Abdominal Mesh Use in Pedicled Rectus Abdominis Flaps for Pelvic Reconstruction

Overview

Journal Plast Reconstr Surg Glob Open

Specialty General Surgery

Date 2024 Aug 27

PMID 39188961

Authors

Laura L Barnes

Michael C Holland

Rachel Lentz

Jacquelyn A Knox

Hani Sbitany

Merisa Piper

Affiliations

Soon will be listed here.

Abstract

Background: Rectus abdominis flap coverage of high-risk perineal wounds following extirpative pelvic procedures can result in improved perineal outcomes. However, rectus abdominis flap harvest has morbidity associated with the donor site, including hernia or bulge development. The risk-benefit profile of mesh use in this scenario is not well-defined in the literature.

Methods: We performed a retrospective chart review of all patients who underwent rectus abdominis flap coverage of pelvic defects at our institution during July 2012-January 2021. Patient characteristics and postoperative outcomes were assessed. Patients were stratified into groups based on whether mesh was used and whether primary fascial closure was achieved. Donor site outcomes were analyzed between groups.

Results: One hundred consecutive patients were included. When considering all patients in whom primary fascial closure was achieved, the use of mesh did not significantly decrease rates of hernia development. Mesh use in this setting was associated with significantly greater rates of infection, requiring procedural intervention (12% versus 0%, = 0.044). When considering all patients in whom mesh was used, primary fascial closure was associated with decreased rates of hernia development, and this trended toward significance (16.1% versus 0.0%, = 0.058).

Conclusions: When closing a pedicled rectus abdominis flap donor site, if primary fascial closure is achievable, the addition of mesh to reinforce the repair does not have an added benefit. Mesh use in this setting was not shown to prevent hernia or bulge development, and was found to be associated with significantly greater rates of infection, requiring procedural intervention.

References

Proctor M, Westwood D, Donahoe S, Chauhan A, Lynch A, Heriot A . Morbidity associated with the immediate vertical rectus abdominus myocutaneous flap reconstruction after radical pelvic surgery. Colorectal Dis. 2019; 22(5):562-568. DOI: 10.1111/codi.14909. View

Campbell C, Butler C . Use of adjuvant techniques improves surgical outcomes of complex vertical rectus abdominis myocutaneous flap reconstructions of pelvic cancer defects. Plast Reconstr Surg. 2011; 128(2):447-458. DOI: 10.1097/PRS.0b013e31821e6fd2. View

Den Hartog D, Dur A, Tuinebreijer W, Kreis R . Open surgical procedures for incisional hernias. Cochrane Database Syst Rev. 2008; (3):CD006438. PMC: 8924951. DOI: 10.1002/14651858.CD006438.pub2. View

Mortensen A, Grossmann I, Rosenkilde M, Wara P, Laurberg S, Christensen P . Double-blind randomized controlled trial of collagen mesh for the prevention of abdominal incisional hernia in patients having a vertical rectus abdominis myocutaneus flap during surgery for advanced pelvic malignancy. Colorectal Dis. 2016; 19(5):491-500. DOI: 10.1111/codi.13552. View

Cobb W, Carbonell A, Kalbaugh C, Jones Y, Lokey J . Infection risk of open placement of intraperitoneal composite mesh. Am Surg. 2009; 75(9):762-7. View

Schellerer V, Bartholome L, Langheinrich M, Grutzmann R, Horch R, Merkel S . Donor Site Morbidity of Patients Receiving Vertical Rectus Abdominis Myocutaneous Flap for Perineal, Vaginal or Inguinal Reconstruction. World J Surg. 2020; 45(1):132-140. PMC: 7752873. DOI: 10.1007/s00268-020-05788-5. View

Radwan R, Tang A, Harries R, Davies E, Drew P, Evans M . Vertical rectus abdominis flap (VRAM) for perineal reconstruction following pelvic surgery: A systematic review. J Plast Reconstr Aesthet Surg. 2020; 74(3):523-529. DOI: 10.1016/j.bjps.2020.10.100. View

Johnstone M . Vertical Rectus Abdominis Myocutaneous Versus Alternative Flaps for Perineal Repair After Abdominoperineal Excision of the Rectum in the Era of Laparoscopic Surgery. Ann Plast Surg. 2017; 79(1):101-106. DOI: 10.1097/SAP.0000000000001137. View

Yang X, Wei M, Yang X, He Y, Hao Y, Zhang X . Primary vs myocutaneous flap closure of perineal defects following abdominoperineal resection for colorectal disease: a systematic review and meta-analysis. Colorectal Dis. 2018; 21(2):138-155. DOI: 10.1111/codi.14471. View

10.

Feeney G, Sehgal R, Sheehan M, Hogan A, Regan M, Joyce M . Neoadjuvant radiotherapy for rectal cancer management. World J Gastroenterol. 2019; 25(33):4850-4869. PMC: 6737323. DOI: 10.3748/wjg.v25.i33.4850. View

11.

Leber G, Garb J, Alexander A, REED W . Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg. 1998; 133(4):378-82. DOI: 10.1001/archsurg.133.4.378. View

12.

Daigeler A, Simidjiiska-Belyaeva M, Drucke D, Goertz O, Hirsch T, Soimaru C . The versatility of the pedicled vertical rectus abdominis myocutaneous flap in oncologic patients. Langenbecks Arch Surg. 2011; 396(8):1271-9. DOI: 10.1007/s00423-011-0823-6. View

13.

Harries R, Radwan R, Dewi M, Cubitt J, Warbrick-Smith J, Sadiq O . Outcomes Following Immediate Vertical Rectus Abdominis Myocutaneous (VRAM) Flap-Based Perineal Reconstruction Following Resectional Surgery For Pelvic Malignancies. World J Surg. 2021; 45(7):2290-2297. DOI: 10.1007/s00268-021-06044-0. View

14.

Touny A, Othman H, Maamoon S, Ramzy S, Elmarakby H . Perineal reconstruction using pedicled vertical rectus abdominis myocutaneous flap (VRAM). J Surg Oncol. 2014; 110(6):752-7. DOI: 10.1002/jso.23692. View

15.

Butler C, Gundeslioglu A, Rodriguez-Bigas M . Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg. 2008; 206(4):694-703. DOI: 10.1016/j.jamcollsurg.2007.12.007. View

16.

Buscail E, Canivet C, Shourick J, Chantalat E, Carrere N, Duffas J . Perineal Wound Closure Following Abdominoperineal Resection and Pelvic Exenteration for Cancer: A Systematic Review and Meta-Analysis. Cancers (Basel). 2021; 13(4). PMC: 7916499. DOI: 10.3390/cancers13040721. View