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Watanabe T, Sasaki K, Nozawa H, Murono K, Emoto S, Matsuzaki H, Yokoyama Y, Abe S, Nagai Y, Shinagawa T, Sonoda H, Sukchol L, Ishihara S. Robotic Versus Laparoscopic Abdominoperineal Resection for Locally Advanced Rectal Cancer Following Preoperative Chemoradiotherapy. In Vivo 2024; 38:1834-1840. [PMID: 38936926 PMCID: PMC11215614 DOI: 10.21873/invivo.13636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND/AIM The usefulness of robotic surgery compared to laparoscopic surgery for rectal cancer has been reported; however, few reports exist on robotic abdominoperineal resection (APR). The aim of this study was to compare the outcomes of robotic and laparoscopic surgery to determine their usefulness in patients with locally advanced rectal cancer who had undergone preoperative chemoradiotherapy (CRT). PATIENTS AND METHODS This retrospective study included 43 patients with locally advanced rectal cancer who underwent preoperative CRT and robotic (22 patients) or laparoscopic APR (21 patients) between December 2012 and September 2022. We examined the short- and long-term outcomes in the robotic and laparoscopic groups. RESULTS The median follow-up durations were 36 and 48 months for the robotic and laparoscopic groups, respectively. No significant differences in operative time, intraoperative blood loss, or overall complication rates were observed. However, the incidence of organ/space surgical site infection (SSI) was significantly lower in the robotic surgery group than in the laparoscopic group (9.1% vs. 38.1%, p=0.034) and the 3-year overall survival rate was significantly higher in the robotic surgery group than in the laparoscopic group (95% vs. 67%, p=0.029). CONCLUSION Robotic APR was associated with a significantly lower rate of organ/space SSIs than the laparoscopic approach, indicating the usefulness of the robotic approach.
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Affiliation(s)
- Tatsuki Watanabe
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhito Sasaki
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroaki Nozawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Koji Murono
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shigenobu Emoto
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Matsuzaki
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yuichiro Yokoyama
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Shinya Abe
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yuzo Nagai
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takahide Shinagawa
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirofumi Sonoda
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Lim Sukchol
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Soichiro Ishihara
- Department of Surgical Oncology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Riva CG, Kelly ME, Vitellaro M, Rottoli M, Aiolfi A, Ferrari D, Bonitta G, Rausa E. A comparison of surgical techniques for perineal wound closure following perineal excision: a systematic review and network meta-analysis. Tech Coloproctol 2023; 27:1351-1366. [PMID: 37843643 DOI: 10.1007/s10151-023-02868-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 09/28/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND To mitigate pelvic wound issues following perineal excision of rectal or anal cancer, a number of techniques have been suggested as an alternative to primary closure. These methods include the use of a biological/dual mesh, omentoplasty, muscle flap, and/or pelvic peritoneum closure. The aim of this network analysis was to compare all the available surgical techniques used in the attempt to mitigate issues associated with an empty pelvis. METHODS An electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science was performed (Last date of research was March 15th, 2023). Studies comparing at least two of the aforementioned surgical techniques for perineal wound reconstruction during abdominoperineal resection, pelvic exenteration, or extra levator abdominoperineal excision were included. The incidence of primary healing, complication, and/or reintervention for perineal wound were evaluated. In addition, the overall incidence of perineal hernia was assessed. RESULTS Forty-five observational studies and five randomized controlled trials were eligible for inclusion reporting on 146,398 patients. All the surgical techniques had a comparable risk ratio (RR) in terms of primary outcomes. The pooled network analysis showed a lower RR for perineal wound infection when comparing primary closure (RR 0.53; Crl 0.33, 0.89) to muscle flap. The perineal wound dehiscence RR was lower when comparing both omentoplasty (RR 0.59; Crl 0.38, 0.95) and primary closure (RR 0.58; Crl 0.46, 0.77) to muscle flap. CONCLUSIONS Surgical options for perineal wound closure have evolved significantly over the last few decades. There remains no clear consensus on the "best" option, and tailoring to the individual remains a critical factor.
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Affiliation(s)
- C G Riva
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - M E Kelly
- School of Medicine, Trinity College Dublin, Dublin, Ireland
- The Trinity St. James's Cancer Institute, Dublin, Ireland
| | - M Vitellaro
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy.
