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41 Pelvic Reconstruc tive Procedures
465
plan. Finally, one must review all previous operative procedures and available imaging to prevent
errors from poor ap selection.
Intraoperative
Wide surgical preparation and draping of the pelvis and donor sites is essential for exposure. A
position change may be required to appropriately
access and mobilize donor tissue, such as switching to prone positioning to elevate gluteal aps
for posterior perineal defects.
In addition to antiseptic skin preparation, prophylactic intravenous antibiotics should be
administered within 60 minutes of the start of
surgery and re-dosed as indicated to prevent
infection. Every effort should be made to optimize surgical efciency to decrease operative
time as lengthy surgeries have increased risks of
complications [5].
The reconstructive surgeon must rst critically evaluate the extent of the anatomic defect
including deep space and skin involvement
(Fig.41.1). Any heavily radiated, devitalized, or
traumatized tissue that remains should be
debrided back to healthy, vascularized tissue to
facilitate healing. It is important to wait until the
nal debridement before nalizing your ap
design.
Thoughtful and meticulous ap design, dissection, and inset are imperative in achieving a
successful reconstruction.
In cases of a large pelvic defect with a deep
space component, the surgical plan should
include obliteration of the dead space with bulky
muscle, omental or de-epithelized aps. The
extra tissue helps cover exposed pelvic structures
and mechanically supports the internal organs.
This can effectively prevent internal herniation,
prolapse and uid collection which all predispose
the patient to infection, incisional dehiscence,
and stulae [3, 4, 8, 15].
In cases of a large skin defect, the ap should
incorporate a skin paddle to replace the resected
perineal skin. Otherwise, there would be undue
tension on primary skin closure and an increased
risk of incisional dehiscence [3]. A skin paddle
can also be utilized to resurface vaginal defects.
Intraoperative templates are useful in designing
the ap dimensions. However, the skin paddle
should be slightly oversized to account for tissue
thickness, edema, and rotation, and to avoid a
tight closure which could compress the vascular
pedicle [16] (Fig.41.2).
When designing and elevating aps, the
reconstructive surgeon must have a thorough
understanding of the vascularity of the various
aps including pedicle location, arc of rotation,
Fig. 41.1 Large pelvic defect with internal dead space
and external skin defect
Fig. 41.2 Flap design based on an intraoperative template of a perineal defect made with hydrocolloid
dressing
466
J. Pribaz and K. Whalen
and location and reliability of cutaneous perforators. With this knowledge, surgeons can make
modications to ap design to meet the unique
requirements of the defect [17]. Dominant perforators should be incorporated into the ap design
when feasible to improve vascularity. A handheld
doppler is helpful in identifying perforators for
this purpose.
In the case of rectus abdominis aps, designing the skin paddle over the robust periumbilical
perforators improves perfusion. The skin paddle
can also be oriented obliquely and extend beyond
the costal margin to increase the length of the ap
for use in large or posteriorly oriented defects
[18, 19]. Any part of the ap that cannot reach the
perineum should be de-epithelialized rather than
de-skinned because maintenance of the dermal
plexus improves vascularity to the distally oriented skin paddle. Leaving the inferior attachment of the rectus muscle is advised to prevent
stretching, twisting, kinking, or avulsion of the
vascular pedicle once it is transposed into the pelvis (Fig.41.3).
For advancement aps from the thigh or buttocks, the ap should be designed large enough to
include reliable perforators, provide sufcient
skin coverage, and allow for ap re-advancement
if needed [19]. The leading edges can also be deepithelialized to ll internal dead space
(Fig.41.4).
It is important to discuss preserving the omentum with the extirpative surgeons if you are planning to incorporate it into the reconstruction. The
omentum should be adequately dissected based
on the right or left gastroepiploic pedicle to avoid
tension on the blood supply and prevent a tight
intrabdominal band that may lead to internal hernia [7].
Once the ap has been elevated, it can be
transferred to the recipient site. One must release
all scar contractures and radiated tissue to avoid
constriction and pressure on the ap, which can
develop once postoperative edema has set in. If
there is any concern about the vascularity of the
ap, the subcutaneous tunnel should be released
to accommodate the transferred tissue. The skin
paddle can be extended to include a wide skin
bridge to cover the tracks of the pedicled ap and
eliminate the need for a tunnel (Fig.41.5).
