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412 J. M. Broyles et al.
Fig. 39.3 VRAM (vertical
rectus abdominis) coverage
of perineal defect
is not large enough to obliterate very large perineal defects. Furthermore, the distal tip of the
myofasciocutaneous flap can be rather bulky
with questionable venous return leading to venous congestion and wound-healing problems.
Gluteus Maximus Muscle
The gluteus maximus muscle is typically harvested as a muscle-only flap, but can be harvested as
a myocutaneous flap if needed. The flap is based
on the superior gluteal artery and has a short axis
for rotation, rendering it useful only for defects
posterior perineum [20, 21]. The superior half of
the muscle is less useful for perineal reconstruction, but may provide durable coverage for sacral
defects. The inferior half of the muscle is able
to provide coverage for the ipsilateral ischium as
well as extending down to the posterior most aspect of the perineum [22].
The gluteus maximus flap provides a robust,
relatively large amount of vascularized muscle
and fascia. The donor site of the flap can be
closed with relative ease using a V to Y advancement closure. Because the flap has such a large
muscle component, the gluteus maximus is prone
to denervation atrophy. Additionally, the proximity to the sciatic nerve can provide for a potential
source of morbidity during dissection. Finally,
the flap is less useful for anterior defects as the
arc of rotation is insufficient to reach areas of the
anterior perineum.
Pudendal Flap
The pudendal flap, also known as the Singapore
flap, is a local fasciocutaneous flap that is based
on the posterior labial vessels of the proximal,
inner thigh. The flap can be harvested as a sensate flap based on the posterior labial branch of
the pudendal nerve, making it an ideal solution
for vaginal vault reconstruction. These flaps can
be harvested unilaterally or bilaterally and are
able to provide thin, sensate, fasciocutaneous
coverage of smaller defects of the anterior and
lateral vaginal walls [23, 24].
Advantages of the pudendal flap are revealed
in the flap’s thin, sensate flap design. Additionally, the inner thigh provides a well-tolerated donor
site with minimal morbidity. This flap does not
provide vascularized muscle, and therefore, there
is little mobility restriction seen postoperatively.
Disadvantages are seen in the fact that this is a
smaller flap that is not well suited to provide coverage for larger perineal defects. Additionally,
this flap is in close proximity to the perineum and
may be compromised in the setting of neoadjuvant radiotherapy.
Fig. 39.4 Surface anatomy
of ALT (anteriolateral
thigh) flap displaying arterial pedicle
41339 Breakdown/Non-healing of Perineal Wound
Anteriolateral Thigh Flap
The anteriolateral thigh (ALT) flap has traditionally been described as a free flap rather than a
pedicled flap and has been used to reconstruct a
wide variety of defects in the pelvis, perineum,
and lower abdomen [25]. The flap is harvested as
a fasciocutaneous flap based on the descending
branch of the lateral circumflex femoral artery.
In addition to a relative ease of dissection, the
flap can provide vast amounts of skin and fascia
while allowing for minimal donor site morbidity
(Fig. 39.4) [25, 26].
Advantages of the ALT flap include a reliable
dissection which can provide an abundance of
vascularized skin and fascia. The flap has a reliable vascular pedicle with a wide arc of rotation.
If additional soft-tissue bulk is required for dead
space obliteration, the ALT can be harvested as
Fig. 39.5 ALT (anteriolateral thigh) flap for perineal
reconstruction
a myofasciocutaneous flap with vastus lateralis
(Fig. 39.5).
Disadvantages of the ALT flap are best visualized with corpulent patients where increasing
the amount of adipose tissue and fascia can limit
mobilization into the perineum. Furthermore,
the larger flaps, which are required for vast dead
space obliteration, can be prone to venous congestion and wound-healing difficulties.
Postoperative Care
Ambulation
In an effort to mitigate the thrombotic effects of
surgery as well as potentially offload pressure
on the wound closure and flap, ambulation is
recommended on the first postoperative day. If
medical and/or surgical comorbidities preclude
414 J. M. Broyles et al.
mobilization, the patient should be turned every
2 h to decease the incidence of ischemic ulcer
creation as well as to offload incisional pressure.
