Pedicled Anterolateral Thigh Flap with the Vastus Lateralis Muscle for Extensive Pelvic and Perineal Defect Reconstruction through a Trans-Abdominal Approach

以帶蒂大腿前外側皮瓣併股外側肌經腹部途徑進行同時重建廣泛性骨盆腔及會陰部缺損之案例報告

蔡佳津(Chia-Chin Tsai) ； 謝式洲(Shyh-Jou Shieh)

《臺灣整形外科醫學會雜誌》 27卷3期 (2018/09) Pp. 188-197

摘要

Background: The reconstruction of extensive perineal and pelvic defects following abdominoperineal resection and pelvic exenteration for the resection of malignancies is very challenging with high morbidity rate. Myocutaneous flap reconstruction has been proposed to be better than primary closure in decreasing wound complications and enhancing healing. Multiple flaps options including local, regional, and free flaps have been discussed. The use of pedicled anterolateral thigh flap with the vastus lateralis muscle is a feasible and effective method. Aim and Objectives: We reported and discussed the successful reconstruction of perineal and pelvic defects using pedicled anterolateral thigh flap with the vastus lateralis muscle in a patient with advanced-stage rectal cancer after extensive oncological resection. Material and Methods: We presented a case of 60-year-old male with recurrent rectal adenocarcinoma who underwent multiple previous surgeries and chemo-radiotherapy. Pedicled anterolateral thigh flap with the whole vastus lateralis muscle was used for the reconstruction of a complex pelvic and perineal defect after oncological resection. Rather than the most commonly used anterior perineal approach, we adopted the trans-abdominal approach for extensive dead space filling after pre-sacral tumor removal. Perineal wound was reconstructed without tension using the anterolateral thigh flap skin paddle. Donor site was primarily closed. Results: The hospitalization course was uneventful. The patient recovered well without any complication and was able to proceed to the subsequent oncologic treatment 2 months after surgery. There was no donor site morbidity or functional limitation. Follow-up image study showed well-enhanced pedicle of the flap and full coverage of the defect. Conclusion: Pedicled anterolateral thigh flap with the vastus lateralis muscle provides adjustable well-vascularized muscle bulk and skin for reconstruction of extensive pelvic and perineal defects with reduced surgical or wound complications and low donor site morbidity. The trans-abdominal approach enables the reconstruction of an even more extensive defect over the pre-sacral and perineal region.

關鍵字

perineal and pelvic reconstruction ； anterolateral thigh flap ； trans-abdominal

並列摘要

背景：惡性腫瘤行經腹部和會陰切手術及骨盆廓清術術後之廣泛性骨盆腔及會陰部缺損重建十分具有挑戰性且常伴隨手術相關併發症。利用肌皮瓣進行重建相較於傷口直接縫合被認為能減少傷口的併發症，並且能促進組織癒合。許多肌肉及肌皮瓣，包含局部、區域，或是游離皮瓣都曾經被使用、比較，以及討論。以帶蒂大腿前外側皮瓣合併股外側肌肉進行此類病患的重建為一可行且有效的手術方式。目的及目標：我們報告且討論一位罹患後期直腸癌症病患在接受腫瘤切除手術後，以帶蒂大腿前外側皮瓣併股外側肌經腹部途徑成功的進行廣泛性骨盆腔及會陰部缺損一次重建的過程及結果。材料及方法：我們提出一位60歲直腸腺狀惡性腫瘤反覆復發，且過去接受過數次手術和化學及放射線治療的病患，在再次手術進行腫瘤切除後，以帶蒂大腿前外側皮瓣併全股外側肌肉進行骨盆腔及會陰部缺損之一次重建。有別於以往較常使用的經前方會陰側方式，我們使用了經腹部途徑進行重建，能更有效的填塞病患尾骶骨前腫瘤移除後之廣泛性死腔。會陰部傷口則以大腿前外側皮瓣在沒有張力之下進行重建，皮瓣供區則是直接縫合。結果：病患住院病程平順且傷口恢復良好，無任何手術相關併發症發生，並且得以在術後兩個月即開始進行化學治療及放射線治療等進一步腫瘤治療的計畫。皮瓣供區傷口癒合良好，無其他併發症或是功能上之限制。術後追蹤的電腦斷層影像檢查可見清晰的經腹部途徑皮瓣血管根蒂且有效的填塞缺損之區域。結論：帶蒂大腿前外側皮瓣併股外側肌可以提供可調整大小的、血循良好的肌肉組織以及皮膚來進行廣泛性骨盆腔及會陰部缺損一次重建，同時具有低手術和傷口併發症，低皮瓣捐贈區併發症的特性。經腹部途徑的手術方式則可有效的重建範圍更廣泛，尤其是延伸到尾骶骨附近的骨盆腔併會陰部缺損。