Perineal Reconstruction: Principles and Practice

Preface
Contents
About the Editor
1: Surgical Anatomy and Pathology of Perineal Area
1.1 Introduction: Surgical Anatomy
1.2 The Anal Canal
1.3 Soft Tissues, Pelvic Floor, and Perineum
1.4 Applied Anatomy: Anatomical Landmarks and Spaces
1.5 Pathology
1.6 Non-Oncological Conditions
1.7 Infections
1.8 Perianal Abscess
1.9 Fissures and Fistulae
1.9.1 Cysts
1.10 Neoplastic Pathology
1.11 Paget’s Disease
1.12 Melanoma
1.12.1 Soft Tissue Tumors of the Perineum
1.13 Multimodality Treatments
1.14 Surgical Procedures
References
2: Perineal Defects: A Colorectal Surgeon’s Perspective
2.1 Introduction
2.2 Indications for Perineal Reconstruction in Colorectal Surgery
2.3 Radiology of Perineal Lesions
2.4 Multidisciplinary Team Decision Making
2.5 Types of Perineal Excision
2.6 Pelvic Multivisceral Exenteration
2.6.1 Patterns of Rectal Cancer Recurrence
2.6.2 Types of Pelvic Exenteration
2.7 Stomas
2.8 Conclusion
References
3: Perineal Reconstruction in Gynecological Oncology: Indications and Insights
3.1 Primary Vulval Squamous Cell Cancer
3.1.1 Primary Closure
3.1.2 Advancement VY Flaps
3.1.3 VIN-Vulval Intraepithelial Neoplasia
3.2 Extramammary Paget’s Disease of the Vulva
3.3 Vaginal Cancer and VaIN
3.4 Exenteration for Recurrent Gynecological Cancer Involving Perineum, the Vulva, and Vagina
3.5 Vulval Sarcoma
3.6 Malignant Melanoma of the Vulva or Vagina
References
4: Urological Aspects of Perineal Surgery and Reconstruction
4.1 Introduction
4.2 Key Urological Anatomical Considerations
4.3 Urological Cancers and the Perineum
4.3.1 Prostate Cancer
4.3.2 Bladder and Urethral Cancer
4.3.3 Penile Cancer
4.3.4 Pelvic Exenteration
4.4 Benign Conditions Affecting the Perineum
4.4.1 Infection
4.4.1.1 Urethral Surgery
4.5 Conclusions
References
5: Radiotherapy of Perineal and Pelvic Malignancies
5.1 Volume Definition for EBRT
5.2 Radiobiology
5.2.1 Acute Radiation Effects
5.2.2 Late Radiation Effects
5.2.2.1 Patient Factors
5.2.2.2 Radiotherapy Factors
5.3 Prostate Cancer Radiotherapy
5.3.1 Introduction
5.3.2 Evolution of the Treatment of Prostate Cancer
5.4 Anal Cancer Radiotherapy
5.4.1 Introduction
5.4.2 Evolution of the Treatment of Anal Cancer
5.5 Rectal Cancer Radiotherapy
5.6 Radiotherapy for Endometrial Cancer
5.7 Radiotherapy for Cervical Cancer
5.8 Vulval Cancer
References
6: Classification of Perineal Defects
References
7: Anesthetic Considerations for Perineal Reconstructive Surgery
7.1 Introduction
7.2 Preoperative Management
7.2.1 The Preoperative Assessment
7.2.1.1 The Surgical Stress Response
7.2.1.2 Evaluation of Physiological Fitness for Major Surgery
7.2.1.3 Optimizing Fitness
7.2.1.4 Discussion of Risk and Consent for Anesthesia
7.2.1.5 Anticipating Specific Problems with Anesthesia
7.2.1.6 Premedication
7.3 Intraoperative Management
7.3.1 Patient Monitoring
7.3.2 Epidural Placement and Anesthetic Induction
7.3.3 Airway Management
7.3.4 Maintenance of Anesthesia
7.3.5 Invasive Mechanical Ventilation Via the Endotracheal Tube
7.3.6 Antibiotic Prophylaxis
7.3.7 Preventing Pressure Ulceration
7.3.8 Positioning
7.3.8.1 Prone
7.3.8.2 Lithotomy
7.3.9 Temperature Management
7.3.10 Fluids
7.3.11 Analgesia
7.3.11.1 Antiemesis
7.3.12 Emergence
7.4 Postoperative Considerations
7.4.1 Postanesthetic Care Unit
7.4.1.1 Pain Control
7.4.1.2 Postoperative Nausea and Vomiting (PONV)
7.4.1.3 Other Aspects of Immediate Postoperative Recovery
7.4.2 Critical Care/High Dependency Phase
References
8: Lotus Petal and V-Y Advancement Flaps
8.1 Introduction
8.2 Anatomical Blood Supply of the Perineum (Fig. 8.1)
8.3 The Lotus Petal Flap for Perineal Reconstruction
8.4 The Perineal Body
8.5 Planning V-Y Flaps for Perineal Reconstruction
8.6 Discussion
References
9: Gracilis Flap
9.1 Introduction
9.2 Anatomy of the Flap
9.3 Flap Elevation
9.3.1 Gracilis Muscle
9.3.1.1 Preoperative Markings (Fig. 9.1)
9.3.1.2 Position
9.3.1.3 Operation
9.3.1.4 Postoperative Treatment
9.3.2 Myocutaneous Gracilis Flap (TMG, i.e., Transverse Myocutaneous Gracilis Flap or TUG, i.e., Transverse Upper Gracilis)
9.3.2.1 Preoperative Markings (Fig. 9.2)
9.3.2.2 Position
9.3.2.3 Operation (Figs. 9.3 and 9.4a, b)
9.3.2.4 Postoperative Treatment