In our practice, a combination of early ambulation as well as instructing the patient to resist sitting in a chair is used for a minimum of 2 weeks
postoperatively. Using this strategy, prolonged
pressure on the incision is avoided and the potential for subsequent flap necrosis is mitigated.
Drain Management
When closing wounds over an area of tumor extirpation, a vast amount of dead space is invariably created. It is critical for the reconstructive
surgeon to mitigate this dead space with a combination of vascularized soft tissue and closedsuction drains. The placement of closed-suction
drains will assist in the elimination of seroma and
hematoma formation and should be left in place
until each drain produces less than 30 ml of exudate per day over a span of 3 consecutive days.
These drains should be removed in sequence,
rather than simultaneously.
Complications
pressure wound therapy. Larger wounds, which
may dictate prolonged wound care regimens,
should be evaluated in the operating room, and
sharp debridement with additional flap closure
may be indicated.
Aggressive management with debridement of
devitalized tissue, wound care, and culture-specific antibiotics will typically allow all wounds
to heal secondarily following flap reconstruction.
Perineal wounds closed primarily in the setting
of prior radiotherapy have a much higher rate of
complications leading to persistent drainage and
potential fistula formation. These sequelae are
mitigated through careful analysis of the wound
bed and appropriate reconstructive techniques.
Summary
Perineal reconstruction with pedicled fasciocutaneous or myofasciocutaneous flaps can be performed safely, with acceptable complication rates
in the presence of contamination, compromised
soft-tissue vascularity, and radiotherapy. For optimal results multidisciplinary teams should work
in concert to properly evaluate the patient and
discuss ideal treatment scenarios.
Complications rates in patients requiring softtissue coverage of viscera and/or require adjuvant therapy are devastating to the patient and
the surgical teams. The most commonly encountered complications include seroma, hematoma,
wound infection, and flap failure. In patients
where soft-tissue fluid collections are suspected,
imaging studies such as CT or MRI are indicated
to evaluate the location and extent of the suspected collection. If there is any indication of infection, culture directed, broad-spectrum antibiotics
should be started and sharp debridement of all
necrotic tissue should be performed.
Flap failure, either partial or complete, can
occur for a myriad of reasons and should generate an operative evaluation of the flap to interrogate the potential for reversible problems.
Small wounds can generally be managed conservatively with dressing changes and/or negative
Key Points: Preventing Complications
1. Communication between the plastic and reconstructive surgery, surgical oncology, and
medical oncology teams is of the upmost importance when planning surgery. Adequate
communication allows for the surgical teams
to provide full disclosure to the patient with
regard to potential donor site morbidity. Additionally, this allows for proper preoperative
imaging and evaluation of potential flap donor
sites to reconstruct the perineum.
2. When closing wounds over the perineal area,
it is critical to identify structures that must be
covered with vascularized tissue. Local muscle flaps based on axial pattern blood supplies
are optimal to obliterate dead space and cover
hollow viscous organs within the surgical
field.
41539 Breakdown/Non-healing of Perineal Wound
3. Attempting closure of large perineal wounds
in a primary fashion without a muscle flaps
will led to higher rates of wound dehiscence,
seroma, and infection. The surgeon should
obliterate all associated dead space in the surgical wound with both vascularized tissue and
closed-suction drains. Preventing hematoma
and seroma formation is an important component to the success of any wound closure.
4. When reconstructing soft-tissue defects of the
perineum, it is critical to maintain a wound
bed free of devitalized tissue. Scar tissue and
devitalized adipose and muscle fascia will act
as a nidus for infection and should be removed
with sharp debridement.
5.
Patients and surgical teams should be advised
to offload all
pressure onto the wound closure
site. Aggressive, early ambulation should be
initiated to prevent ischemic pressure necrosis
of the closure.
