The use of bone anchors for autologous flap fixation in perineal reconstruction: a case report
A 64-year-old female presented to our office with a perineal hernia (Fig. ) 1.5 years after abdominoperineal resection (APR). She had a history of recurrent low-lying rectal cancer for which she received neoadjuvent external beam radiation and chemotherapy, followed by APR. Physical examination showed the hernia was reducible and tender to palpation. Radiation skin changes were also noted in the perineum. The patient reported not being able to sit due to pain related to the hernia. She also did have a large ventral hernia related to her previous abdominal surgeries.\nDue to her history of perineal radiation, we decided to treat her with a VRAM (Fig. ) via trans-abdominal approach. There was concern about securing the flap in the perineum due to the size of the defect and previous radiation making the tissues friable. In light of this, we decided to use bone anchor fixation to secure the autologous flap. She also underwent abdominal wall reconstruction with separation of components and mesh placement during the same operation.\nA standard VRAM was harvested from the abdominal wall. The bowel and abdominal contents were then returned to the abdominal cavity. Several Fastin Mitek brand (Raynham, MA) bone anchors were placed in the bones surrounding the pelvic outlet, including the fecal promintory, pubic tubercle and pelvic rim (Fig. ). Holes were pre-drilled after the bone had been exposed. The anchors were then screwed into place with suture attached. Care was taken not to injure the ureters, sacral venous plexus, surrounding nerves and blood vessesl. The skin of the flap of the VRAM was de-epithelialized. The bone-anchored suture was then passed through the dermis of the flap. The flap was parachuted down into the pelvis and the sutures were tied to secure the flap in place. This created a pelvic sling to close off the pelvic inlet from the abdominal cavity.\nPost-operatively the patient did well. She did however present with infected abdominal mesh 3 months after surgery. She was returned to the OR for removal of the abdominal mesh. The perineal repair at that time was intact. At 18 month follow-up, there was good healing of all the wounds and no recurrence of either hernia (Fig. ).