| | - M Rottoli
- Surgery of the Alimentary Tract, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - A Aiolfi
- General Surgery, Istituto Clinico Sant'Ambrogio, Milan, Italy
| | - D Ferrari
- Department of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN, USA
| | - G Bonitta
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
| | - E Rausa
- Colorectal Surgery Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133, Milan, Italy
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Gambardella C, Mongardini FM, Karpathiotakis M, Lucido FS, Pizza F, Tolone S, Parisi S, Nesta G, Brusciano L, Gambardella A, Docimo L, Mongardini M. Biosynthetic Mesh Reconstruction after Abdominoperineal Resection for Low Rectal Cancer: Cross Relation of Surgical Healing and Oncological Outcomes: A Multicentric Observational Study. Cancers (Basel) 2023; 15:2725. [PMID: 37345062 PMCID: PMC10216202 DOI: 10.3390/cancers15102725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Local wound complications are among the most relevant sequelae after an abdominoperineal resection (APR) for low rectal cancer. One of the proposed techniques to improve the postoperative recovery and to accelerate the initiation of adjuvant chemotherapy is the mesh reinforcement of the perineal wound. The aim of the current study is to compare the surgical and oncological outcomes after APR performed with a biosynthetic mesh reconstruction versus the conventional procedure. METHODS From 2015 to 2020, in two tertiary centres, the surgical outcomes, the wound events (i.e., surgical site infections, wound dehiscence and the complete healing time) and the oncological outcomes (i.e., time length to start adjuvant chemo-radiotherapy, an over 8-week delay in chemotherapy and the recurrence rate) were retrospectively analysed in patients undergoing APR reinforced with biosynthetic mesh (Group A) and conventional APR (Group B). Results Sixty-one patients were treated with APR (25 in Group A and 36 in Group B). Patients in Group A presented lower time for: healing (16 versus 24 days, p = 0.015), inferior perineal wound dehiscence rates (one versus nine cases, p = 0.033), an earlier adjuvant therapy start (26 versus 70 days, p = 0.003) and a lower recurrence rate (16.6% vs. 33.3%, p = 0.152). CONCLUSIONS In our series, the use of a biosynthetic mesh for the neo-perineum reconstruction after a Miles' procedure has resulted in safe, reproducible results affected by limited complications, guarantying a rapid start of the adjuvant therapy with clear benefits in oncological outcomes. Further randomized clinical trials with long-term follow-up are needed to validate these results.
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Affiliation(s)
- Claudio Gambardella
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Federico Maria Mongardini
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Menelaos Karpathiotakis
- Division of General Surgery, Policlinico Umberto I, Sapienza University of Rome, 00185 Rome, Italy; (M.K.); (M.M.)
| | - Francesco Saverio Lucido
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Francesco Pizza
- Department of Surgery, Hospital ‘A. Rizzoli’, Lacco Ameno, 80076 Naples, Italy;
| | - Salvatore Tolone
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Simona Parisi
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Giusiana Nesta
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Luigi Brusciano
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Antonio Gambardella
- Department of Precision Medicine, University of Campania “L. Vanvitelli”, 80138 Naples, Italy;
| | - Ludovico Docimo
- Division of General, Oncological, Mini-Invasive and Obesity Surgery, University of Study of Campania “Luigi Vanvitelli”, 80131 Naples, Italy; (F.M.M.); (F.S.L.); (S.T.); (S.P.); (G.N.); (L.B.); (L.D.)
| | - Massimo Mongardini
- Division of General Surgery, Policlinico Umberto I, Sapienza University of Rome, 00185 Rome, Italy; (M.K.); (M.M.)
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Mori GA, Tiernan JP. Management of Perineal Wounds Following Pelvic Surgery. Clin Colon Rectal Surg 2022; 35:212-220. [PMID: 35966381 PMCID: PMC9374536 DOI: 10.1055/s-0042-1742414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Despite advancements in understanding and technique, there remain significant challenges in the management of a complex perineal wound following pelvic surgery. Complications including wound sepsis, fistulation, persistent sinus, and herniation produce additional morbidity and health care costs. This article details the methods of optimizing patient and operative factors to mitigate this risk, alongside strategies to deal with sequelae of wound failure.
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Affiliation(s)
- George A Mori
- John Goligher Colorectal Unit, St James's University Hospital, Leeds, United Kingdom
| | - Jim P Tiernan
- John Goligher Colorectal Unit, St James's University Hospital, Leeds, United Kingdom
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Larson B, Azizi S, Ma T. OUP accepted manuscript. J Surg Case Rep 2022; 2022:rjac194. [PMID: 35592457 PMCID: PMC9113013 DOI: 10.1093/jscr/rjac194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 04/11/2022] [Indexed: 11/15/2022] Open
Abstract
We present a case of a chronic perineal sinus following abdominoperineal resection with management via endoscopic electrocauterization. This patient presented with 1 year of bloody, mucus drainage from a perineal wound following abdominoperineal resection for anastomotic leak and stricture from a remote low anterior resection for T2N1 rectal cancer. We describe a novel use of endoscopic electrocautery to debride, de-epithelialize and ultimately eliminate the sinus cavity. The patient’s postoperative course was uncomplicated and reported decreased drainage at 2- and 4-week postoperative follow-up. Long-term plans include sequential drain downsizing to facilitate cavity closure. Our findings suggest that endoscopic electrocauterization can safely and effectively reduce chronic perineal sinus drainage to facilitate cavity elimination, while avoiding morbidity associated with more invasive operative interventions.
