Modifizierter doppelt gestielter VRAM-Lappen zur simultanen Rekonstruktion eines Perineum- und posterioren vaginalen Defekts

The management of locally advanced pelvic tumors regularly requires radical surgical resection. The resection results in significant intrinsic and extrinsic pelvic defects. The advent of composite flaps has revolutionized vaginal and perineal reconstruction. Flaps provide bulky tissue to obliterate dead space, recruit vascularized tissue to an irradiated area and facilitate the skin closure. The authors present a modified vertical rectus abdominis myocutaneous (VRAM) flap for simultaneous reconstruction of a perineal and posterior vaginal defect following radical pelvic and abdominoperineal resection, based on two individual perforators off the inferior epigastric artery and vein with an excellent outcome. The English full-text version of this article is available at SpringerLink (under supplemental).     

Limb preservation by Gore-Tex vascular graft for groin recurrence after postoperative adjuvant radiation in vulvar cancer

BACKGROUND:Recurrent vulvar cancer involving the femoral artery after groin radiation is usually considered inoperable. A patient with such recurrent vulvar cancer successfully treated by femoral vascular graft and rectus abdominis myocutaneous flap reconstruction with limb salvage is described. CASE: A 51-year-old woman had recurrent vulvar cancer involving the right femoral vessels 6 months after a radical vulvectomy plus inguinal lymphadenectomy and postoperative pelvic and groin radiation. Radical en bloc excision of tumor along with the involved femoral artery and vein followed by Gore-Tex vascular graft and rectus abdominis myocutaneous flap reconstruction led to a complete remission. However, occlusion of the grafted vessels occurred 21 months following bypass surgery. Since the compensatory collaterals were established, debridement and removal of the occluded graft were carried out. The patient has been clinically free of disease for more than 48 months since graft reconstruction surgery. CONCLUSION: It is highlighted that aggressive tumor resection with limb salvage is feasible even for patients with vulvar cancer of the groin recurrence involving the femoral artery after primary surgery and groin radiation.     

Short gracilis myocutaneous flaps for vulvovaginal reconstruction after radical pelvic surgery

The short gracilis myocutaneous flap derives its blood supply from terminal branches of the obturator artery, and the vascular pedicle derived from the medial femoral circumflex artery is sacrificed. Twenty-one short gracilis myocutaneous flaps were used for vulvovaginal reconstructions in 11 patients undergoing radical pelvic surgery: bilateral flaps in nine patients for neovaginal construction after pelvic exenterations, bilateral flaps in one patient for vulvovaginal reconstruction after radical vulvovaginectomy, and a unilateral flap in one patient for vulvovaginal reconstruction after radical vulvectomy with partial vaginectomy. Major complications consisted of bilateral flap necrosis occurring in one patient who had received preoperative irradiation to the vulva and groin combined with chemotherapy. Minor degrees of necrosis (less than 5%) and/or separation of vaginal suture lines occurred in five patients without marked loss of the flaps. Vaginal caliber and depth are excellent in ten patients (91%) after follow-up of 1-22 months. The short gracilis flap is an excellent alternative to the more bulky gracilis flap, which derives its blood supply from perforating branches of the femoral artery. Based on our experience, the short gracilis flap provides adequately vascularized tissue for vulvovaginal reconstruction in patients after radical pelvic surgery, but should not be used in patients who have received extensive groin irradiation.     

Major mandibular reconstruction with vascularized bone graft

Mandibular reconstruction is one of the most challenging fields in plastic and reconstructive surgery. Deficiencies of the mandible occur in congenital anomalies, trauma, oral and mandibular neoplasms and osteoradionecrosis. Conventional reconstructive aids like bone grafting or insertion of a metallic implant often fail in such situations due to poor local blood supply, deficient oral lining, inadequate skin coverage, large mandibular defects, irradiated fields or infected wounds. A free vascularized bone graft of a osteocutaneous flap overcomes the incompetence of conventional mandible reconstruction. It offers not only a desirable length of vascularized bone, but also has an adequate skin lining for oral mucosa and external tissue deficiencies, as well as a "sandwich reconstruction" for the mandible. The results are usually satisfactory in terms of function and aesthetics. Experience in 8 cases with iliac and scapular osteocutaneous free flaps are presented and discussed in this report. We conclude that a vascularized bone graft, especially the iliac crest, provides reliable and contented results for major mandibular reconstruction.     

