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Perineal and Vaginal Reconstruction

Perineal and Vaginal Reconstruction. Immediate pelvi-perineal reconstruction. Reconstruction of pelvis and perineum is required only under certain circumstances. Extended skin loss Extensive pelvic floor loss Partial/complete vaginal removal AP/pelvic clearance

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Perineal and Vaginal Reconstruction

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  1. Perineal and Vaginal Reconstruction

  2. Immediate pelvi-perineal reconstruction Reconstruction of pelvis and perineum is required only under certain circumstances. • Extended skin loss • Extensive pelvic floor loss • Partial/complete vaginal removal • AP/pelvic clearance • Excision after radiotherapy

  3. Immediate pelvi-perineal reconstruction • Split skin graft • Skin flaps • Omentum • Gracilis muscle, either as a muscle flap or myocutaneous flap • rectus abdominis flap, in either myofascial or myocutaneous form

  4. Immediate pelvi-perineal reconstruction Radical extrasphincteric proctectomy

  5. Immediate pelvi-perineal reconstruction Delayed skin grafting

  6. Vertical rectus abdominis flap (VRAM) Transverse rectus abdominis flap (TRAM) Gracilis flap Gluteal flaps Posterior thigh flaps Immediate pelvi-perineal reconstruction

  7. Immediate pelvi-perineal reconstruction Omentoplasty and gracilis muscle transposition

  8. Immediate pelvi-perineal reconstruction

  9. Advantages of immediate gracilis muscle reconstruction • minimal functional disturbance • pelvic floor repair “internal benefit” • perineal repair “external benefit” • neo-vaginal reconstruction • urethral reconstruction

  10. Immediate pelvi-perineal reconstruction Skin flap reconstruction of perineal/vaginal defects • Transpositional • Rotational • Advancement

  11. Perineal and Vaginal Reconstruction Exenterative pelvic surgery – eleven year experience of the Swansea Pelvic Oncology Group. Nguyen DQA et al, EJSO 2005 • 130 patients – mixed group of rectal and gynaecological cancers (median follow up 14 months) • No deaths within 30 days • Morbidity rate 28% • Predicted 5y survival 53%

  12. Bell et al, Brit J Surg 2005 31 patients – one stage flap, VRAM 26 – recurrent or persistent epidermoid cancer or low rectal cancer. 21 – high dose preoperative radiotherapy 3 weeks post op – perineal wound healed in 27 of 31 9 flap related complications 3 partial flap necrosis 2 vaginal stenosis Soper JT et al, Int J Gynecol Cancer 2005 32 cases – 14 vs. 18, TRAM vs. VRAM 1988-2003 88% previous radiotherapy, 66% urinary conduit Rectosigmoid resection/anastomosis 25% Median survival 14 months 6% post operative mortality 15% flap-specific complications – not design related 12% vaginal stricture/stenosis Perineal and Vaginal Reconstruction

  13. Perineal and Vaginal Reconstruction • Meticulous case selection with input from all members of the multidisciplinary team. • Careful and thorough counselling of the patient and relatives. • Appropriate facilities for post operative monitoring and management. • High level of consultant input from all disciplines is necessary for a successful outcome.

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