CORRESPONDENCE

TVRAM flap: a modified rectus abdominis musculocutaneous flapfor anal cancer salvage surgery

J. Navarro Cecilia • J. Gutierrez Saınz •

C. Luque Lopez • B. Duenas Rodrıguez

Received: 20 December 2012 / Accepted: 10 February 2013 / Published online: 2 March 2013

� Springer-Verlag Italia 2013

Dear Sir,

Despite the evolution of chemoradiation therapy, radical

surgery remains an important part of the therapeutic arsenal

for anal canal carcinoma, and up to 27 % of patients will

undergo this at some point during the course of their dis-

ease [1].

The increased risk of poor healing of the large perineal

wound that has been subject to radiation and wide local

excision to obtain tumor-free lateral margins makes it

necessary to use approaches that facilitate closure of the

perineal defect with healthy and well-vascularized tissue

without placing the tissue under undue tension.

To use a modified rectus abdominis musculocutaneous

flap, in a patient with recurrent cloacogenic anal cancer

who had undergone radiochemotherapy and total pelvic

exenteration, we extended the classic cutaneous pattern

with a transverse and paraumbilical flap (transverse and

vertical rectus abdominis musculocutaneous flap—

TVRAM), based on paraumbilical random vascularization

from the right rectus abdominis (Fig. 1). The flap was

designed vertically to be approximately 4 cm wide and to

extend from the umbilicus cephalad toward the rib margins.

The cutaneous paddle pattern with the dermocutaneous

modification was sutured together, following a longitudinal

axis, in such a way that the lower border of the additional

dermocutaneous flap was sutured to the lower border of the

classic flap. This resulted in a more extensive structure than

the classic cutaneous pattern. The flap was freed entirely

from the posterior sheath of the rectus muscle. The anterior

sheet of fascia was incised only with the vertical pattern

from the umbilicus to the pubis, and the flap was isolated

down to the level of origin from the internal iliac vessels of

the deep inferior epigastric pedicle. The lateral 2–3 cm of

the rectus muscle was transected, leaving approximately

1 cm attached to the pubic bone. This stabilizes the pedicle

and at the same time allows the transposed tissue to be

tension-free. This might avoid torsion or stretching of the

blood supply. The flap was rotated toward the pelvic cav-

ity, and it was arranged to fill the perineal and pelvic defect

(Fig. 2). Abdominal mesh was used to close the anterior

sheath of the fascia even though the incisional tension

would not have been excessive. Two suction drains were

positioned in the perineum transabdominally (Fig. 3).

The perineal wound healed completely within 15 days.

There were no complications involving the abdominal wall

(Fig. 4). The patient was alive at the 18-month follow-up

with no evidence of surgical complications.

Perineal wound healing after chemoradiation and sal-

vage colorectal surgery is associated with a high risk of

complications, more important in patients with anal cancer

surgery (50 vs. 10 % from rectal cancer surgery) [2, 3].

Furthermore, with preoperative radiotherapy, perineal

wound problems increased significatively in patients with

anal cancer (62 vs. 11 %) [4]. Therefore, alternative pro-

cedures to primary closure of the perineal wound appear to

be required after radical surgery. Lefevre et al. [5] evalu-

ated VRAM and omentoplasty for reconstruction in

patients with persistent or recurrent anal cancer. They

concluded that there was a significantly lower incidence of

J. Navarro Cecilia � J. Gutierrez Saınz � B. Duenas Rodrıguez

Department of Surgery, Hospital Complex of Jaen, Jaen, Spain

J. Navarro Cecilia (&)

C/ Dolores Ibarruri n 29 Ptal 6 3 B, 14011 Cordoba,

Cordoba, Spain

e-mail: dr.jnavarro@hotmail.com

C. Luque Lopez

Department of Obstetrics and Gynecology, University Hospital

Reina Sofıa, Cordoba, Spain

123

Tech Coloproctol (2014) 18:509–511

DOI 10.1007/s10151-013-0988-9

perineal complications (26.8 vs. 48.9 %), shorter time until

wound healing (18.7 vs. 117 days) and a dramatic reduc-

tion in perineal hernias (0 vs. 15 %) with VRAM.

The use of a TVRAM for the reconstruction of large

perineal defects appears to be a better option than the use

of a classic cutaneous TRAM flap because its form allows

for a safer reconstruction, with a very low tendency for

retraction and dehiscence.

Conflict of interest None.

References

1. Mariani P, Ghanneme A, De la Rochefordiere A, Girodet J, Falcou

MC, Salmon RJ (2008) Abdominoperineal resection for anal

cancer. Dis Colon Rectum 51:1495–1501

Fig. 1 TVRAM design

Fig. 2 Exenteration defect

Fig. 3 Appearance of the flap in position

Fig. 4 Primary closure of the abdominal wall without tension

510 Tech Coloproctol (2014) 18:509–511

123

2. El Gazzaz G, Kiran RP, Lavery I (2009) Wound complications in

rectal cancer patients undergoing primary closure of the perineal

wound after abdominoperineal resection. Dis Colon Rectum

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(2001) Results of salvage abdominoperineal resection for recurrent

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(2005) Risk factors for perineal wound complications following

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myocutaneus flap on survival, recurrence, morbidity and wound

healing. Ann Surg 250:707–711

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