外阴癌广泛切除术后患者外阴重建术的临床分析

目的探讨外阴癌广泛切除术后创面修复、外阴重建的手术治疗方法。方法回顾性分析2003年3月—2005年10月北京协和医院收治的14例外阴癌患者的临床资料,14例患者均行外阴广泛性局部扩大切除术,采用带蒂股前外侧皮瓣或下蒂腹直肌肌皮瓣修复外阴缺损创面,并行外阴重建术。结果14例行外阴重建术的患者中,有13例患者的皮瓣全部成活,于术后12～14 d切口拆线,切口Ⅰ期愈合,其中1例行股前外侧皮瓣转移修复术的患者腹股沟区手术切口发生感染,但其皮瓣及供区植皮Ⅰ期愈合;1例行股前外侧皮瓣转移修复术的患者皮瓣发生部分坏死,面积约4 cm×6 cm,经局部换药、创面植皮治疗,术后36 d完全愈合。14例患者接受了2～20个月的术后随访,重建后的外阴形态丰满,富有弹性,阴道口无狭窄,疤痕无明显挛缩。结论应用股前外侧皮瓣或腹直肌肌皮瓣转移修复外阴癌广泛切除术后的皮肤软组织缺损,进行外阴重建,可使患者在手术切除肿瘤后获得外阴解剖外观及部分功能的恢复,具有临床应用价值。     

Inferior epigastric haemorrhage, an avoidable complication of laparoscopic clip sterilization

Forty laparoscopists were questioned as to their preferred site for introducing a Samaritan clip applicator during sterilization procedures. The introduction sites were compared with the location recommended by Lieberman (1976) and with the surface anatomy of the inferior epigastric vessels. Of those gynaecologists questioned, only 12% used a site within 1 cm of that recommended by Lieberman; 25% used a site within 1 cm of the epigastric vessels as suggested by surface anatomy. It is proposed that a second puncture site in the midline or at the lateral border of the rectus muscle should be used to avoid the complication of inferior epigastric vessel trauma at laparoscopic sterilization procedures.     

Inferior epigastric haemorrhage, an avoidable complication of laparoscopic clip sterilization

Summary. Forty laparoscopists were questioned as to their preferred site for introducing a Samaritan clip applicator during sterilization procedures. The introduction sites were compared with the location recommended by Lieberman (1976) and with the surface anatomy of the inferior epigastric vessels. Of those gynaecologists questioned, only 12% used a site within 1 cm of that recommended by Lieberman; 25% used a site within 1 cm of the epigastric vessels as suggested by surface anatomy. It is proposed that a second puncture site in the midline or at the lateral border of the rectus muscle should be used to avoid the complication of inferior epigastric vessel trauma at laparoscopic sterilization procedures.     

Distal external iliac lymph nodes in early cervical cancer.

OBJECTIVE: To evaluate the utility of the deep circumflex iliac vein as a landmark for the caudal limit of external iliac lymphadenectomy for early cervical cancer. METHODS: During dissection of the distal (caudal), anterior (ventral) aspect of the external iliac vessels in conjunction with radical hysterectomy for carcinoma of the cervix, a careful search was made for the deep circumflex iliac vein. Lymph nodes immediately above this vein were sent as adjacent and lymph nodes caudal to the vein were sent as distal. The distance from the vein to the femoral canal was measured. RESULTS: Seventy-one women were studied over 40 months. Fifty-five had squamous cell carcinoma, 15 had adenocarcinoma, and one had adenosquamous carcinoma. The mean distance from the deep circumflex iliac vein to the femoral canal was 16 mm. Sixty-three patients had dissections distal to identified deep circumflex iliac veins and 49 (77%) of these had distal lymph nodes removed. The median number of pelvic lymph nodes removed was 24 (range nine to 68), and the median number of distal lymph nodes removed was 1.0 from each side. Lymph node metastases were found in 13 women (18%). One subject with multiple macroscopically positive nodes had a single positive distal lymph node. Thus, a small number of distal lymph nodes were found in most women with early invasive cervical cancer, and 8% of those with positive nodes had involvement of this nodal group. CONCLUSION: The deep circumflex iliac vein was an appropriate landmark for the caudal limit of external iliac lymphadenectomy.     

