Pelvic Reconstruction in Gynecologic Oncology Surgery

Preoperative Evaluation and Patient Selection

All patients undergoing pelvic resection should be offered a preoperative reconstructive evaluation. This serves both to answer patient questions regarding expectations and also to customize the reconstruction according to each patient’s particular needs. Some of the challenges in obtaining a successful reconstruction may include:

• Adverse effects of neoadjuvant versus adjuvant therapies, including chemotherapy and radiation

• Presence of patient morbidities, including but not limited to diabetes, smoking, obesity, prior surgeries, and malnutrition

• Iatrogenic impairments, including edema and lymphedema, wound tension, and poor perfusion of tissues

Preoperative planning, when possible, helps to minimize associated morbidities of reconstruction. Factors to be considered in the planning of a reconstruction may include:

• Size, volume, and location of defect

• Patient’s ability or inability to heal

• Availability of potential donor sites

• Ease of donor site closure (skin, fascial levels)

• Flap pedicle viability

• Location of perforators to skin (for flap design)

Secondary Intention and Complex Primary Closure

As mechanisms of healing, both secondary intention and complex primary closure are among the simpler ways to achieve perineal closure. Secondary intention allows a patient to be treated with local wound care, to better allow her innate mechanisms of healing to work. Complex closure involves wide undermining of the remaining soft tissues to allow for a tension-free closure in layers. This technique may be useful for small partial vaginectomies, vulvectomies, or perineal resections ( Fig. 20.1 ).

Skin Grafting and Skin Substitutes

Skin grafts may be harvested as split or full thicknesses of dermis. The former may be harvested in larger sizes, but the latter tend to contract less with time. In either circumstance, skin grafts require a well-vascularized wound bed for survival. Bolstering a skin graft may enhance its take in the first days after placement. However, appropriate bolsters may be difficult to achieve in the perineal region, especially because of the flow of urine and/or stool.

Skin substitutes have become commonplace in reconstructive surgery. They are often derived as acellular matrices from dermis or other organ systems, from both human and animal sources. They may aid in coverage in these challenging areas, where skin grafts are less likely to survive.

Local Flaps

Local flaps are tissues that can be advanced or rotated from their starting positions while remaining connected to a sufficient blood supply. Because local tissues tend to have the greatest similarity with their resected counterparts, it is best to follow the adage “When possible, replace like with like.” Local flaps take advantage of the inherent laxity of nearby tissues, which allows for mobilization with primary closure of the donor site. There are a variety of well-described local flaps for the perineal region. Two commonly used flaps are the Singapore flap and the V -to- Y advancement flap.

The Singapore flap, also known as the pudendal flap, may be based anteriorly or posteriorly. A full thickness of tissue (skin, subcutaneous fat, and fascia) is elevated to maximize perfusion. Although they can be designed as random pattern flaps (i.e., based on dermal blood supply), axial flaps based off the pudendal vessels (included with the deeper fascia) tend to have better perfusion. These flaps can be harvested unilaterally or bilaterally and are effective for partial vaginal and/or vulvar reconstructions ( Fig. 20.2 ).

Procedure Details

Markings are made lateral to the vulva in the area of the proximal medial thigh. Local anesthetic may be used. Incisions are made with scalpel and electrocautery down through the fascia. The base of the flap is elevated such that flap rotation may be sufficient to reach the full extent of the defect. Wide undermining of the donor site is performed to reduce tension on primary layered closure. The flap is sutured in multiple layers to its recipient site.

V -to- Y advancement allows local tissues to be approximated while perfusion is maintained via centrally based perforating vessels. The greatest advancement is achieved by incising a full thickness of skin, fat, and fascia but with only enough undermining that the central perforators are still maintained. The V -to- Y design allows for primary closure of the donor site. Depending on the size and location of the defect, V -to- Y advancement flaps can be performed in either the lithotomy or jackknife prone positions ( Fig. 20.3 ).