When performing free tissue transfer (which
is uncommon, due to the large number of regional
ap options), recipient vessels must be inspected
Fig. 41.3 Design of an extended oblique vertical rectus
abdominus myocutaneous (VRAM) ap. Note the intrapelvic portion is de-epithelialized to preserve the subdermal plexus and the inferior muscular attachment to the
pubis is maintained to prevent pedicle kinking, twisting,
and avulsion when transferring the ap into the pelvis
Fig. 41.4 Design of bilateral V-Y gluteal fasciocutaneous aps for secondary reconstruction after dehiscence
and distal ap necrosis of a VRAM ap. Note the leading
edges are marked for de-epithelialization to ll internal
dead space
41 Pelvic Reconstruc tive Procedures
Fig. 41.5 Right pedicled anterolateral thigh with an
extended skin paddle to cover the pedicle’s course and
prevent the need for a constrictive subcutaneous tunnel
intraoperatively to ensure they are intact and outside of the zone of radiation. If local vessels are
unavailable, an arteriovenous vascular loop from
regional vessels can be created with a vein graft
[20].
Intraoperative ap perfusion can be assessed
by observing clinical bleeding patterns or by the
use of SPY angiography technology. Tissue with
evidence of poor blood ow should be excised
prior to ap inset.
In addition to the recipient site, one must also
consider the donor site’s morbidity. To reduce the
risk of bulge or herniation formation after transfer of rectus abdominis muscles, it is critical to
restore the abdominal wall. The fascia can be
closed primarily when harvesting a muscle-only
rectus abdominis ap. In cases that require a
myocutaneous ap, the anterior rectus sheath and
overlying soft tissue are harvested with the muscle resulting in a fascial defect. Adjunctive techniques to reduce abdominal wall morbidity in this
setting include fascia-sparing rectus muscle harvest with primary fascial closure, component
separation with primary fascial closure, or placement of an inlay mesh that is inset on proper anatomic tension [15, 18]. Biologic mesh should be
considered in contaminated or infected wound
beds.
In patients where the abdominal donor site is
not available due to previous surgeries or multiple ostomies, the thigh or gluteal tissue can be
used. These aps are ideally harvested as fascio-
467
cutaneous aps in ambulatory patients to preserve mobility [8, 14]. A pinch test veries that
the donor site can be closed primarily without
excessive tension. Incisions should be oriented
along resting skin tension lines to allow for larger
ap harvest and inconspicuous donor site closure. Skin grafting of the donor site may be
required if it cannot be closed primarily.
Measures should be taken to prevent uid collection which can later become a source of infection. Careful hemostasis is essential during all
stages of the operation. Multiple drains should be
placed including at least one large caliber drain in
the pelvis and a drain beneath the ap. Progressive
tension sutures can also be considered to minimize dead space at the donor site.
The ap should be inset loosely to prevent
kinking of the pedicle or perforators [7]. A meticulous multilayer, water-tight cutaneous closure
should be performed while avoiding overly tightened sutures that can result in tissue necrosis.
There are several options for dressings and the
choice is often surgeon dependent. The ideal
dressing absorbs drainage, protects the incision
from shear forces, minimizes trauma to surrounding skin, and allows regular monitoring of the
incision and aps by the surgical team. Absorbent
abdominal gauze pads and mesh panties are simple, cheap and achieve the above goals. Dressings
should be changed at least daily and as needed
for saturation or contamination.
Postoperative
Protocols vary based on surgeon and institutional
preference, but postoperative activity modication and positioning is critical in preventing pressure induced necrosis and dehiscence in the early
postoperative period. Optimal positioning
depends on the exact location of the ap but
ranges from prone to supine and lateral decubitus. Air-uidized mattresses are a useful adjunct
for pressure ofoading. Some surgeons opt for
bed rest for the rst 1–3 days, while others
encourage early ambulation to prevent venous
thromboembolism. Sitting or waist exion
greater than 30 degrees is generally prohibited
468
J. Pribaz and K. Whalen
for 3–6weeks to avoid direct pressure on the ap
and tension on the skin closure. Once patients
start ambulating, they should be instructed to logroll to stand with the guidance of a physical therapist [2, 4, 9].
