D'Annunzio Elsa, Valverde Alain, Lupinacci Renato Micelli
Department of Digestive Surgery, Diaconesses Croix Saint Simon Hospital, Paris, France.
Arq Bras Cir Dig. 2020 Nov 20;33(2):e1507. doi: 10.1590/0102-672020190001e1507. eCollection 2020.
Myocutaneous flap of the rectus abdominis filling the perineal defect after APR.. Abdominoperineal excision of the rectum (APR) remains the only potential curative treatment for very low rectal adenocarcinoma and squamous cell carcinoma of the anus. Yet, it implies a significant perineal exenteration and has set the attention on the perineal reconstruction.
To present technique used in one case of APR for anal cancer, with resection of the vaginal posterior wall with large perineal defect which has called for the necessity of a flap for reconstruction.
To cover the large perineal defect and reconstruct the posterior vaginal wall was perform a standardized and reproducible surgical technique using oblique rectus abdominis myocutaneous (ORAM) flap. The overlying skin of this flap is thick and well vascularized by both superficial branches and perforators of the superior epigastric artery and the deep inferior epigastric artery which serves as the vascular pedicle for the ORAM flap.
This procedure was applied in a 65-year-old woman with recurrent squamous cell carcinoma of the anus infiltrating the posterior wall of the vagina. Was performed an APR with en-bloc resection of the vaginal posterior wall in order to achieve tumor-free margins. Postoperative course was uneventful and she was discharged home at postoperative day 9. Final pathological report confirmed the oncological adequacy of the procedure (R0) and showed a rypT4N0 lesion.
Flap reconstruction is an effective way to cover the perineal wound reducing both perineal complication rate and wound healing delay. The ORAM is particularly interesting for female whose tumors require resection and subsequent reconstruction of the posterior wall of the vagina.
腹直肌肌皮瓣修复腹会阴联合切除术后的会阴缺损。腹会阴联合直肠癌根治术（APR）仍然是治疗极低位直肠腺癌和肛门鳞状细胞癌唯一可能的根治性治疗方法。然而，它意味着广泛的会阴切除，因此会阴重建受到关注。
介绍1例肛管癌行APR手术的技术，该病例中阴道后壁切除后出现大的会阴缺损，需要皮瓣重建。
为覆盖大的会阴缺损并重建阴道后壁，采用标准化且可重复的手术技术，即使用腹直肌斜行肌皮瓣（ORAM瓣）。该皮瓣覆盖的皮肤厚，由腹壁上动脉和腹壁下动脉的浅支及穿支充分供血，腹壁下动脉作为ORAM瓣的血管蒂。
该手术应用于1例65岁复发性肛门鳞状细胞癌浸润阴道后壁的女性患者。行APR并整块切除阴道后壁以获得切缘无肿瘤残留。术后过程顺利，术后第9天出院。最终病理报告证实手术的肿瘤学安全性（R0），显示为ypT4N0病变。
皮瓣重建是覆盖会阴伤口的有效方法，可降低会阴并发症发生率和伤口愈合延迟。对于肿瘤需要切除并随后重建阴道后壁的女性患者，ORAM瓣尤其适用。