Femoral vessel coverage with dura mater after inguinofemoral lymphadenectomy

Twenty patients undergoing inguinofemoral lymphadenectomy for vulvar malignancy had the femoral vessels covered with freeze-dried human cadaver dura mater; 5 patients had a radical vulvectomy and 15 had a modified radical vulvectomy, and a total of 38 groins were explored. The dura mater was sutured to the inguinal ligament, sartorius muscle fascia, and adductor longus muscle fascia. Three of the thirty-eight wounds had wound breakdown uncovering the dura mater; each of the groins healed satisfactorily by secondary intention without exposing the femoral vessels. Three patients developed cellulitis without wound breakdown and three patients developed lymphocysts. All groin wounds have healed completely and there have been no delayed complications. The mean follow up was 12.5 months (range, 2-30 months). Coverage of the femoral vessels with dura mater after inguinofemoral lymphadenectomy appears to be a safe and effective alternative to the technically more difficult and more time-consuming sartorius muscle transplant.     

Aberrant obturator vessels in minimally invasive pelvic lymph node dissection

The presence of aberrant obturator vessels, arising from the external iliac circulatory system and their lesion during a surgical intervention in the area, may lead to bleeding, which is difficult to control. For a period of 5 years, 133 endoscopic bilateral pelvic lymph node dissections in patients with cervical cancer were performed, and the present aberrant vessels were registered and filmed. Aberrant obturator vessels were present in 58 cases (43.6 %). Eight obturator arteries and 58 obturator veins, branches of the external iliac vascular system, were visualized. Arterial type of obturator variation was found in one (0.07 %) case, venous type—in 50 (37.5 %), and combined (arterial and venous) type—in seven (5.26 %), out of all patients. Of the observed aberrant obturator arteries, three were found to arise from the inferior epigastric artery, and five from the external iliac artery. Of all available 73 veins, 51 (70 %) drained directly into the external iliac vein and 22 (30 %) in the inferior epigastric vein. The frequency of the aberrant obturator veins was 27.44 % (n?=?73), and of the arteries—3 %, related to the investigated pelvic halves (n?=?266). The presence of aberrant obturator vessels is a relatively common anatomic variation, important for the clinical practice.     

Complete groin lymphadenectomy with preservation of the fascia lata in the treatment of vulvar carcinoma

OBJECTIVE: The goal of this study was to assess the local groin recurrence of vulvar carcinoma in patients treated by complete groin node dissection with preservation of the fascia lata (GNDPFL). METHODS: This study is a retrospective chart review of 60 patients with Stage I-IV vulvar carcinoma who underwent radical vulvectomy and GNDPFL between 1990 and 1998. All superficial inguinal nodes and the deep femoral nodes on the anterior and medial surfaces of the femoral vein within the fossa ovalis were removed en bloc while sparing the fascia lata and the cribriform fascia over the femoral artery. RESULTS: Of the 60 study patients, 14 patients had Stage I disease, 20 Stage II, 21 Stage III, and 5 Stage IV. The mean number of nodes removed was 10 per groin. Thirty-nine patients had benign nodes on groin dissection. None of these 39 patients developed cancer recurrence in the dissected groins. Twenty-one of the sixty study patients (34%) had malignant nodes on groin dissection. Of these 21 patients, 2 experienced cancer recurrence in the groins. Our study describes a groin recurrence rate of 7.6% in patients with fewer than three malignant unilateral groin nodes. Postoperatively, 13% of patients developed lymphedema and 15% formed lymphoceles. CONCLUSIONS: The zero groin recurrence rate in patients with negative nodes and the low rate of recurrence in patients with positive nodes indicate that groin lymphadenectomy with preservation of fascia lata is complete, therapeutic, and comparable to radical techniques of lymphadenectomy involving skeletonization of femoral vessels, resection of fascia lata, and muscle transposition.     

Limb sparing surgery for vulvar groin recurrence: A case report and review of the literature

Abstract. Sevin B-U, Abendstein B, Oldenburg WA, O'Connor M, Waldorf J, Klingler JP, Knudsen MJ. Limb sparing surgery for vulvar groin recurrence: a case report and review of the literature.
Hemipelvectomy was successfully avoided in a patient with extensive necrotic groin recurrence of vulvar cancer after prior radiation therapy. Tumor-free resection margins were achieved by wide excision of the recurrence including resection of the pubic bone and adjacent muscles. After resection of the femoral artery, blood supply to the leg was restored by an extra-anatomic axillopopliteal bypass. A myocutaneous flap from the contralateral rectus abdominis was used for primary wound closure. Limb salvage was achieved and the patient experienced pain relief, excellent cosmesis, and independent gait. Aspects of treatment options, even though primarily palliative, in groin recurrence of vulvar carcinoma are discussed.     

