Perineal wound complications after abdominoperineal resection

Abstract

Perineal wound complications following abdominoperineal resection (APR) is a common occurrence. Risk factors such as operative technique, preoperative radiation therapy, and indication for surgery (i.e., rectal cancer, anal cancer, or inflammatory bowel disease [IBD]) are strong predictors of these complications. Patient risk factors include diabetes, obesity, and smoking. Intraoperative perineal wound management has evolved from open wound packing to primary closure with closed suctioned transabdominal pelvic drains. Wide excision is used to gain local control in cancer patients, and coupled with the increased use of pelvic radiation therapy, we have experienced increased challenges with primary closure of the perineal wound. Tissue transfer techniques such as omental pedicle flaps, and vertical rectus abdominis and gracilis muscle or myocutaneous flaps are being used to reconstruct large perineal defects and decrease the incidence of perineal wound complications. Wound failure is frequently managed by wet to dry dressing changes, but can result in prolonged hospital stay, hospital readmission, home nursing wound care needs, and the expenditure of significant medical costs. Adjuvant therapies to conservative wound care have been suggested, but evidence is still lacking. The use of the vacuum-assisted closure device has shown promise in chronic soft tissue wounds; however, experience is lacking, and is likely due to the difficulty in application techniques.

Keywords: Abdominoperineal resection; perineal wound complication; tissue transfer; vacuum-assisted closure device; wound management.

Figure 1

Vertical rectus abdominis myocutaneous (VRAM) flap reconstruction of the left labia, posterior vagina, and perineum after abdominoperineal resection for squamous cell cancer of the left Bartholin's gland. The tumor was invading the anal sphincter complex. The patient received neoadjuvant chemotherapy and radiation therapy. (A) Pictures show preoperative markings. (B) Intraoperative perineal, vaginal, and labial defect. (C) Immediate postoperative flap reconstruction. (D) 6-week follow-up. Photographs courtesy of Susan M. Pike, M.D., Plastic and Reconstructive Surgery, Scott & White University Medical Campus, Round Rock, TX.

Figure 2

Vertical rectus abdominis myocutaneous (VRAM) flap reconstruction of the perineum after abdominoperineal resection in a man with locally advanced rectal cancer that invaded through the perineal skin. The patient received neoadjuvant chemoradiation therapy. (A) Pictures show preoperative markings. (B) Intraoperative perineal defect. (C) Immediate postoperative flap reconstruction. (D) 6-week follow-up. Photographs courtesy of Susan M. Pike, M.D., Plastic and Reconstructive Surgery, Scott & White University Medical Campus, Round Rock, TX.

Figure 3

Gracilis myocutaneous flap reconstruction of the perineum and posterior wall of the vagina in a woman with locally advanced rectal cancer that invaded into the vagina. The patient received neoadjuvant chemoradiation therapy. (A) Pictures show preoperative markings. (B) Intraoperative perineal and vaginal defect. (C) Immediate postoperative flap reconstruction. (D) 3-month follow-up. Photographs courtesy of Susan M. Pike, M.D., Plastic and Reconstructive Surgery, Scott & White University Medical Campus, Round Rock, TX.