[Microsurgical reconstruction of the pelvic floor after pelvic exenteration. Reduced morbidity and improved quality of life by an interdisciplinary concept].
Pelvic exenteration for advanced or recurrent rectal cancer often results in complex defects associated with high complication rates and morbidity for the patients. The goal of therapy is therefore restoration of functional stability and adequate soft tissue coverage, thus enhancing the quality of life with limited life expectancy by an interdisciplinary approach. We report on eight patients treated by combined interdisciplinary pelvic exenteration with resection of the sacrum and subsequent coverage of the pelvic floor defect with free latissimus dorsi muscle flaps. All patients were treated in two stages according to a pre-established therapeutic algorithm. First, an abdominal and transsacral pelvic exenenteration was performed with an ileostomy and ileum conduit system and the pelvic floor was closed with vicryl meshes. The open wound was optimized by vacuum-assisted closure (VAC) therapy before reconstruction of the pelvic floor was undertaken 10-12 days later with free latissimus dorsi musculocutaneous flaps either anastomosed to the lower or upper gluteal vessels or to an AV-loop using the saphenous vein as connection to the groin vessels. In all cases a sufficient and stable reconstruction of the pelvic floor could be achieved and no flap loss occurred. In three patients a minor wound dehiscence occurred, which could be closed by secondary suture. The time span between the free flap transfer and stable wound closure was 19-28 days. Later complications such as fistula formation and chronic wound infections were not observed. The survival of the patients ranged from 10-36 months. The present two-stage concept of pelvic floor reconstruction with free latissimus dorsi muscle flaps for wound closure after pelvic exenteration improves postoperative morbidity and mortality and increases the quality of life of the affected patients. A shortened period of open wound therapy brings additional economic benefits. Because of its anatomical features the free latissimus dorsi flap can be regarded as the method of choice of microsurgical reconstruction within an interdisciplinary concept after pelvic exenteration.