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Perineal reconstruction

Grab & smith

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Perineal reconstruction

  1. 1. Dr.Akasha Amber PGR PLS BVH,BWP PERINEAL RECONSTRUCTION
  2. 2. INTRODUCTION  Close proximity to various organ systems  Complexity of defects  Risks in reconstruction  Careful planning
  3. 3. Blood Supply  Femoral artery:  Superficial & deep Ext. Pudendal A.(abdominal and perineal branches)  Skin and fascia of anterior triangle  Internal iliac artery:  Pudendal Artery  Posterior triangle via:  Penile/clitoral A.  Superficial peineal A  Posterior sacral artery
  4. 4. Causes For Reconstruction Of Defects
  5. 5. Goals Of Reconstructions  No reconstruction until primary cause is resolved  GOALS:  Wound healing/coverage  Single stage reconstruction  Restoration of normal or near normal function  Minimal associated morbidity
  6. 6. Reconstruction Of Perineum  Ladder of reconstruction  Simplest to complex reconstructive options  Small defects  Moderate sized defects  Large Extensive defects  APR, Pelvic exenteration  Complications of extensive defects  flap selection  Amount of tissue, adequacy of blood supply, scar at donor site, patient positioning during surgery, operative approach(perineal vs laparotomy)
  7. 7. Options For Reconstruction  Primary closure  Secondary healing  Wet to moist dressing  Negative pressure therapy  Skin grafting  Local flaps  Regional flaps  Free tissue transfer
  8. 8. Regional Flaps  Vertical Rectus Abdominis Myocutaneous(VRAM) Flap  Pedicled greater omental flap  Gracilis falp  Posterior thigh flap  Singapore flap(pudendal thigh flap) Others:  Gluteal flap  Medial thigh flap  Perforators flaps  Pedicled ALT Flap, Deep Inferior Epigastric Perforator flap, Superior Gluteal Artery Perforator
  9. 9. VRAM FLAP  Benefits:  Large amount of tissue  Reliable vascular pedicle  With or without skin paddle(transverse/verticle/oblique)  Skin paddle for perineal skin  Pelvic reconstruction ,vaginal reconstruction  Fewer post operative complications  Limitations:  Twisting while insetting  Unreliable skin paddle in obese
  10. 10. Vertical and oblique designs of RAM fllaps Cutaneous paddle inset for external perineal skin reconstruction
  11. 11. Pedicled Greater Omental Flap  Useful Option when:  undergoing laparotomy  narrow pelvis  Obese  VRAM flap unavailable  Right or Left Gastroepiploeic vessels  For pelvic filling,perineal and vaginal reconstruction  Covered with skin grafts
  12. 12. Gracilis Flap  Ascending br of medial circumflex femoral artery  Skin paddle in proximal and middle third  Extended dissection upto profunda femoris artery for long pedicle Benefits:  Versatile  Minimum donor site morbidity,no laparotomy required  Outside radiation field  Functional muscle transfer  As regional or free flap Limitations:  Short pedicle  Unreliable skin paddle  Not for large defects
  13. 13. Posterior Thigh Flap  Inferior gluteal artery  Centre of posterior thigh  Very large bulk of tissue  Sensate flap (posterior cutaneous femoral nerve)  Skin paddle upto 34cm x 15cm  Prior check on patency of internal iliac vessel  For very large defects,bilateral flaps
  14. 14. Singapore Flap  Pudendal thigh flap  superficial perineal artery, pudendal nerve, posterior cutaneous nerve of thigh  Versatile fasciocutaneous flap  Axial sensate flap  Frequent use for vaginal reconstruction  As VY flap or bilateral flaps use
  15. 15. Complications  Pelvic abscess,chronic drainage,wound dehisence,bowel herniation, adhesions, intestinal obstruction  Wound infection, seroma, delayed wound healing
  16. 16. Perineal reconstruction of female patient  Vulval and vaginal reconstruction Goals:  Primary wound healing/single stage procedure  Pelvic floor restoration  Decreased pelvic dead space  Sexual function restoration
  17. 17. Congenital Vaginal Defects  Mullerian duct agenesis/atresia associated with:  Mayer-Rokitansky-Kuster-Hauster Syndrome  Gender dysmorphia, imperforate anus, bladder extrophy  Treatment: Nonsurgical techniques Surgical techniques Frank method / vaginal dilators Mclndoe operation (STSG over vaginal stent after dissection between bladder and rectum) Intestinal colpoplasty (Sigmoid colon or jejunal flap) Modified singapore flap(pudendal thigh flaps) Gracilis and posterior thigh flaps
  18. 18. Acquired vaginal defects  Surgery,burn,trauma,infections  Partial/complete defects Type of defects Etiology Surgical Option Type 1A(Partial) Anterior &/or lateral wall Primary vaginal wall malignancy, urinary tract resection Uni/bil fasciocutaneous modified singapore flap Type 1B(Partial) Colorectal carcinomas involving vaginal walls Pedicled VRAM flap Type 2A(Circumferential) Upper 2/3rd resection Rolled pedicled rectus myocutaneous flap/ Intestinal colpoplasty Type 2B(Circumferential) Total exenteration Bilteral gracilis myocutaneous flap
  19. 19. Functional Restoration Of Male Patient  Congenital defects, trauma, infections, lymphatic malformations, malignancies Goals:  Reconstruction of phallus with a canal for urine and sperm  Erectile capability  Sufficient length  Tactile and erogenous sensation
  20. 20. Reconstructive Options  STSG(non meshed)  Redundant foreskin of uncircumscribed patients  Scrotal flaps  Local flaps  Dressing: foam, negative pressure therapy
  21. 21. TOTAL PENILE RECONSTRUCTION:  Phalloplasty; regional flaps e.g ALT flap and free flaps  Radial forearm flap preferred SCROTAL RECONSTRUCTION:  Stsg  Testicular burrial  Large defects: VRAM,ALT, superomedial thigh flap PENILE REPLANTATION:  Within 6 hours of warm ischemia,within 16 hours of cold ischemia  2 layered urethral closure over catheter  Minimal dissection of neurovascular bundle  Tunica albuginea closure  Microsurgical anastomosis of dorsal artery and dorsal vein  Epineural repair of dorsal nerve  Suprapubic cystostomy
  22. 22. THANK YOU
  • kunalsayani

    Nov. 28, 2019
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    Nov. 6, 2018
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    Sep. 26, 2018
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    Jul. 24, 2018
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    Jul. 10, 2018
  • dranudeep

    Jun. 15, 2018

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