Female plastic and reconstructive surgeons�� personal decision making for breast cancer treatment and reconstruction

Introduction

No original articles have been published exploring female surgeons?? preferences for breast cancer treatment and reconstruction if they were to be diagnosed with breast cancer.

Materials and methods

107 female breast plastic and reconstructive surgeons were surveyed as to the methods of breast cancer treatment and reconstruction they would opt for if they were diagnosed with a 2?cm invasive breast carcinoma.

Results

75% stated that they would opt for mastectomy rather than undergo breast conserving surgery and radiation (21%). Most (95%) of those choosing a mastectomy would opt for reconstruction. For reconstruction choices, 50% of those surveyed would have autologous breast reconstruction with abdominal tissue (38% deep inferior epigastric perforator flap; 12% transverse rectus abdominis muscle flap). 26% would choose tissue expansion with implant and 19% would opt for a latissimus dorsi flap. For those choosing tissue expansion with implant reconstruction 64% would choose a silicone implant, 9% would choose a saline implant and 27% felt either type of implant would be acceptable. For those choosing latissimus dorsi flap with implant reconstruction, 69% would choose a silicone implant, 13% would choose a saline implant and 19% felt either type of implant would be acceptable.

Discussion

Female surgeons offer an exclusive insight into surgical outcomes following breast cancer therapy and reconstruction. This study suggests that due to their clinical experiences they have knowledge as to outcomes and consequences of breast cancer treatment and reconstruction and their choices do not always adhere to current guidelines.     

Inferior epigastric artery pseudoaneurysm following trocar injury

Herein is described the development of an inferior epigastric pseudoaneurysm caused by a trocar injury during laparoscopic surgery. After the accessory trocar was placed in the left lower quadrant, the patient's condition became clinically unstable, requiring blood transfusions postoperatively and transfer to our tertiary care center. On arrival, she continued to have pain, with a palpable tender mass in the left lower quadrant. A computed tomography scan revealed a 5 × 6-cm mass in the anterior rectus sheath, with central hyperattenuation. This was better characterized at ultrasonography. The findings were consistent with an unstable pseudoaneurysm from the left inferior epigastric artery, with surrounding hematoma. Urgent embolization was performed by Interventional Radiology using coils inserted distal, into, and proximal to the pseudoaneurysm. The patient's condition was stable after the procedure, and she returned to the referring hospital for convalescence. Pseudoaneurysm of the inferior epigastric artery from a trocar injury is a rare occurrence. This case is the first report of a pseudoaneurysm forming in the inferior epigastric artery resulting from a trocar injury during gynecologic surgery.     

Implications for port placement of deep circumflex iliac artery damage at laparoscopy

A cannula injury to the deep circumflex iliac vessels led to substantial morbidity and required surgical repair. Surgeons must increase their awareness of the anatomy of these vessels and place laparoscopic ports to minimize the risk of injury. (J Am Assoc Gynecol Laparosc 6(2):221-223, 1999)     

May-Thurner syndrome resulting in acute iliofemoral deep vein thrombosis during the second trimester of pregnancy

Described is a 27-year-old pregnant woman with May-Thurner syndrome who experienced extensive pelvic and lower extremity thromboses during the antepartum period. The patient was referred for a symptomatic deep venous thrombosis at 23 weeks of gestation. Ultrasonography demonstrated a massive thrombus in the left iliofemoral vein. Heparin was given intravenously. Due to the possibility of pulmonary embolism during or immediately after delivery, a temporary inferior vena cava filter was inserted at 36 weeks of gestation. Labor was induced at 37 + 5 weeks of gestation; labor proceeded uneventfully and a male infant was born. Postpartum computed tomography (CT) demonstrated compression of the left common iliac vein by the right common iliac artery and lumbar vertebra. CT venogram demonstrated poor flow through the common iliac vein and well-developed collateral vessels. Critical stenosis at the origin of the left common iliac vein was consistent with a diagnosis of May-Thurner syndrome.