Vertical Rectus Abdominis Myocutaneous Flaps, Gluteal Flaps, and Plastic Surgery Reconstruction in Colorectal Surgery

Emre Gorgun

Raymond Isakov

Perioperative Considerations

Several flaps are available to bring healthy, well-vascularized tissue into complex, often irradiated, and large wounds that would otherwise take months to heal or not heal at all.
Prior or planned surgeries (eg, ostomies) need to be accounted for when choosing the type of flap utilized.
Vertical rectus abdominis myocutaneous flaps (VRAMs) fill the pelvis with muscle bulk and can also be used for vaginal wall reconstruction.
VRAMs result in relatively lower complication rates compared with other flap types.
VRAMs use an oblique or vertical skin flap and an inferior pedicle.
VRAMs are the most commonly used abdominal flap in the perineal region and consists of skin, subcutaneous tissue, and muscle.
Gluteal and gracilis flaps also provide healthy bulking tissue and can be used to heal in defects following abdominoperineal resection and fistula (eg, rectourethral and rectovaginal).
Multidisciplinary approach with plastic surgery is advised.

Positioning

Positioning should be in the lithotomy position for harvesting of a VRAM and gracilis graft.
Prone positioning is typically utilized for gluteal flaps.
Change of positioning for various segments of the operation may be necessary.
Proper perineal and lower extremity skin preparation is required for all grafts.

VERTICAL RECTUS ABDOMINIS MYOCUTANEOUS FLAPS

Technique

After standard sterile preparation and draping, palpate and outline the rectus abdominis muscle and then mark the midline and lateral borders of the flap.
Start the incision from the midline down to the linea alba and down to the mons pubis.
Designate the skin island to fill the perineal defect, and when cutting the skin island, pay attention to preserve the blood supply.
Extend the incision laterally to dissect the flap from the rectus sheath.
Ligate the perforators coming off of posterior rectus sheath.

After separating the rectus muscle, open the posterior sheath to enter the abdomen (Fig. 50-1).

FIGURE 50-1 ▪ Borders of the ventral rectus flap are marked based on the dimensions of the defect. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)

Incise the lateral and superior margins of the flap deep into the fascia.
Identify and preserve the deep inferior epigastric artery pedicles.

After complete dissection and mobilization of the flap, rotate the flap 180 degrees on the long axis, and using the abdominal incision, pass the flap deep into the pelvis and position it in the perineum (Figs. 50-2, 50-3 and 50-4).

FIGURE 50-2 ▪ Flap is incised and raised then rotated 180 degrees and passed through pelvis to close the defect. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)