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Affiliation(s)
- Brandon Larson
- Department of Colon and Rectal Surgery, Summa Health System, Akron, OH, USA
| | - Shayan Azizi
- Department of Colon and Rectal Surgery, Summa Health System, Akron, OH, USA
| | - Truong Ma
- Department of Colon and Rectal Surgery, Summa Health System, Akron, OH, USA
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Galliamov EA, Agapov MA, Markaryan DR, Kakotkin VV, Kazachenko EA, Kubyshkin VA. RECURRENT PERINEAL HERNIA — LAPAROSCOPIC SURGICAL TREATMENT: CLINICAL CASE. SURGICAL PRACTICE 2020. [DOI: 10.38181/2223-2427-2020-3-59-64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background: Recurrent postoperative perineal hernia is a rare complication of such operation as posterior pelvic evisceration. This condition can reduce the quality of life in the postoperative period and requires surgical restoration of the impaired pelvic anatomy.Clinical case: A 54-year old female patient applied to the MSU University clinic in July 2020 with the protrusion in the perineal area. She was diagnosed with recurrent perineal postoperative hernia. She was diagnosed with rectal cancer T4N1M0 and uterine dysplasia in 2017, 6 courses of neoadjuvant polychemoradiation therapy were performed; she underwent extralevator abdominal-perineal resection with uterine extirpation and the permanent colostomy formation in 2018. A perineal postoperative hernia was diagnosed in March 2020, perineal transabdominal plastic surgery was performed with a mesh implant. A recurrent perineal hernia was diagnosed in April 2020, the patient underwent laparoscopic alloplasty with a composite mesh implant. On the 9th postoperative day, she was discharged in a satisfactory condition without any complaints.Conclusion: Postoperative perineal hernia is a fairly rare complication in surgical practice. The recurrent rate is quite high. The insufficient number of patients, the short follow-up period and the wide range of surgical treatment methods do not allow evaluating the results adequately. It is necessary to conduct large randomized clinical trials to assess the efficacy of surgical interventions and to determine the indications for certain procedures.
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Affiliation(s)
- E. A. Galliamov
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU); Federal State Autonomous Educational Institution of Higher Education I. M. Sechenov First Moscow State Medical University (Sechenov University)
| | - M. A. Agapov
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU)
| | - D. R. Markaryan
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU)
| | - V. V. Kakotkin
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU)
| | - E. A. Kazachenko
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU)
| | - V. A. Kubyshkin
- Federal State Budget Educational Institution of Higher Education M. V. Lomonosov Moscow State University (Lomonosov MSU)
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Comparison of Effective Cost and Complications after Abdominoperineal Resection: Primary Closure versus Flap Reconstruction. Plast Reconstr Surg 2020; 144:866e-875e. [PMID: 31688766 DOI: 10.1097/prs.0000000000006158] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Flap reconstruction is recommended for select patients undergoing abdominoperineal resection to mitigate complications. However, the clinical effectiveness and financial implications of flap reconstruction remain unknown. The authors aim to compare the costs and complications for patients undergoing abdominoperineal resection with and without flap reconstruction. METHODS The Truven MarketScan Databases (2009 to 2016) were used to perform retrospective population-based analysis of colorectal carcinoma patients who underwent abdominoperineal resection with and without flap reconstruction. Univariate and multivariable logistic regressions were used to study effective cost (cumulative cost/number of healthy days) and complications. RESULTS Of 2557 total abdominoperineal resection patients, 194 patients underwent flap reconstruction. Patients undergoing flap reconstruction had a higher Elixhauser Comorbidity Index (p = 0.004) and were more likely to have local invasion (p < 0.001). At 6 months postoperatively, there were no differences in complications between the two groups (p = 0.116). Flap reconstruction was protective against intraabdominal infections (OR, 0.4; 95 percent CI, 0.2 to 0.9; p = 0.033) but conferred an increased risk of wound complications (OR, 1.5; 95 percent CI, 1.0 to 2.3; p = 0.039). Total median cost of care was similar (abdominoperineal resection alone, $40,050; abdominoperineal resection with flap, $41,380; p = 0.456). Effective cost was greater for abdominoperineal resection alone ($259/healthy day) than abdominoperineal resection with flap ($186/healthy day) but was not statistically significant (p = 0.17). CONCLUSIONS Patients with flap reconstruction displayed a higher comorbidity score and more extensive disease, but these unfavorable factors did not result in a higher complication rate, total cost, or effective cost. Therefore, flap reconstruction for complex perineal defects confers a benefit in select patients and is a judicious use of health care resources. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Risk factors for delayed perineal wound healing and its impact on prolonged hospital stay after abdominoperineal resection. World J Surg Oncol 2019; 17:226. [PMID: 31864365 PMCID: PMC6925835 DOI: 10.1186/s12957-019-1768-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 12/06/2019] [Indexed: 11/23/2022] Open
Abstract
