Techniques of pelvic floor defect reconstruction after extended surgeries of rectal cancer

A significant proportion of patients with colorectal cancer are diagnosed at advanced stages, requiring extensive surgical procedures that create a substantial “dead space” in the pelvic cavity. One of the major complications of such interventions is perineal hernia formation, which significantly affects quality of life by causing pain, urinary dysfunction, bowel obstruction, fistula formation, and ulcerative skin defects.
Currently, various techniques exist for the prevention and management of this complication. Simple perineal wound closure is the most accessible technique; however, in cases of large defects, it does not provide reliable closure and is associated with increased risks of wound dehiscence, infection, and subsequent hernia formation.
Autologous reconstruction of the pelvic floor defect involves the use of flaps based on the rectus abdominis muscle (vertical rectus abdominis myocutaneous flap, VRAM), gracilis muscle (m. gracilis), gluteus maximus muscle (unilateral or bilateral), as well as skin flaps. The V RAM flap demonstrates low incidence of perineal hernias and acceptable survival rates but requires high level of surgical expertise and may not be feasible in laparoscopic approaches or in patients with multiple stomas. Graciloplasty is effective for selected patients, including those undergoing minimally invasive surgery, but it may be associated with a higher complication rates compared to V RAM. The use of gluteus maximus muscle flaps allows for defect reconstruction with good vascularization but carries risks of muscle function impairment and postoperative pain. Skin flaps are less invasive and may reduce the likelihood of hernia formation, though current statistical data remain limited.
Alloplastic reconstruction of the pelvic floor defect is performed using synthetic or biological meshes. Recent studies suggest that biological meshes significantly reduce the incidence of perineal hernias compared to simple wound closure. However, their use substantially increases treatment costs. The application of synthetic materials requires strict isolation of bowel loops from the mesh surface to prevent adhesions and infectious complications; experience with these materials and long-term outcomes remain limited.
Thus, the choice of pelvic floor reconstruction technique depends on defect size, the patient’s overall condition, the surgical team’s expertise, and the availability of necessary materials. A universal “gold standard” has not yet been established. Further multicenter studies and comparative analyses are needed to determine optimal indications for each method and to develop standardized clinical protocols.

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