Due to the dependent nature of these surgical
sites, the incisions are prone to uid egression
and maceration. It is important to keep the incisions dry with frequent dry dressing changes.
Closed suction drains should be maintained for
several weeks until output is less than approximately 30cc per day to prevent uid collections
in gravity-dependent zones [2, 4]. It is also advisable to leave perineal drains in place until the
intrabdominal drains have been removed by the
extirpative surgeons. Sutures are removed once
incisions are fully healed.
Postoperative antibiotics, especially in
patients with foreign materials such as mesh,
should be considered to prevent infection.
Patients are closely monitored for derangements
such as anemia, hyperglycemia, hypothermia,
hypovolemia, and malnutrition and optimized
accordingly.
Recognition
Fluid Collection
Supercial uid collections can be palpated on
exam and may be associated with incisional
drainage. Clear drainage is most consistent with a
seroma but can also indicate a urine leak.
Sanguineous drainage suggests a hematoma and
purulence is concerning for an abscess.
Laboratory studies are useful to evaluate for
associated anemia or leukocytosis. Fluid analysis
including culture, cytology, and creatinine can
also help determine the etiology of the collection
and guide treatment.
Infection
Supercial infection can be diagnosed on exam
with ndings of warmth, erythema, edema, and
tenderness. Deeper organ space infections are
best identied with imaging such as ultrasound
or computed tomography. Signicant pain,
necrotic tissue with malodorous drainage, and
rapidly progressive sepsis are signs of a serious
necrotizing soft tissue infection. This clinical
diagnosis requires a high index of suspicion and
warrants prompt surgical exploration.
Early identication of complications is best
achieved with close postoperative monitoring.
Patients are typically hospitalized for 7 to 14days
and seen in the clinic weekly or biweekly until
drains are removed and complete healing is
observed.
Wound Dehiscence andDelayed
Wound Healing
Delayed wound healing is the most common
complication after female pelvic reconstructive
surgery and requires timely diagnosis and treatment. Wound dehiscence or delayed healing is
recognized on exam as lack of completely
opposed skin edges greater than two weeks after
surgery.
Partial or Total Flap Loss
Pedicled and free aps are susceptible to vascular
compromise by pedicle compression, clotting, or
kinking which necessitate timely intervention in
the operating room to prevent ap loss [2]. These
patients should be closely monitored postoperatively by experienced clinicians with serial ap
checks which include ap color, turgor, capillary
rell, temperature, and doppler when applicable.
Flaps that are pale, cool and have weak or absent
arterial doppler signals and slow capillary rell
likely have arterial insufciency. Flaps with dark,
purplish discoloration, edema, and brisk capillary
rell are suffering from venous insufciency.
Early recognition of a perfusion problem is
essential in salvaging aps.
41 Pelvic Reconstruc tive Procedures
469
Fistula
Fistulae can be identied on exam by abnormal
connections between anatomic structures such as
the skin, bladder, vagina, and rectum. Patients
may note abnormal drainage as well. Static and
dynamic imaging can be helpful in further characterization of the stula.
Donor Site Complications
Donor site hernia can be diagnosed as a palpable
bulge on physical exam or with computed tomographic scans. As with ap recipient sites, donor
sites are also subject to wound dehiscence, uid
collections, and infection and are recognized as
above. In the case of abdominal incisional dehiscence, the wound should be gently probed or
imaged to assess for fascial integrity.
Management
Wound Dehiscence andDelayed
Wound Healing
Small wounds that are supercial and involve
less than one-third of the incision can be managed conservatively with local wound care such
as saline moist-to-dry gauze packing. These
wounds typically completely heal by secondary
intention. Larger wounds can be treated with
negative- pressure wound therapy or operative
debridement and secondary closure to accelerate
healing. Expedited healing is especially important when the patient requires adjuvant therapy
[2, 11].
Fluid Collection
Fluid collections including hematoma, seroma,
and abscesses should be treated with percutaneous or open drainage. A simple seroma can be
treated with serial aspiration or drain placement.
