Commentary on “30 days postoperative outcome associated with vertical rectus abdominis myocutaneous (VRAM) flap reconstruction after pelvic surgery” by Thomsen TV, Warming P, Hasanbegovic E, Rindom MB & Stolle LB

Excerpt

We are pleased to share some comments related to the recent article by Thomsen et al. [1] about immediate postoperative complications following vertical rectus abdominis myocutaneous (VRAM) flap-based reconstruction after pelvic surgery. This retrospective observational cohort study included 67 patients who underwent pelvic-perineal reconstruction with a transpelvic VRAM flap and analyzed the donor and recipient site complications in the early 30 postoperative days. The most frequent indication to surgery was ano-rectal cancer (77.6%) and the mean flap skin island size transferred was 80.4 cm. The most frequently performed ablative procedure was abdominoperineal excision (71.6%), while pelvic exenteration (PE) accounted for 25% of the cases. Only 4 patients (6%) had a BMI > 32. The types of complications were divided into minor, if they required only bedside revision or antibiotics, or major if they required interventional drainage or secondary surgery. Twenty-eight patients (42%) developed complications; 14 (21%) were classified as minor and 14 as major (21%); 20 occurred at the level of the recipient site, while 10 at the level of the donor site. Dehiscence of the wound was the most frequent (17 cases) and required re-surgery in 6 cases, 5 in the recipient and 1 in the donor site. Fascia rupture in the donor site occurred in 2 cases. The authors found a correlation with complications only for BMI > 32. No correlation was found for smoking or previous radiation therapy (RT). We commend the authors for this interesting study. Reconstruction of the pelvic and perineal area compels the surgeon to deal with wide dead space that can collect fluid and, particularly in presence of a previous RT, can become infected causing dehiscence, sepsis, and potentially patients’ death. Moreover, this area is populated by fecal and urinary bacteria and any flap can be compressed during limbs adduction. VRAM flap with an endopelvic course is the best flap to achieve reconstruction of perineal and pelvic defect because it provides a wide skin island, fills the pelvic floor defect, and closes the passage to the bowel from the pelvis to the perineum, preventing postoperative herniation. The risk of recipient site wound complication is generally lower with a VRAM flap, since local flaps can only re-distribute the wound tension, without eliminating it, with an increased risk of breakdown. Moreover, VRAM flap can fill the pelvic floor, eliminating the dead space, thus reducing the risk of infection. The real problem associated with this flap is the weakening of the abdominal wall, often worsened by the presence of fecal and urinary ostomies. …