Background Perineal wound complications are a long-lasting issue for abdominoperineal resection (APR) patients. Complication rates as high as 60% have been reported, with the most common complication being delayed perineal wound healing. The aim of this study was to identify risk factors for delayed perineal wound healing and its impact on prolonged hospital stay. Methods We included low rectal tumor patients who underwent APR at a referral medical center from April 2002 to December 2017; a total of 229 patients were included. The basic characteristics and surgical outcomes of the patients were analyzed to identify risk factors for delayed perineal wound healing (> 30 days after APR) and prolonged hospital stay (post-APR hospital stay > 14 days). Results All patients received primary closure for their perineal wound. The majority of patients were diagnosed with adenocarcinoma (N = 213, 93.1%). In the univariate analysis, patients with hypoalbuminemia (albumin < 3.5 g/dL) had an increased risk of delayed wound healing (39.5% vs. 60.5%, P = 0.001), which was an independent risk factor in the multivariable analysis (OR 2.962, 95% CI 1.437–6.102, P = 0.003). Patients with delayed wound healing also had a significantly increased risk of prolonged hospital stay (OR 6.404, 95% CI 3.508–11.694, P < 0.001). Conclusions Hypoalbuminemia was an independent risk factor for delayed wound healing, which consequently led to a prolonged hospital stay. Further clinical trials are needed to reduce the incidence of delayed perineal wound healing by correcting albumin levels or nutritional status before APR.
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Bingmer K, Ofshteyn A, Dietz DW, Stein SL, Steinhagen E. Outcomes in immunosuppressed anal cancer patients. Am J Surg 2019; 219:88-92. [PMID: 31477240 DOI: 10.1016/j.amjsurg.2019.08.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/07/2019] [Accepted: 08/13/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Immunosuppressed patients have an increased risk of developing anal cancer, but little data exists regarding outcomes of this population. METHODS A retrospective review of anal cancer patients at a single academic institution from 2006 to 2017 was performed. RESULTS 19 (14%) of 136 anal cancer patients were immunosuppressed. Immunosuppressed patients were more likely to be hypoalbuminemic (21% vs. 6%, p = 0.025), less likely to complete chemotherapy (58% vs. 80%, p = 0.031) or exhibit a complete response to chemoradiation (57% vs. 82%, p = 0.037), and more likely to experience recurrence (53% vs. 25%, p = 0.013). Hypoalbuminemia was significantly associated with worse overall (HR 6.4, CI 2.2-19.2, p < 0.001) and progression-free (HR 4.4, CI 1.8-10.4, p < 0.001) survival. CONCLUSIONS Immunosuppressed patients have poor tolerance of chemotherapy and response to chemoradiation, and an increased rate of recurrence. This finding is possibly due to the relationship between immunosuppression and hypoalbuminemia, which was associated with worse overall and progression-free survival.
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Affiliation(s)
- Katherine Bingmer
- University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - Asya Ofshteyn
- University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - David W Dietz
- University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - Sharon L Stein
- University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA
| | - Emily Steinhagen
- University Hospitals Research in Surgical Outcomes & Effectiveness Center (UH-RISES), Department of Surgery, University Hospitals, Cleveland Medical Center, Cleveland, OH, USA.
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Coelho JAJ, McDermott FD, Cameron O, Smart NJ, Watts AM, Daniels IR. Single centre experience of bilateral gracilis flap perineal reconstruction following extra-levator abdominoperineal excision. Colorectal Dis 2019; 21:910-916. [PMID: 31017735 DOI: 10.1111/codi.14654] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 03/25/2019] [Indexed: 02/08/2023]
Abstract
AIM A variety of tissue flaps have been described for the closure of perineal wounds following abdominoperineal excision of the rectum (APE) or exenteration for locally advanced/recurrent rectal cancer and salvage surgery for anal cancer. The aim of this study was to demonstrate the utility of the bilateral pedicled gracilis muscle flaps (BPGMFs) as a reconstruction option in these patients. This is of particular benefit when using a laparoscopic approach for the abdominal component of the operation, avoiding disruption of the abdominal wall and risk of herniation with other reconstruction options, e.g. vertical rectus abdominis myocutaneous flaps. METHOD This is a retrospective single centre case series of patients who underwent reconstruction of perineal defects using BPGMFs using a novel weave technique, from January 2008 to August 2017. RESULTS There were 25 patients (16 female), with a median follow-up of 19 months (3-102). The indications for BPGMFs were cancer resection (21) and perineal hernia (4). The median length of stay was 14 days (6-60). All-cause mortality was 36% within the follow-up period. A healed perineal wound was achieved in 72% of patients within 30 days (84% of patients received neoadjuvant chemoradiotherapy). The overall donor site complication rate was 20% (including infection, dehiscence, numbness, haematoma and seroma) and 28% for the perineal site (including infection, dehiscence and prolapse). CONCLUSIONS BPGMFs provide an important option for reconstruction of the perineum particularly with a minimally invasive approach or with two stomas.