A larger, persistent collection or abscess may
necessitate extensive incision and drainage. In
the case of an abscess, patients should be placed
on culture-directed antibiotic therapy. A patient
with a suspected urine leak should be evaluated
and treated by the appropriate surgical team.
Infection
Cellulitis and local wound infection dened as
localized erythema without uid collection or
dehiscence can be treated with antibiotic
therapy.
Open, infected wounds are best treated with
frequent dressing changes that promote mechanical debridement and drainage of purulent and
necrotic tissue. Loosely packed moist-to-dry
dressings with saline or Dakin’s solution can be
utilized for this purpose.
Deep organ space infections are diagnosed on
imaging or re-exploration and are often dealt
with by the ablative surgeon with serial debridement, removal of infected prosthetics, drain
placement, and infectious disease consultation
for antibiotic management.
Partial or Total Flap Loss
If a ap shows acute signs of arterial or venous
insufciency, it should be explored in the operating room emergently. One must investigate the
pedicle for compression or kinking. In the case of
a free ap, the arterial or venous anastomosis
needs to be revised if there is a clot present.
Flaps that have early signs of venous congestion can be treated conservatively with leech
therapy to improve ap circulation [21].
Progressive venous insufciency warrants operative exploration as above.
Partial ap loss, dened as necrosis involving
less than one-third of the ap volume, should be
treated with bedside or formal operative debridement once the necrotic tissue has fully demarcated. This can be followed by local wound care,
negative-pressure wound therapy, delayed primary closure, or ap re-advancement.
When larger or total ap loss occurs, the nonviable ap should be excised in the operating
470
J. Pribaz and K. Whalen
ab
Fig. 41.6 (a) Right pedicled gracilis muscle ap isolated on its vascular pedicle. (b) Gracilis muscle ap inset for
repair of rectovaginal stula
room. The resulting defect can be temporized
with negative-pressure wound therapy until
Donor site dehiscence, uid collections, and
infection are treated as above.
denitive reconstruction with a lifeboat ap is
performed. One should already have a secondary
and tertiary reconstructive option in mind in the
Conclusion
event of ap loss (Fig.41.5a–b).
Reconstruction plays an important role in facilitating extensive pelvic resections in the setting
Fistula
of malignancy. Complications are unfortunately
a reality of reconstructive surgery and com-
Extensive stulae can be addressed with a muscle
or musculocutaneous ap to obliterate dead space
and separate the involved anatomic organs. The
gracilis ap is an ideal choice as it is located outside of the eld of radiation and is typically
spared in abdominal-based extirpative surgeries
(Fig.41.6a–b) [22, 23].
Donor Site Complications
monly occur in the pelvis due to its poor woundhealing environment. It is imperative to
minimize risks at every stage of patient care,
carefully analyze complications when they do
occur, be prepared with a lifeboat for salvage
reconstruction, and learn from mistakes to prevent them in the future.
References
A clinically signicant donor site hernia or bulge
can be addressed with exploration and repair with
inlay or only mesh for abdominal wall support.
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Index
A
Abdominal perineal resection (APR), 389
Abdominal wall problems, 435
Abdominal wound infection, 432
Ablative procedures, 338
Abnormal placentation, 51, 52, 312
Activated partial thromboplastin time (aPTT), 7
Active voiding trial, 369
Acute coagulopathy, 313
Acute enteritis, 396, 397
Adhesiolysis, 441
Adjunctive techniques, 467
Aging-related impairments, 24, 26, 27