Key Points: Managing Complications
1. Early, postoperative venous congestion of
soft-tissue flaps should prompt the surgical
team to evaluate the reconstruction in the operating room for any potentially reversible
causes of ischemia to prevent total or subtotal
flap loss.
2. Signs or symptoms of infection around the
reconstructed area should be visualized radiographically to evaluate for the presence of hematoma, seroma, or abscess so that the appropriate management may be performed within
a timely fashion.
3. If possible, enteral or parenteral nutritional
supplementation should begin in the perioperative setting with protein supplementation
to ensure adequate wound-healing potential.
4. Small areas of incisional dehiscence are not uncommon in larger reconstructions and should be
managed conservatively with dressing changes
and/or negative pressure wound therapy.
5. Large areas of wound dehiscence should
prompt operative evaluation to evaluate the
integrity of the flap and the potential need for
revisionary procedures.
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Complications After TEM (Transanal Endoscopic Microsurgery) and TAMIS (Transanal Minimally Invasive Surgery)
Maria Widmar and Julio Garcia-Aguilar
40
Background
Decades before advances in antisepsis, perioperative care, and surgical technique made the combined abdominal/perineal excision of the rectum
possible, the extraperitoneal portion of the rectum
was accessed by simple diagnostic and therapeutic interventions. Removal of the entire rectum
and mesorectum, first without and later with
preservation of the sphincters, soon became the
optimal treatment for patients with distal rectal
cancer. However, these operations have always
been associated with significant morbidity and
long-lasting functional sequelae. Local treatment
of cancer of the extraperitoneal portion began to
gain popularity in the 1950s, as an alternative to
complete removal of the rectum in patients with
early-stage tumors, or those considered unsuitable for a major operation.
For years, the local excision of rectal tumors
was performed through a posterior parasacral incision popularized by Kraske in the nineteenth century, by the transsphincteric approach described
by York-Mason, or transanally as described by
Parks. The parasacral and transsphincteric approaches provide relatively good exposure of the
distal rectum, particularly of the anterior wall.
J. Garcia-Aguilar () · M. Widmar
Department of Surgery, Memorial Sloan Kettering
Cancer Center, New York, NY 10065, USA
e-mail: garciaaj@mskcc.org
M. Widmar
e-mail: widmarm@mskcc.org
However, they are associated with significant
morbidity, in particular rectocutaneous fistulae
(in the parasacral approach), sphincter dysfunction, and anal incontinence (in the transsphincteric approach). The transanal approach, while
safer than the parasacral or transsphincteric, is a
technically challenging procedure and allows access only to tumors located in the distal rectum.
The first transanal endoscopic platform,
known as transanal endoscopic microsurgery
(TEM), was introduced in the 1980s by Gerhard
Buess. Its purpose was to facilitate local excision (LE) and extend the indications for LE to
tumors located in the mid- and even the upper
rectum. Commercialized by The Wolf Corporation (Richard Wolf Medical Instruments Corp.,
Vernon Hills, IL), the TEM platform includes
a number of large bore-operating proctoscopes,
a specifically designed insufflation system and
instruments, and binocular optics that provide
tridimensional visualization. The equipment is
complex and expensive and is available at only
a limited number of institutions. The Storz Company (KARL STORZ GmbH & Co., Tuttlingen,
Germany) later developed a simplified transanal
endoscopic operation (TEO) platform, which
also uses large bore-operating proctoscopes but
takes advantage of the insufflation, instrumentation, and optics of conventional laparoscopy.
This platform, while less expensive than TEM,
utilizes less sophisticated instrumentation and
does not provide tridimensional visualization.
In recent years, surgeons have adopted the access device used in single-port laparoscopy for
T. M. Pawlik et al. (eds.), Gastrointestinal Surgery, DOI 10.1007/978-1-4939-2223-9_40,
© Springer Science+Business Media New York 2015
417
418 M. Widmar and J. Garcia-Aguilar
transanal minimally invasive surgery (TAMIS).