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Affiliation(s)
- J A J Coelho
- Department of Plastic & Reconstructive Surgery, Royal Devon & Exeter Hospital, Exeter, UK
| | - F D McDermott
- Department of Colorectal Surgery, Royal Devon & Exeter Hospital, Exeter, UK
| | - O Cameron
- Department of Colorectal Surgery, Royal Devon & Exeter Hospital, Exeter, UK
| | - N J Smart
- Department of Colorectal Surgery, Royal Devon & Exeter Hospital, Exeter, UK
| | - A M Watts
- Department of Plastic & Reconstructive Surgery, Royal Devon & Exeter Hospital, Exeter, UK
| | - I R Daniels
- Department of Colorectal Surgery, Royal Devon & Exeter Hospital, Exeter, UK
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11
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Omental flaps in patients undergoing abdominoperineal resection for rectal cancer. Int J Colorectal Dis 2019; 34:1227-1232. [PMID: 31123808 DOI: 10.1007/s00384-019-03319-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Following abdominoperineal resection (APR) for rectal cancer, perineal wound complications are common. Omental flap creation may allow for decreased morbidity. The aim of this study was to assess wound complications in rectal cancer patients undergoing APR with and without the addition of an omental flap. METHODS The National Surgical Quality Improvement Program Proctectomy targeted database from 2016 to 2017 was used to identify all patients undergoing APR for rectal cancer. The primary outcomes were wound complications such as superficial site infection, deep wound infection, organ space infection, and wound dehiscence. RESULTS There were 3063 patients identified. One hundred seventy-three (5.6%) patients underwent APR with an omental flap repair while 2890 (94.4%) patients underwent APR without an omental flap repair. Patients in both groups were similar with regard to age, gender, body mass index, American Society of Anesthesia class, and neoadjuvant cancer treatment (all p > 0.05). Patients who underwent an omental flap repair were significantly more likely to have a postoperative organ space infection (10.4% vs. 6.5%, p = 0.04). There was no significant difference in rates of superficial site infection, deep wound infection, wound dehiscence, or reoperation between the two patient groups. In multivariable analysis, omental flap creation was independently associated with organ space infection (OR 1.72, 95%CI 1.02-2.90, p = 0.04). CONCLUSIONS This is the largest study to evaluate omental flap use in rectal cancer patients undergoing APR. Omental flaps are independently associated with organ space infection.
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O'Kelly SM, Moore ZEH. Antenatal maternal education for improving postnatal perineal healing for women who have birthed in a hospital setting. Cochrane Database Syst Rev 2017; 12:CD012258. [PMID: 29205275 PMCID: PMC6486191 DOI: 10.1002/14651858.cd012258.pub2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND The female perineum becomes suffused and stretched during pregnancy, and further strain during vaginal childbirth contributes to approximately 85% of women experiencing some degree of trauma to the perineal region. Multiple factors play a role in the type and severity of trauma experienced, including parity, delivery method, and local practices. There is ongoing debate about best midwifery practice to reduce perineal trauma. Once perineal trauma has occurred, treatment also varies greatly, depending on its degree and severity, local practice and customs, and personal preference. In order to optimise wound-healing outcomes, it is important that wounds are assessed and managed in an appropriate and timely manner. A perineal wound may cause significant physical and/or psychological impact in the short or long term, however little evidence is available on this subject.Antenatal education serves to prepare women and their partners for pregnancy, delivery and the postpartum period. The delivery of this education varies widely in type, content, and nature. This review examined antenatal education which is specifically tailored towards perineal care and wound healing in the postnatal period via formal channels. Appropriate patient education positively impacts on wound-healing rates and compliance with wound care. Risk factors that contribute to the breakdown of wounds and poor healing rates may be addressed antenatally in order to optimise postnatal wound healing. It is important to assess whether or not antenatal wound-care education positively affects perineal healing, in order to empower women to incorporate best practice, evidence-based treatment with this important aspect of self-care in the immediate postnatal period. OBJECTIVES To evaluate the effects of antenatal education on perineal wound healing in postnatal women who have birthed in a hospital setting, and who have experienced a break in the skin of the perineum as a result of a tear or episiotomy, or both. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2017), ClinicalTrials.gov (8th September 2017), the WHO International Clinical Trials Registry Platform (ICTRP) (8th September 2017) and reference lists of retrieved studies. SELECTION CRITERIA We considered randomised controlled trials (RCTs) which referred to all formal methods of antenatal education and addressed care of a potential perineal wound as a result of a tear or episiotomy, which was experienced by pregnant women who planned to give birth within a hospital setting.Trials using a cluster-RCT and a quasi-randomised design would have been eligible for inclusion in this review but none were identified. Cross-over trials were not eligible for inclusion in this review. Studies published in abstract form would have been eligible for inclusion in this review, but none were identified.We planned to consider all formal methods of antenatal education which addressed care of a perineal wound. We also planned to consider all contact points where there was an opportunity for formal education, including midwifery appointments, antenatal education classes, obstetrician appointments, general practitioner appointments and physiotherapist appointments. DATA COLLECTION AND ANALYSIS Two review authors independently assessed titles and abstracts of the studies identified by the search strategy for their eligibility. MAIN RESULTS No studies met the inclusion criteria for this review. We excluded one study and one other study is ongoing. AUTHORS' CONCLUSIONS We set out to evaluate the RCT evidence pertaining to the impact of antenatal education on perineal wound healing in postnatal women who have birthed in a hospital setting, and who experienced a break in the skin of the perineum as a result of a tear or episiotomy, or both. However, no studies met the inclusion criteria. There is a lack of evidence concerning whether or not antenatal education relating to perineal wound healing in this cohort of women will change the outcome for these women in relation to wound healing, infection rate, re-attendance or re-admission to hospital, pain, health-related quality of life, maternal bonding, and negative emotional experiences. Further study is warranted in this area given the significant physical, psychological and economic impact of perineal wounds, and the large proportion of childbearing women who have experienced a postnatal wound. The benefits of any future research in this field would be maximised by incorporating women in a range of socio-economic groups, and with a range of healthcare options. This research could take both a qualitative and a quantitative approach and examine the outcomes identified in this review in order to assess fully the potential benefits of a tailored antenatal package, and to make recommendations for future practice. There is currently no evidence to inform practice in this regard.
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Affiliation(s)
- Sonia M O'Kelly
- Ranelagh MedicalGeneral Practice (Public Health)22‐26 Sandford RoadRanelaghDublin 6Ireland
| | - Zena EH Moore
- Royal College of Surgeons in IrelandSchool of Nursing & Midwifery123 St. Stephen's GreenDublinIrelandD2
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Althumairi AA, Canner JK, Gearhart SL, Safar B, Sacks J, Efron JE. Predictors of Perineal Wound Complications and Prolonged Time to Perineal Wound Healing After Abdominoperineal Resection. World J Surg 2017; 40:1755-62. [PMID: 26908238 DOI: 10.1007/s00268-016-3450-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Perineal wound following abdominoperineal resection (APR) is associated with high complication rate and delayed healing. We aim to evaluate the risk factors for delayed wound healing and wound complications following APR. METHODS A retrospective review of patients who underwent APR was performed. Non-delayed wound healing occurred within 6 weeks. Major complications included infection, necrosis, and dehiscence that required surgical interventions. Minor complications included drainage and superficial dehiscence that were treated conservatively. Patients were compared for type of wound closure (primary vs. flap reconstruction). Effect of patients' demographic and clinical variables on time to healing, and on major and minor wound complications was examined. RESULTS 215 patients were identified, of which 175 (81 %) had primary closure and 40 (19 %) had flap reconstruction. Overall, major wound complications occurred in 14 (7 %) of patients and minor wound complications occurred in 48 (22 %). Mean time to wound healing was 6.3 weeks in the primary closure group and 9.3 weeks in the flap reconstruction group (p = 0.02). Delayed wound healing occurred in 44 (25 %) of the primary closure group and in 25 (62 %) of the flap reconstruction group (p < 0.001). Delayed wound healing was associated with smoking (p = 0.005), hypoalbuminemia (p = 0.05), neoadjuvant chemotherapy (p = 0.02), and flap reconstruction (p = 0.03). Hypoalbuminemia was associated with major wound complications (p = 0.002), while neoadjuvant chemotherapy was associated with minor wound complications (p = 0.01). CONCLUSIONS Wound complications and delayed healing are related to patients' nutritional status, smoking, and neoadjuvant chemotherapy. Patients with these risk factors are at risk of delayed wound healing even if they underwent flap reconstruction.
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Affiliation(s)
- Azah A Althumairi
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Joseph K Canner
- Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan L Gearhart
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Bashar Safar
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Justin Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287, USA.