Alvimopan, 15, 16
Anal cancer, 394
Anal sphincteroplasty, 342
Anal squamous cell carcinoma, 388, 395
Anastomotic bleeding, 408
Anastomotic leak, 161
Anastomotic strictures, 406, 408
Angular pregnancies, 306
Anorectal and urinary problems, 435
Anorectal stula, 215, 216
Anorectal manometry, 223
Antegrade colonic irrigation, 344
Anticoagulation, 7
Anus, anal margin, and vulvar, 421
Apical tenderness, 373
APR/ELAPE for rectal cancer, 391
Arterial embolization, 360
Asherman’s syndrome, 47
B
Bilateral uterine artery ligation, 294
Bilateral V-Y gluteal fasciocutaneous aps, 466
Bipolar thermal energy, 283
Bladder cancer (BCa), 117
Bladder defects, 328
Bladder dysfunction, 368, 369
Bladder injury, 297, 298, 327, 366, 367
during pelvic dissection, 281
management, 65, 66, 281, 282
prevention, 64
recognition, 64, 65
risk factors, 64
Bladder toxicity, 419
Body image/psychological issues, 434
Bowel injury, 67, 68, 247, 248, 298
and complications, 441, 442
genital tract prolapse, 76
Bowel obstruction, 433
Brachytherapy, 417, 418
C
Carbohydrate loading, 14
Carbon dioxide embolism, 247
CAUTI, 371
Cellulitis and local wound infection, 469
Cervical and cesarean scar ectopic pregnancy, 306, 307
Cervical injury, 313, 314
Cesarean birth, 291
Cesarean delivery, 294
Cesarean hysterectomy, 293
incidence, 319
PAS, 321, 322, 324, 325
Charles procedure, 338
Charlson comorbidity index, 429
Chemoprophylaxis, 4–6
Chemoradiotherapy (CRT), 387
Chylous ascites, 361
Clinical coagulopathy, 327
Clitoral-sparing surgery, 345
Colonic reservoir, 148, 149
Colo-rectal anastomosis, 432
Colorectal anastomotic leak (AL), 401–403
Colorectal dysfunction, 369, 370
Colorectal malignancies, 439
Colorectal surgery, 441
Complex advanced stula therapy, 216, 217
Complex pelvic sidewall anatomy, 440
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5
473
474
Index
Composite pelvic resection, ovarian cancer
anastomotic bleeding, 384
anastomotic leak, 381–383
anastomotic stricture, 384, 385
bowel injury, 383, 384
post-operative hemorrhage, 378, 379
ureteral injury, 379, 380
vascular injury, 377, 378
Computed tomography pulmonary angiography
(CT-PE), 7
Conduit necrosis, 161
Contemporary cesarean delivery of a term infant, 294
Continent cutaneous urinary diversion (CCUD)
afferent segment, 152
colonic reservoir, 148, 149
efferent segment, 150, 152
ileal reservoir, 149
ileocaecal reservoir, 146–148
incidence, 145
outcome, complications, and gender, 149, 150
Continuous bladder irrigation (CBI), 119
Cornuostomy, 306
Crohn’s disease, 215, 216
Cryptoglandular abscess, 207–209
Cystitis, 120
D
D-dimer, 6
Deep inltrating endometriosis (DIE)
bladder endometriosis, 257
diagnosis, 255
gastro-intestinal endometriosis, 260, 262
nerve-sparing surgery, 256
pathophysiology, 255
surgical approach, 256
treatment, 256
ureteral complications, 258–260
ureteral endometriosis, 257, 258
ureteral injury, 258–260
Deep organ space infections, 469
Delayed/missed ureteral injury, 443
Delayed wound healing, 468
Delorme’s procedure, 238
Delphi technique, 404
Denonvilliers fascia, 413
Direct oral anticoagulants (DOACs), 7
Discitis, 236, 237
Disruption of the mesentery, 358–359
Disseminated intravascular coagulation (DIC), 313,
325, 327
Donor site complications, 470
Donor site hernia, 469
Donor site morbidity, 464
Duodenum, 359
Dysuria, 120, 121
E
Early pregnancy loss, 313
Ectopic pregnancy
complications, 301
diagnosis, 301
medical and surgical management, 301
Electrolyte/biochemical imbalances, 435
Empty pelvis syndrome, 434
Endoluminal approaches, see Transanal local excision
(TAE)
Endometritis, 299
Endopelvic fascia, 89
Endorectal advancement ap (ERAF), 213, 214
Endoscopic mucosal resection (EMR), 190
Endoscopic submucosal dissection (ESD), 190
Endosponge, 404
Enhanced recovery after surgery (ERAS)
history, 13
