V-Y Gluteal Fasciocutaneous Advancement Flap after Robotic Abdominoperineal Resection
This video demonstrates a robotic APR with V-Y gluteal flap reconstruction for the perineal defect after resection of extramammary Paget disease of the anus. This video not only highlights the technical steps and pearls of a robotic TME for an appropriate, oncologic APR but also a reconstructive option that, when done correctly, can offer superb coverage for an enlarged or radiated perineal defect.
- Evaluation by plastic surgeon for reconstruction option–preoperative marking as needed in holding room
- Preoperative bowel preparation per institutional protocol
- Preoperative education and marking for colostomy
- Lithotomy or abdominal resection
- Arms tucked and padded
- Adequately secured (straps, tape, etc) for Trendelenburg positioning
- Prone positioning for perineal dissection, specimen removal, and reconstruction/closure
- Abdominal portion:
- Appropriate robotic port placement for abdominoperineal resection (APR)
- Identify and preserve the left ureter and gonadal vessels
- High ligation of the vascular pedicle under no tension (inferior mesenteric artery for rectal pathology, superior rectal artery in this case for Paget disease)
- Adequate total mesorectal excision (TME), beginning posteriorly
- Place cottonoid/sponge posteriorly firmly in the most distal pelvis against the tip of the coccyx to act as the target point for subsequent peroneal entry at base of TME dissection
- Prone/perineal portion:
- Ensure adequate perianal margin (disease specific, ie, Paget disease)
- Use Lone Star retractor to facilitate dissection and visualization
- Palpate and identify coccyx as target for posterior dissection–identify and remove sponge
- iv. Eviscerate specimen and carefully dissect anterior attachments (beware of prostate in males)
- Closure of defect–in this instance, with V-Y flap
- Preserve inferior gluteal arteries
- Obtain adequate enough mobilization for tension-free skin anastomosis
- Always identify and preserve the left ureter during any left sided and/or rectal dissection.
- Place a cottonoid/sponge in the deepest, posterior portion of TME dissection to help with identification of the correct plane when approaching from perineum later.
- Send skin margins (if for Paget disease) before completing closure.
- The use of the large hooks in the Lone Star retractor can offer superior retraction.
- Have a primary and secondary (backup) plan for closing large perineal defects.
Potential areas for injury or complications:
- Ureteral injury if not identified and protected
- Inadequate TME
- Potential for presacral bleeding during TME
- Positive margin in Paget disease
- Injuring necessary perforating vessels for gluteal flap