9.4 Indications and Techniques in Reconstructions (Fig. 9.5)
9.4.1 Filling of a Cavity and Coverage of Contaminated Wounds or Large Perineal Defects
9.4.2 Fistula Corrections (Fig. 9.6a–d)
9.4.3 Reconstructions of Urethral and Anal Sphincters
9.4.4 Scrotoplasty (Fig. 9.7a–c)
9.4.5 Pelvic Floor Reconstruction
9.4.6 Vaginoplasty
9.4.7 Phalloplasty (Fig. 9.12a, b)
9.5 Benefits of Gracilis Flaps
9.6 Drawbacks and Problems with Gracilis Flaps and Their Donor Sites
9.7 Complications of Gracilis Flaps
9.7.1 Muscle Flap
9.7.2 Myocutaneous Gracilis Flap
9.8 Conclusion
References
10: Profunda Artery Perforator Flap for Perineal Reconstruction
10.1 Introduction
10.2 Surgical Anatomy and Preoperative Planning
10.3 Surgical Technique
10.4 Postoperative Management
10.5 Complications
10.6 Technical Pitfalls and Pearls
10.7 Editors Comments
References
11: Anterolateral Thigh Perforator Flap
11.1 Historical Background
11.2 Surgical Anatomy
11.3 Indications
11.4 Surgical Technique
11.5 Tips and Tricks
11.6 Conclusion
References
12: Abdominal Flaps
12.1 Introduction
12.2 Abdominal Flaps
12.2.1 Rectus Abdominis Myocutaneous Flap
12.2.1.1 Advantages
12.2.1.2 Disadvantages
12.2.2 Deep Inferior Epigastric Perforator Flap
12.2.2.1 Advantages
12.2.2.2 Disadvantage
12.2.3 Omental Flap
12.2.3.1 Advantages
12.2.3.2 Disadvantage
12.2.4 Postoperative Care
12.3 Conclusion
References
13: Pudendal Artery Perforator Flap and Other Reconstructive Options in Perineal–Pelvic Reconstruction
13.1 Introduction
13.2 Regional Considerations
13.3 Reconstructive Options
13.4 Abdominally-Based Reconstruction
13.5 Thigh-Based Reconstruction
13.6 Groin- and Gluteal-Based Reconstruction
13.6.1 Pudendal Flaps
13.6.2 Gluteal Flaps
13.7 Other Flaps
13.8 Conclusion
13.9 Cases
References
Further Reading
14: Omental Flap
14.1 Introduction
14.2 Role of Omentum After Major Pelvic Surgery
14.3 Preoperative Evaluation and Patient Selection
14.4 Omental Anatomy
14.5 Surgical Procedure
14.6 Postoperative Complications After Pedicled Omental Flap
References
15: Infantile Hemangiomas of the Perineal Area
References
16: Use of Lasers in Perineal Area
16.1 Introduction
16.2 Laser Physics
16.3 Types of Lasers
16.4 Carbon Dioxide (CO2) Laser
16.4.1 Clinical Indications
16.4.2 Advantages of CO2 Laser
16.4.3 Contraindications
16.4.4 Practical Considerations of Use in Perineal Pathology
16.4.4.1 Preoperative Considerations
16.4.4.2 Intraoperative Considerations
16.4.4.3 Postoperative Course and Follow-Up
16.4.5 Outcomes
16.4.6 Complications
16.5 Conclusion
References
17: Complications Following Perineal Surgery and Perineal Reconstruction
17.1 Introduction
17.2 Types of Complications
17.3 Predictors and Risk Factors for Complications
17.4 Musculocutaneous Flap Reconstruction
17.5 Fasciocutaneous and Perforator Flaps
17.6 VRAM Versus Thigh Flaps
17.7 Omentoplasty
17.8 Management of Perineal Complications
17.9 Intra-Abdominal Complications
17.9.1 Postoperative Ileus (POI)
17.9.2 Small-Bowel Obstruction
17.9.3 Stoma Complications
17.9.4 Perineal Hernias
17.9.5 Enteroperineal Fistula
17.10 Conclusion
References
18: Surgical Management of Lower Limb Lymphedema After Pelvic/Perineal Resections
18.1 Introduction
18.2 Lymphaticovenous Anastomosis Technique
18.2.1 Pathophysiology
18.2.2 Indication and Treatment Strategy
18.2.3 Diagnostic Imaging Technique
18.2.4 Preoperative Preparation and Surgical Planning
18.2.5 Surgical Technique
18.2.6 Postoperative Care
18.2.7 Outcomes
18.3 Vascularized Lymph Node Transfer Technique
18.3.1 Mechanism of Action of VLN Transfer
18.3.2 Surgical Indications and Preoperative Planning for VLN Transfer
18.3.3 VLN Flap Donor-Site Selection
18.3.4 Recipient Location for VLN Transfer
18.3.5 Postoperative Care for VLN Transfer
18.4 Liposuction
18.4.1 Preoperative Management
18.4.2 Surgical Technique
18.4.3 Postoperative Care
18.4.4 Outcomes
References
19: New Frontiers in Perineal Reconstruction
19.1 Introduction
19.2 Vaginal Reconstruction
19.2.1 Intestinal Flaps
19.2.2 Large Intestine
19.2.3 Small Intestine
19.2.4 Colon–Cecum–Appendix Flap
19.3 Penile Reconstruction
19.4 Urethral Reconstruction
19.5 Perineal Reconstruction
19.6 Anal Sphincter Reconstruction
19.7 Conclusion
References