Case ReportReconstruction of the pelvic floor and perineum with human acellular dermal matrix and thigh flaps following pelvic exenteration
Introduction
A major challenge of pelvic reconstructive surgery is restoring support for intra-abdominal organs. Failure to do so has been reported to result in such sequelae as perineal hernias, pelvic organ prolapse and even perineal evisceration. Implantable mesh materials have been used to address several inherent aspects of pelvic floor reconstruction including prevention of abdominal and pelvic organ prolapse, pelvic floor resuspension after oncologic resection and augmentation of bladder function. The implantable materials used are principally constrained by three factors: the durability of repair, tissue biocompatibility and material-related complications. Historically, surgical repairs of the pelvic floor have included synthetic absorbable and non-absorbable mesh materials. The use of non-absorbable synthetic meshes has been reported to yield effective, long-lasting surgical repairs in the pelvis [1]. Unfortunately, permanent synthetic materials are prone to infection, extrusion, adhesions and foreign body reactions [2]. The use of absorbable synthetic materials results in limited durability of the repair because the tissue plane remaining after their resorption is not sufficiently strong. Repairs performed with absorbable mesh have been reported to have recurrence rates as high as 100%.
Bioprosthetic mesh materials, including human acellular dermal matrix (HADM), have the potential to provide the durability of permanent synthetic meshes with markedly improved tissue biocompatibility [3]. These materials are processed to remove host cells but preserve the native three-dimensional biologic tissue matrix thereby preserving its tissue conductivity (ability to incorporate into recipient wounds with cellular incorporation and revascularization). AlloDerm (HADM, Lifecell Corporation, Branchburg, NJ) is derived from human dermis, is not chemically cross-linked and has been shown to become remodeled by the surrounding tissue to a well-vascularized, cellularized, structurally intact layer with preservation of adequate tensile strength [3], [4], [5], [6], [7]. HADM has been used for chest, pelvic and abdominal wall repair with durable results and relatively few complications, even given such adverse circumstances such as prior radiation therapy, wound contamination and placement directly over bowel [4], [5], [8], [9]. Bioprosthetic mesh materials such as HADM have the potential to provide the durability of the permanent synthetic meshes with markedly improved tissue biocompatibility [3]. Despite an increasing body of experience in abdominal wall reconstruction using HADM, however, its application in pelvic reconstruction has not been as widespread. Challenging pelvic floor reconstructions are not uncommon and the use of bioprosthetic mesh materials may offer an optimal solution. We report a surgical technique using HADM and thigh-based flaps for pelvic floor and perineal reconstruction following radical resection for the treatment of recurrent vulvar cancer and severe osteoradionecrosis. To our knowledge, this specific technique has not been reported.
Section snippets
Case report
A 75-year-old woman with squamous cell carcinoma (SCC) of the vulva was initially treated with wide excision followed by radiation therapy and chemotherapy. She returned 6 months later with locally recurrent SCC and full-thickness osteoradionecrosis of the vagina and vulva, along with chronic drainage from a rectovaginal fistula (Fig. 1). She had required numerous hospitalizations over a 2-month period for pain management and treatment of local and systemic infections before transfer to our
Discussion
In this case, resection of recurrent, radiated vulvar cancer resulted in a massive pelvic floor defect which posed a significant risk of pelvic organ herniation. Durable reinforcement was deemed necessary, and this was accomplished at the time of resection using HADM in conjunction with two thigh-based soft tissue flaps. Most pelvic and perineal defects following cancer resection can be repaired with local tissue rearrangement and/or tissue flaps, without the use of prosthetic mesh. However,
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