Similar to TEO, TAMIS utilizes conventional
laparoscopic insufflation, instrumentation, and
optics. A number of groups are now using the da
Vinci® Surgical System, a robotic platform (Intuitive Surgical, Inc.®, Sunnyvale, CA), to enhance visualization and precision during TAMIS.
A number of studies have demonstrated the
advantages of LE compared to conventional rectal cancer surgery: faster recovery; lower morbidity; minimal bowel, urinary, and sexual dysfunction; and, in many patients, avoidance of a
stoma. However, LE—at least when performed
using the conventional transanal approach—provides inferior oncologic results compared to radical surgery for stage I rectal cancer [1–4]. Local
recurrence is higher for patients with T1 and
T2 tumors treated with LE; for patients with T2
tumors, long-term survival is lower compared to
TME. The combination of adjuvant or neoadjuvant chemoradiation with LE for T2 tumors may
improve the results compared to LE alone, but
these approaches are still under investigation [5–
9]. A number of reports indicate that LE of rectal
cancer performed with TEM, TEO, and TAMIS
is associated with a lower risk of local recurrence
compared to TAE [10–12]. However, most studies comparing different techniques are small, retrospective case series using historical controls.
In spite of the uncertain oncological results, the fact
is that the proportion of early-stage rectal cancers treated by LE continues to increase worldwide. As the indications for these procedures expand, and as their use
in patients who have undergone neoadjuvant radiation
increases, knowledge about diagnosis and management
of the associated complications is of high importance.
TEM, TEO, or TAMIS, as these techniques allow
local excision of tumors located in the intraperitoneal portion of the rectum. The reported overall
complication rate ranges from 6 to 20 % [10, 13–
15]. These estimates come mostly from the TEM
literature, as there are still relatively few series
reporting outcomes after TAMIS. The complication rate appears to be higher in patients who
have undergone neoadjuvant chemoradiation
therapy (CRT) [16]. In a study by Marks and colleagues in 2008, the wound dehiscence rate was
significantly higher in radiated versus non-radiated patients (25.6 % vs. 0) [17]. Though a majority
responded to conservative management, 1 of the
11 patients required a diverting colostomy.
are fever, urinary retention, rectal bleeding, sepsis, suture line dehiscence, rectovaginal fistula,
penetration into the peritoneal cavity, rectal pain,
temporary incontinence, and anorectal stenosis
[1–39]. In nearly all of the studies, urinary retention and bleeding were the most common complications.
common complications of TEM and TAMIS.
However, their occurrence may necessitate reoperation including temporary or permanent diversion. Severe pain requiring readmission has been
attributed to these complications. In instances
where TME is necessary after LE, pelvic sepsis
and the resulting inflammation may further complicate dissection. Tables 40.1 and 40.2 summarize the literature on surgical complications after
TEM or TAMIS.
Postoperative Fever
The most frequently reported complications
Pelvic abscess and sepsis are relatively un-
Complications of TEM and TAMIS
The proportion of patients developing complications after TEM, TEO, and TAMIS is low, compared to radical surgery. The types of complications are similar to those observed after TAE;
however, complications related to penetration
into the peritoneal cavity are more common after
A high temperature in the immediate postoperative period is common. However, in most
patients this is temporary and is not necessarily followed by the development of other septic
complications. The cause of early postoperative
fever is unknown, but may be related to transient
bacterial translocation immediately after the
procedure.
