VM69 - Robotic Vertical Rectus Abdominis Muscle Flap After Abdominoperineal Resection

Purpose/Background: Abdominal perineal resections (APRs) are commonly used to treat low rectal and anal cancers. This complex operation may require using a flap for tissue closure in the pelvis. Multiple flaps have been used to aid in wound healing such as rectus abdominis, gluteus, and gracilis muscle flaps to limit the complications related to the perineal wounds like skin break down, dehiscence and feared pelvic evisceration. In order to raise these flaps, colon and rectal surgeons must frequently rely on plastic reconstructive surgery involvement and an additional incision. Robotic APRs allow for an excellent view of the posterior rectus sheath and a vertical rectus abdominis muscle flap without the need for an additional incision or assistance from plastic surgery. The anterior rectus sheath is also preserved, therefore allowing for the omission of mesh for reconstruction. While this approach has been used in plastic reconstructive surgery and gynecologic surgery, there has been little published on this topic by colon and rectal surgery.

Methods/Interventions: This is a video review of a robotic vertical rectus abdominis muscle flap performed by a colorectal surgeon for a patient with T4b rectal adenocarcinoma who had completed neoadjuvant therapy. An APR was performed in the standard fashion prior to completion of the muscle flap. The right posterior rectus sheath is incised vertically for its entire length. While preserving the inferior epigastric vessels (inferior and lateral origin), the rectus is divided at the costal margin and the muscular flap is then developed inferiorly and rotated into the pelvis all while leaving the anterior rectus sheath intact. The posterior rectus sheath is then closed with Stratafix.

Results/Outcomes: This was a successfully performed totally robotic vertical rectus abdominis muscle flap. The patient’s postoperative course was complicated by pulmonary embolism requiring anticoagulation, despite prophylactic anticoagulation use. The patient did not have any long term intra-abdominal complications of the flap or perineal wound.

Conclusion/Discussion: Robotic vertical rectus abdominis muscle flap allows for tissue flaps to be raised to reinforce the perineal incision without the need for assistance by plastic reconstructive surgery. This also creates a more cosmetic closure for the patient with lower risk of abdominal wall complications. The perineal incision is still closed primarily and three additional 8mm robotic trocars need to be placed to accommodate this technique. In the appropriate patient population, robotic vertical rectus abdominis muscle flap is a viable option for perineal wound reinforcement and can be performed by colorectal surgeons who are familiar with this approach.