immunonutrition, 17
intraoperative considerations, 15
postoperative considerations, 15, 16
prehabilitation, 17
preoperative considerations, 14, 15
RC/PLND/UD, 13
thromboembolic events, 17
USC protocol, 14
Enteric stula, 433
Enterocutaneous stula, 160, 161
Entrapped ovary, 273
Estrogen-based contraception, 4
Extensive stulae, 470
Extensive subcutaneous edema, 434
External beam radiation therapy (EBRT), 417
External iliac vein, 353
Extra-levator abdominal perineal resection (ELAPE),
389
F
Fecal diversion, 344, 383, 403
Fecal incontinence (FI), 200
after radical vulvectomy, 344
anal insertion devices, 225
bowel function, 221
bulking agents, 226
complications, 395
denition, 221
diagnosis and evaluation, 222, 223
gynecologic malignancy, 222
OASIS, 221
prevention, 200
PTNS, 227
radiation therapy, 222
radiofrequency tissue remodeling, 226
recognition, 201
risk factors, 200
SNM, 227, 228
treatment, 201, 224, 225, 228
vaginal bowel control systems, 225, 226
VMR, 228
Female pelvic surgery
healing problems, 389
Index
475
locally progressive/recurrent disease, 389
pelvic exenteration (see Pelvic exenteration (PEx))
positive resection margins, 389
salvage surgeries, 389
Female pelvis, 286, 287
Female urethra, 280
Female urethrectomy
advancement meatoplasty, 106, 107
distal urethrectomy, 103, 106, 107
higher-stage urethral cancers, 104
meatal stenosis and distal urethral stricture, 105, 106
meatotomy, 106
noncancerous diseases, 105
pubovaginal slings, 112, 113
PUC, 103
radical urethrectomy, 104, 105
SUI, 107–112
surgical intervention, 105
vulvar and vaginal cancers, 105
Femoral nerve injuries, 451
Femoral triangle, 335
Fistulae, 469
Fistula-in-ano
anatomy, 210
ERAF, 213, 214
etiology, 209
stula plug/brin glue, 212
stulotomy, 211
history, 209
imaging, 211
LIFT, 212, 213
location, 210
minimally invasive techniques, 214, 215
seton placement, 211, 212
subcutaneous/submucosal stulas, 209
treatment, 211
Fistula laser tract closure (FiLaC), 214
Flap design, 465
Flap reconstruction, 463
Floating villi technique, 304
Fluid collections, 469
Fractures of pelvic ring and acetabulum, 454, 455
Frailty
aging, 23, 24
assessment, 24, 25
benets, 25, 26
denition, 23
geriatricians and geriatric care providers, 27, 28
health-related outcomes, 25
interventions, 26, 27
Fried Frailty Index, 24
Future pregnancy outcome, 305
Genital tract prolapse
bowel injury, 76
intraoperative injuries
management, 75
prevention, 73, 74
recognition, 74
sacrospinous ligament xation and sacral
colpopexy, 73
nerve injury, 76–78
post operative complications, 78
urinary tract injury, 75, 76
Genitourinary complications, 277–280
Geriatric comanagement, 27
Giant liposarcoma, 284
Gonadotropin releasing hormone (GnRH), 43
Gracilis myocutaneous ap, 342
Gracilis neosphincter/articial sphincter, 344
Groin dissection, 339
Groin pain, 85
GROINSS-V-1 prospective trial, 333
GROINSS-V-I study, 339
Gut microbiome, 35
Gynecologic cancers, 340
Gynecologic oncology, 441
H
Hardware failure, 455
Hematuria, 177
Hemipelvectomies, 451
Hemoperitoneum, 303
Hemorrhage, 320
after dilation and curettage/dilation and evacuation,
309
management, 63, 64
prevention, 62
recognition, 62, 63
risk factors, 61
Hernia, 436
Horseshoe abscess, 208
Human chorionic gonadotropin (hGC), 301
Hypogastric (internal iliac) arteries and veins, 283
Hysterectomy, 307
bladder injury, 64–66
bowel injury, 67, 68
hemorrhage
management, 63, 64
recognition, 62, 63
risk factors, 61
indications, 61
prevention, 62
ureteral injury, 66, 67
vaginal cuff dehiscence, 68, 69
G
Gastrointestinal (GI) complications, 15
Gastro-intestinal endometriosis, 260, 262
General emotional support in preoperative and
postoperative phases, 344
Generous meatotomy, 95
I
Ileal conduit urinary diversion
anastomotic leak, 161
conduit necrosis, 161
enterocutaneous stula, 160, 161