Table 40.1 Select TEM (transanal endoscopic microsurgery) studies
Kumar
[24]
Patients ( n)
Indication:( cancer,
benign, both)
Complications ( %)
Mortality ( %)
Septic complications ( n)
Dehiscence 0 17 9 0 3 5 0 36 3
Abscess/pelvic sepsis 2 – 1 7 – – 5 – –
Peritoneal entry 9 – – – 20 13 9 16 –
Missed peritoneal entry 1 1 – 1 – 1 1 – –
Fistula 1 2 – 0 – 5 2 2 2
Fever UO – – – – 2 – – – –
Table 40.2 Select TAMIS (transanal minimally invasive surgery) studies
Patients ( n)
Indication: ( cancer, benign, both)
Complications ( %)
Mortality ( %)
Septic complications ( n)
Dehiscence – – – – –
Abscess – – – – –
Peritoneal entry
Missed peritoneal entry – – – – –
Fever UO – – 1 – –
a
2 converted to TEM (transanal endoscopic microsurgery), 2 had concurrent TMEs (total mesorectal excisions)
325 36 135 262 269 300 424 588 326
Both Both Cancer Both Both Both Cancer Both Both
10.5 44 10.4 13 21 7.7 14.9 11.4 16
0.3 0 0 0.8 0 0 1.4 0 0
10 20 10 8 26 11 18 54 NR
Perez
[16]
Albert [10] Lee [36] Bridoux [37] Barendse [38] Lim [39]
50 25 14 11
Both Both Both Both Both
8 4 21 7.7 0
0 0 0 0 0
1 0 1 0 0
1 – 0 – –
Lezoche
[15]
Bignell
[20]
Tsai
[28]
Allaix
[25]
Bach
[18]
a
Guerrieri
[8]
16
41940 Complications After TEM (Transanal Endoscopic Microsurgery) ...
Buess
[14]
Wound Dehiscence
The need for closure of the rectal wound during
LE in the extraperitoneal portion of the rectum is
controversial. The potential advantages of wound
closure include securing hemostasis and reducing fecal contamination. The chief disadvantage
is the potential creation of a dead space that may
become a perfect environment for the development of septic complications. The enhanced visualization and new instrumentation provided
by TEMS, TEO, and TAMIS platforms facilitate
suturing and knot-tying or clipping. As a consequence, rectal wounds are almost always closed
watertight after TEM or TAMIS excision. The
closure can be done as a running suture, which is
facilitated by clips instead of knot-tying, or with
interrupted sutures (Fig. 40.1).
The reported rate of wound dehiscence ranges
from 0 to 15 % and can lead to complications such
as stenosis and fistula [16, 18, 19]. The true rate
of wound dehiscence is probably higher because
only symptomatic patients undergo rectal examination in the early postoperative period. Wounds
located closer to the dentate line, particularly in
patients who have received neoadjuvant chemoradiation, are more likely to dehisce [7, 17].
Table 40.3 describes the treatment for wound dehiscences in each of the major TEM and TAMIS
studies discussed above. In the study by Perez et
al., 9 of 11 readmissions within 30 days of TEM
excision were due to severe pain secondary to
wound dehiscence [16]. Furthermore, all patients
420 M. Widmar and J. Garcia-Aguilar
Fig. 40.1 Rectal wounds are almost always closed wa-
tertight after TEM or TAMIS excision. The closure can
be done as a running suture, which is facilitated by clips
instead of knot-tying, or with interrupted sutures
with late complications had been diagnosed with
early wound dehiscence. Lezoche et al. described
partially dehisced suture lines in 9 of 135 patients
(6.7 %), all of which were resolved with antibiotic enemas and “occasionally by fasting and
parenteral nutrition” [15].
Rectal Pain
Persistent anal and rectal pain is a common complaint, particularly in patients with low rectal cancer treated with chemoradiation. In the ACOSOG
Z6041 trial investigating the treatment of T2N0
rectal cancer with preoperative chemoradiation
and LE, 8 % of patients complained of grade
3 anal pain [7]. This has been attributed to the
dehiscence of a wound close to the anal canal,
which, in contrast to the rectal wall, has rich somatic pain innervations. The pain often persists
for several weeks until the dehisced wound heals
[16]. A diverting temporary ostomy should be
considered in patients with very low rectal tumors who have undergone radiation. A diverting
temporary ostomy should be considered even in
those who have not had radiation, depending on
the size of the lesion and the amount of tension
expected after closure. Some surgeons have also
adopted the routine use of antibiotics for an extended period following excision of very distal
tumors [20].