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Thorgersen EB, Goscinski MA, Spasojevic M, Solbakken AM, Mariathasan AB, Boye K, Larsen SG, Flatmark K. Deep Pelvic Surgical Site Infection After Radiotherapy and Surgery for Locally Advanced Rectal Cancer. Ann Surg Oncol 2016; 24:721-728. [PMID: 27766561 DOI: 10.1245/s10434-016-5621-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND High morbidity, increased mortality, and impaired long-term oncologic outcome have been reported after deep surgical site infection (SSI) in rectal cancer surgery. The rate, risk factors and consequences of deep SSI after (chemo)radiotherapy [(C)RT], and surgery for locally advanced rectal cancer (LARC) in a tertiary university hospital single centre cohort of 540 patients are presented. METHODS Patients with LARC, operated between January 1, 2007 and December 31, 2015, were identified in the institutional prospective database. All patients had tumours threatening the mesorectal fascia or invading adjacent organs, with a high rate of T4 tumours (60 %), and all received (C)RT. Risk factors for deep SSI were calculated by multivariable logistic regression analysis. Morbidity data were assessed. Overall survival (OS) and disease-free survival (DFS) between patients with or without deep SSI were estimated. RESULTS Of 540 patients, 104 (19 %) experienced a deep SSI, with the highest rate in the abdominoperineal resection (APR) group with 25 %. APR, good response to (C)RT (low tumour regression grade), age, and operative blood loss were identified as significant (P < 0.05) risk factors for deep SSI in multivariable analysis. No difference was found in OS (P = 0.995) or DFS (P = 0.568). Hospital stay increased with 5 days (P < 0.001), and complete wound healing at the 3-month follow-up decreased from 86 to 45 % (P < 0.001) after deep SSI. CONCLUSIONS Deep SSI is a frequent and major complication after rectal surgery for LARC, with high morbidity, increased hospital stay and protracted wound healing. Interestingly, deep SSI did not influence long-term oncologic outcome.
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Affiliation(s)
- E B Thorgersen
- Department of Gastroenterological Surgery, The Norwegian Radium Hospital Oslo University Hospital, Oslo, Norway. .,Institute of Immunology, Oslo University Hospital Rikshospitalet and University of Oslo, Oslo, Norway.
| | - M A Goscinski
- Department of Gastroenterological Surgery, The Norwegian Radium Hospital Oslo University Hospital, Oslo, Norway
| | - M Spasojevic
- Department of Gastroenterological Surgery, The Norwegian Radium Hospital Oslo University Hospital, Oslo, Norway
| | - A M Solbakken
- Department of Gastroenterological Surgery, The Norwegian Radium Hospital Oslo University Hospital, Oslo, Norway
| | - A B Mariathasan
- Department of Gastroenterological Surgery, The Norwegian Radium Hospital Oslo University Hospital, Oslo, Norway
| | - K Boye
- Department of Oncology, The Norwegian Radium Hospital Oslo University Hospital, Oslo, Norway.,Department of Tumour Biology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway
| | - S G Larsen
- Department of Gastroenterological Surgery, The Norwegian Radium Hospital Oslo University Hospital, Oslo, Norway
| | - K Flatmark
- Department of Gastroenterological Surgery, The Norwegian Radium Hospital Oslo University Hospital, Oslo, Norway.,Department of Tumour Biology, The Norwegian Radium Hospital, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Althumairi AA, Canner JK, Ahuja N, Sacks JM, Safar B, Efron JE. Time to Chemotherapy After Abdominoperineal Resection: Comparison Between Primary Closure and Perineal Flap Reconstruction. World J Surg 2016; 40:225-30. [PMID: 26336877 DOI: 10.1007/s00268-015-3224-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Wound complications are frequent flowing abdominoperineal resection (APR); this can lengthen the time to chemotherapy. Flap reconstruction is being used in an attempt to improve wound healing. OBJECTIVES To assess the effect of flap reconstruction after APR on time to perineal wound healing and administration of adjuvant chemotherapy in patients with rectal adenocarcinoma. METHODS A retrospective review of patients who underwent APR for rectal adenocarcinoma between 2002 and 2012 was performed. Patients were divided into two groups based on type of perineal wound closure (primary vs. flap). Patients were compared for time to perineal wound healing, and time to adjuvant chemotherapy. RESULTS 115 patients were identified; of whom 67 received adjuvant chemotherapy. 56 (84%) patients underwent primary closure while 11 (16%) underwent flap reconstruction. There was no difference in time to perineal wound healing (6.8 vs. 6.3 weeks, p = 0.40) and time to receive adjuvant chemotherapy (9.3 vs. 10.7 weeks, p = 0.79) between the primary closure and flap reconstruction groups, respectively. 25 (45%) of the primary closure group had a delay in receiving adjuvant chemotherapy versus 6 (55%) of the flap reconstruction group (p = 0.55). Delay in receiving adjuvant chemotherapy because of perineal wound complications occurred in 18 (32%) patients with primary closure versus 3 (28%) patients with flap reconstruction (p = 0.14). CONCLUSIONS Flap reconstruction does not reduce the length of time to initiating chemotherapy; there was no difference in length of healing between the two groups. Therefore, flap reconstruction should be selectively used based on the size of the perineal defect.
