separation of the muscle and fasciocutaneous components, allowing closure of the defect around the coccygeal remnant. Perineal herniation and wound complications were recorded. Laparoscopic and open resection techniques were compared, as were outcomes before and after modification of the flap.

Results: There were no flap failures in our cohort of 49 patients. Two patients (4%) required return to theatre acutely for perineal wound complications: one wound dehiscence and one flap related haematoma. Five patients had evidence of perineal hernia, three prior to any modification of the flap and two following. Three had symptoms of which two required elective repair. The flap modifications were made in response to these cases. There were no significant differences in perineal outcomes for laparoscopic versus open, and before and after flap modification.

Conclusions: Over the last eight years, we have refined our perineal reconstruction technique following instances of perineal herniation and major wound dehiscence. We believe that the PMG flap provides robust and reliable option for reconstruction of perineal extralevator abdominoperineal defects.

Background: Extralevator abdominoperineal excision (ELAPE) for rectal cancer results in a significantly larger perineal soft tissue defect than abdominoperineal excision of the rectum (APER). The oncological benefits of ELAPE remain somewhat controversial, Huang A Zhao H Ling T et al. Oncological superiority of extralevator abdominoperineal resection over conventional abdominoperineal resection: a meta-analysis.

Int J Colorectal Dis. 2014; 29: 321-327

Zhou X Sun T Xie H et al. Extralevator abdominoperineal excision for low rectal cancer: a systematic review and meta-analysis of the short-term outcome.

Colorectal Dis. 2015; 17: 474-481

Negoi I Hostiuc S Paun S Negoi RI Beuran M. Extralevator vs conventional abdominoperineal resection for rectal cancer—a systematic review and meta-analysis.

Am J Surg. 2016; 212: 511-526

nevertheless an increase in the number of patients undergoing this procedure for rectal carcinoma necessitates that the reconstructive surgeon has a robust and reliable method of reconstructing the perineum.

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