EP471 - Autologous Peritoneal Graft and Vacuum-Assisted Closure for Reconstruction of a Delayed Complex Pelvic Floor Defect after Robotic Abdominoperineal Resection

Purpose/Background: A major cause of morbidity following abdominoperineal resection are pelvic floor defects. Pelvic floor reconstruction using flaps, omental transposition, primary closure and the use of a mesh are well-described approaches for the management of perineal defects. Although effective, these techniques may not be applicable in patients with cancer that have undergone (chemo)radiotherapy (CRT) and have multiple comorbidities, including cachexia and infection. We present a patient who presented with delayed colo-cutaneous (perineal) fistula after robotic abdominoperineal resection (APR) who was successfully treated with autologous peritoneal graft repair and vacuum-assisted closure.

Methods/Interventions: A 63-year-old male status post neoadjuvant CRT and robotic APR for yT3N0M0 rectal adenocarcinoma represented 18 months after the index operation with spontaneous and uncontrollable loss of fecal content from the site of the previous perineal incision and associated intermittent loss of stoma output. At the time of presentation, he was receiving palliative chemotherapy due to metastatic disease progression with a solitary bone metastasis and was cachectic with a BMI of 15.8 Kg/m2 and an albumin level of 2.5 mg/dl. Physical exam revealed a cylindrical defect on the perineal floor at the site of the previous perineal wound, with a 4cm diameter and a 7cm depth.Following exploratory laparotomy, a loop of redundant sigmoid colon approximately 20 cm centrally to the end stoma was trapped within the minor pelvis and eroded creating the colon end of the colo-cutaneous fistula. After resection of the affected part of the sigmoid colon in order to isolate the pelvis an autologous parietal peritoneum graft, from an incisional hernia sack, was harvested and tailored to the appropriate size. The graft was fixed at the perimetry of the deficit with four 5-0 PDS continuous sutures. A vacuum assisted closure (VAC) system was placed on post-operative day (POD) 4 in continuous negative pressure mode, initially set at 90 mmHg and gradually increased up to 150 mmHg.

Results/Outcomes: The peritoneal graft maintained adequate blood perfusion and remained firm on palpation, thus excluding any communication of the peritoneal viscera with the cavity . The VAC system was used until POD 43, at which point in time the wound had significantly reduced in size. From that point on, the healing process was continued using silver alginate dressings. No clinical or laboratory findings indicative of an infection were observed throughout the healing course

Conclusion/Discussion: This novel technique offers an alternative approach for the closure of perineal defects that could be particularly beneficial in patients fraught to contamination, malnourished, as well as in healthcare settings with limited resources and/or expertise to perform alternative reconstruction options. Our novel technique, is tension-free, omits the need for myocutaneous flaps and hold the potential of decreasing donor site morbidity.

Parachute technique of peritoneal graft