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Affiliation(s)
- Azah A Althumairi
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Joseph K Canner
- Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nita Ahuja
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Justin M Sacks
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA
| | - Jonathan E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Blalock 618, Baltimore, MD, 21287, USA.
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Althumairi AA, Canner JK, Gearhart SL, Safar B, Fang SH, Wick EC, Efron JE. Risk factors for wound complications after abdominoperineal excision: analysis of the ACS NSQIP database. Colorectal Dis 2016; 18:O260-6. [PMID: 27178168 DOI: 10.1111/codi.13384] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 03/24/2016] [Indexed: 02/08/2023]
Abstract
AIM The perineal wound following abdominoperineal excision (APR) is associated with a high complication rate. We aimed to evaluate the risk factors for wound complications and examine the effect of flap reconstruction on wound healing. METHOD The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was searched for patients who underwent APR for rectal adenocarcinoma. They were divided into two groups: primary closure of the perineal wound and flap reconstruction. A logistic regression analysis was performed to identify the risk factors for deep surgical site infection (SSI) and wound dehiscence. RESULTS A total of 8449 (94%) patients from the database underwent primary closure and 550 (6%) underwent flap reconstruction. Patients who underwent flap reconstruction had a longer operation time, a higher incidence of deep SSI, wound dehiscence, more blood transfusion requirement and a higher rate of return to the operating room (all P < 0.001). Risk factors for deep SSI were African American race (OR 1.5, P = 0.02), American Society of Anesthesiologists (ASA) classification ≥ 4 (OR 3.2, P < 0.001), body mass index (BMI) ≥ 35 kg/m(2) (OR 1.7, P = 0.006), weight loss (OR 2, P < 0.001) and closure with a flap (OR 1.9, P < 0.001). Risk factors for wound dehiscence included ASA classification ≥ 4 (OR 2.2, P = 0.003), history of smoking (OR 2.2, P < 0.001), history of chronic obstructive pulmonary disease (OR 1.7, P = 0.03), BMI ≥ 35 kg/m(2) (OR 1.9, P = 0.001) and closure with a flap (OR 2.9, P < 0.001). CONCLUSION Perineal wound complications are related to a patient's race, ASA classification, smoking, obesity and weight loss. Compared with primary closure, closure with a flap was associated with higher odds of wound infection and dehiscence and was not protective of wound complications in the presence of other risk factors. Therefore optimizing the patient's medical condition will lead to a better outcome irrespective of the technique used for perineal wound closure.
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Affiliation(s)
- A A Althumairi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J K Canner
- Center for Surgical Trials and Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - S L Gearhart
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - B Safar
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - S H Fang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - E C Wick
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - J E Efron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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O'Kelly SM, Moore ZEH. Antenatal maternal education for improving postnatal perineal healing for women who have birthed in a hospital setting. Hippokratia 2016. [DOI: 10.1002/14651858.cd012258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sonia M O'Kelly
- Ranelagh Medical; General Practice (Public Health); 22-26 Sandford Road Ranelagh Dublin 6 Ireland
| | - Zena EH Moore
- Royal College of Surgeons in Ireland; School of Nursing & Midwifery; 123 St. Stephen's Green Dublin Ireland D2
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Abstract
BACKGROUND The rectus abdominis muscle is a workhorse for free and pedicled muscle coverage. Traditional harvest violates the anterior rectus sheath and requires an abdominal incision. Robotic harvest can be reliably and efficiently performed using three ports and no additional incisions. METHODS Ten robotic rectus muscle harvests were performed at three institutions as free flaps for extremity coverage and pedicled flaps for minimally invasive pelvic surgery requiring soft-tissue reconstruction. Three contralateral ports and an intraperitoneal approach were used in each harvest. Demographic information, operative variables, and outcomes were recorded. RESULTS All cases were completed robotically by three surgeons at three different institutions. Four muscles were harvested as free flaps for lower extremity and six muscles were used as pedicled flaps, three for abdominopelvic defect reconstruction and two for protection of visceral repair following salvage prostatectomy or anterior pelvic exenteration. Average robotic setup time was 15 minutes. Average robotic harvest time was 45 minutes. Two 8-mm ports and one 12-mm port were used in each case. One patient developed a grade I decubitus ulcer during an extended operation. There were no other complications. All muscles were completely viable following harvest. There were no conversions to open technique, and no hernias or bulges were noted. CONCLUSIONS Robotic rectus muscle harvest is safe, efficient, and reproducible. The anterior rectus sheath can be left completely intact, eliminating incisional morbidity. The cumulative incisional length can be less than 2 inches even for extensive, multiservice pelvic procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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