Transpelvic Oblique Rectus Abdominis Myocutaneous Flap With Preservation of the Rectus Sheath

BACKGROUND: Perineal reconstructive surgery is an effective procedure to decrease the morbidity associated with extensive abdominoperineal resection in the treatment of advanced low rectal and anal malignancies. Rectus abdominis myocutaneous flaps are often utilized in perineal reconstruction with excellent results. However, the main disadvantages are donor-site morbidity and the need for an open procedure after laparoscopic resection, requiring larger incisions with a resultant increase in postoperative pain. Herein, we describe a modified oblique rectus abdominis myocutaneous flap technique that allows sparing of the rectus sheath and the linea alba. TECHNIQUE: We followed the 3 stages regularly described for the procedure: 1) abdominoperineal resection with simultaneous abdominal and perineal team approach, and removal of the specimen through the perineal wound; 2) right oblique rectus abdominis myocutaneous flap with inferior epigastric pedicle, and release of the rectus muscle from its aponeurotic sheath through the skin paddle incision and transposition of the oblique rectus abdominis myocutaneous flap through an incision in the transversalis fascia; and 3) perineal reconstruction by sutures of the skin paddle to the perineal wound skin edges. RESULTS: Release of the rectus muscle within its sheath through the incision in the skin paddle turned out to be a simple surgical procedure, without the need of specialized surgical instruments or additional incisions. There were no complications during the postoperative recovery. Our patient was pain-free 1 month after the surgery, with a well-healed flap and abdominal scar. CONCLUSION: Performance of an oblique rectus abdominis myocutaneous flap that is specifically fitted for the perineal defect after abdominoperineal resection, with muscle dissection performed through the skin paddle incision and transposition into the pelvis through the transversalis fascia, offers good functional outcome while minimizing damage to the abdominal wall.