Peritoneal Perforation
Peritoneal perforation during TEM, TEO, and
TAMIS occurs at a median rate of 4.8 %, although
this ranges from 0 to 32 % in the literature [21].
During excision of anterior tumors, this rate may
be even higher, especially in those located above
9 cm, where entry into the peritoneum should be
expected [19, 22]. The consequences range from
postoperative pain or distention to intraabdominal
sepsis. On a practical note, peritoneal perforation
compromises adequate visualization by evacuating the necessary pneumorectum for TEM,
TAMIS, and TEO procedures. The most feared
complication is peritonitis caused by the seeding of the abdominal cavity with rectal luminal
Table 40.3 Outcomes after wound dehiscence/failure of closure
Kumar [24] Perez [16] Lezoche [15] Tsai [28] Allaix [25] Guerrieri [26]
# Cases 1 17 9 4 5 36
Management
Non-operative
Operative
Transanal – – – – NR 1
Abdominal 1 1 – 2 NR –
Ostomy 1 1 – – NR –
Radical resection – – – – NR –
NR not reported
a
Both patients had peritoneal entry, which was repaired during the primary surgery
0 16 9 2 0 35
1 1 0 2
a
2 1
Table 40.4 Outcomes after peritoneal entry
Kumar
[24]
# Cases 10 1 1 20
Diagnosis
Intraoperative 9 0 0 20 9 16 1
Missed 1 1 1 0 0 0 0
Intraoperative management
Conversion 0 – – 0 1 1 0
Transanal repair 9 – – 20 6 14 1
Radical surgery 0 – – 0 1 1 0
Ostomy 0 – – 0 0 2
Postoperative management
Transanal repair 9 0 – – –
Radical surgery 0 0 – – –
Ostomy 0 0 – 0 – –
Conservative 1 1 – – –
Mortality
NR not reported
a
Also listed in wound dehiscence
b
Intraoperative or postoperative identification not specified
0 0 1 0 0 0 0 0
Perez
[16]
Bignell
[20]
NR NR NR
Tsai
[28]
Allaix
[25]
a
13 9 16 1
NR
NR
Bach
[18]
b
Guerrieri
[26]
0 0
42140 Complications After TEM (Transanal Endoscopic Microsurgery) ...
Albert
[10]
content. There, were early concerns regarding the
possibility of disseminating cancer cells into the
peritoneal cavity after peritoneal perforation. As
outcomes after TEM, TAMIS, and TEO continue
to be studied, there is currently no evidence that
peritoneal perforation compromises oncologic
outcome [21]. In a multinational study specifically examining the effect of peritoneal perforation on outcomes in 888 patients, Baatrup et al.
demonstrated no increase in long-term oncologic
failure [23].
Entry into the peritoneal cavity is typically
recognized during surgery by sudden loss of, or
difficulty maintaining, pneumorectum. The overall risk of peritonitis is low, provided that the
perforation is recognized intraoperatively and the
peritoneal defect and rectal wound are securely
closed. This can typically be accomplished transanally, though a transabdominal repair, either
open or laparoscopic, may be necessary if the
peritoneal or rectal wound closure is suboptimal.
So-called “missed” perforations may present
in the postoperative period with increasing pain,
pneumoperitoneum, or in some cases, evidence
of intraabdominal sepsis. Both conservative
treatment and surgical approaches are described
in the literature. When reoperation is necessary,
either transanal repair or transabdominal washout can be attempted. The decision to divert is
made on a case-by-case basis and depends on the
patient’s clinical status, the timing of presentation, and the degree of contamination of the peritoneal cavity. It is likely that “missed” perforations requiring reoperation are also more likely
to require proximal diversion, compared to those
recognized intraoperatively due to the increased
peritoneal contamination. Table 40.4 describes
the sequelae and treatment of patients with peritoneal perforation.
The possibility of a peritoneal penetration
emphasizes the importance of mechanical bowel
preparation and the use of prophylactic antibiotics in patients undergoing TEM, TEO, or
TAMIS—particularly for tumor located in the
mid- and upper rectum. Patients with peritoneal