Perineal and Vaginal Reconstruction

John Beynon

Powerpoint File

Pelvic surgery for neoplastic and inflammatory conditions can result in excision of components of the urinary, reproductive and lower gastrointestinal tract either in isolation or with adjacent structures to achieve clearance of malignancy or elimination of the septic process.

Functional aspects can be restored by the formation of a colostomy, an ileal conduit, bladder reconstruction, the use of the artificial urinary sphincter and vaginal reconstruction.

Addressing the problem of restoring or preserving function and appearance is paramount. Reconstruction of the pelvis and perineum is required only under circumstances where there is extended skin loss, partial or complete vaginal excision, pelvic floor loss and where excision is following previous radiotherapy. The aim is to repair the pelvic floor achieve skin integrity and obliterate the dead space. A number of techniques are available to achieve this end using a variety of tissues and myocutaneous flaps (1-5). These commonly include the rectus abdominis flap, gracilis muscle, omentum and split skin grafting though there a number of different local rotation flaps that can be utilised and also free flaps in exceptional cases. Most commonly used are rectus abdominis myocutaneous flap, gracilis muscle and myocutaneous flaps and omentum with good results at primary healing being reported (6-15). Similarly these are used for reconstruction of the vaginal following partial excision (16-25). Each case has to be carefully planned depending on individual circumstances.

Total vaginal reconstruction using a sigmoid neovagina usually as an isolated segment has been used for many years though stenosis and prolapse can be problems as can unfortunately be mucinous secretions and odour. In the majority this form of reconstruction has been utilized in the correction of congenital problems and in gender reallocation procedures (26,27).

This reconstructive component of dealing with the large perineal defect or restoring vaginal function whether partial or complete requires the expertise of a specialised reconstructive team of surgeons. The narrow range of techniques available to the ‘generalist’ may not be sufficient to deal with these complex problems. A team approach with careful planning is essential to deal with these cases. This ‘pelvic team’ should ideally include a gynaecologist, urologist, colorectal surgeon, reconstructive plastic surgeon and clinical oncologist (28).

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