改良垂直腹直肌肌皮瓣修复直肠癌经腹会阴联合切除术后皮肤软组织缺损的临床效果

黄覛韬; 屈展; 梁鹏飞; 刘蔚东; 何志友; 崔旭; 郭乐; 陈杰; 李梦娟; 黄晓元; 张丕红

doi:10.3760/cma.j.cn501225-20231030-00156

改良垂直腹直肌肌皮瓣修复直肠癌经腹会阴联合切除术后皮肤软组织缺损的临床效果

doi: 10.3760/cma.j.cn501225-20231030-00156

1.
中南大学湘雅医院烧伤整形外科，长沙　　410008
2.
中南大学湘雅医院基本外科，长沙　　410008
3.
湖南省职业病防治院医美中心，长沙　　410012

基金项目:

湖南省自然科学基金青年基金项目 2022JJ40791

详细信息

通讯作者:
张丕红，Email：zphong@aliyun.com

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出版历程
- 收稿日期: 2023-10-30

Clinical effect of modified vertical rectus abdominis myocutaneous flap in repairing skin and soft tissue defects after abdominoperineal resection for rectal cancer

1.
Department of Burns and Plastic Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
2.
Department of Basic Surgery, Xiangya Hospital, Central South University, Changsha 410008, China
3.
Department of Medical Beauty Center, Hunan Provincial Institute of Occupational Disease Control, Changsha 410012, China

Funds:

Youth Fund Program of Hunan Provincial Natural Science Foundation 2022JJ40791

More Information

Corresponding author: Zhang Pihong, Email: zphong@aliyun.com

摘要

摘要: 目的探讨采用改良垂直腹直肌肌皮瓣修复直肠癌经腹会阴联合切除术后皮肤软组织缺损的临床效果。方法该研究为回顾性观察性研究。2019年6月—2022年7月，中南大学湘雅医院基本外科收治5例符合入选标准的低位直肠癌男性患者，其年龄为65~70岁，肛周皮肤溃疡大小为5 cm×4 cm~11 cm×9 cm，皆行经腹会阴联合切除术。术中会阴部继发皮肤软组织缺损，面积为8 cm×6 cm~14 cm×12 cm（盆底无效腔深度为10~15 cm），均经改良垂直腹直肌肌皮瓣移植修复，肌皮瓣的皮肤面积为9 cm×7 cm~16 cm×12 cm、肌肉体积为18 cm×10 cm×5 cm~20 cm×12 cm×5 cm、血管蒂长18~20 cm。术中保留大部分腹直肌前鞘，将皮瓣通过腹腔转移至受区，将供区残留的两侧腹直肌前鞘反复多次对折缝合，将腹横筋膜的游离缘与腹直肌前鞘缝合，再将供区皮肤直接缝合。术后观察移植肌皮瓣成活情况，记录术后2周内会阴部受区并发症发生情况。随访观察会阴部受区及腹部供区恢复情况，记录腹部供区并发症发生情况以及肿瘤复发与转移情况。结果术后，5例患者移植的肌皮瓣均成活。1例患者术后2 d会阴部受区切口裂开，经间断换药及常规负压封闭引流治疗7 d后愈合；另外4例患者会阴部受区术后2周内均未发生切口裂开、切口感染、脂肪液化等并发症。出院后随访6~12个月显示，会阴部受区皮肤色泽、质地与弹性良好，外观不臃肿；会阴部受区及腹部供区均遗留线状瘢痕，无明显瘢痕增生或色素沉着；腹部供区未发生切口裂开与感染、肠粘连、肠梗阻、腹壁力量减弱等并发症，腹部外形良好，未见局部隆起或腹壁疝形成；患者均无局部肿瘤复发或转移情况。结论采用改良垂直腹直肌肌皮瓣修复直肠癌经腹会阴联合切除术后皮肤软组织缺损，手术方式相对简单，术后供受区外观较好，并发症较少，值得临床推广。
- 创伤和损伤 /
- 外科皮瓣 /
- 直肠肿瘤 /
- 垂直腹直肌肌皮瓣 /
- 经腹会阴联合切除术 /
- 创面修复
Abstract: Objective To investigate the clinical effect of the modified vertical rectus abdominis myocutaneous flap in repairing the skin and soft tissue defect after abdominoperineal resection for rectal cancer. Methods This study was a retrospective observational study. From June 2019 to July 2022, five male patients with low rectal cancer who were conformed to the inclusion criteria were admitted to the Department of Basic Surgery of Xiangya Hospital of Central South University, with ages ranging from 65 to 70 years and the sizes of the perianal skin ulcers ranging from 5 cm×4 cm to 11 cm×9 cm, and all of them underwent abdominoperineal resection. The secondary skin and soft tissue defects in the perineum with an area of 8 cm×6 cm-14 cm×12 cm (with the depth of pelvic floor dead space being 10-15 cm) were repaired intraoperatively with transplantation of modified vertical rectus abdominis myocutaneous flaps with the skin area being 9 cm×7 cm-16 cm×12 cm, the volume of the muscle being 18 cm×10 cm×5 cm-20 cm×12 cm×5 cm, and the vessel pedicle being 18-20 cm in length. During the operation, most of the anterior sheath of the rectus abdominis muscle was retained, the flap was transferred to the recipient area through the abdominal cavity, the remaining anterior sheaths of the rectus abdominis muscle on both sides of the donor area were repeatedly folded and sutured, the free edge of the transverse fascia of the abdomen was sutured with the anterior sheath of the rectus abdominis muscle, and the donor area skin was directly sutured. After the operation, the survival of the transplanted myocutaneous flap was observed. The occurrence of complications in the perineal recipient area was recorded within 2 weeks after the operation. The recovery of the perineal recipient area and the abdominal donor area was observed during follow-up, and the occurrence of complications in the donor area of the abdomen as well as the recurrence of tumors and metastasis were recorded. Results All transplanted myocutaneous flaps in 5 patients survived after surgery. One patient had dehiscence of the incision in the perineal recipient area 2 days after surgery, which healed after 7 d with intermittent dressing changes and routine vacuum sealing drainage treatment. In the other 4 patients, no complications such as incisional rupture, incisional infection, or fat liquefaction occurred in the perineal recipient area within 2 weeks after surgery. Follow-up for 6-12 months after discharge showed that the skin of the perineal recipient area had good color, texture, and elasticity, and was not bloated in appearance; linear scars were left in the perineal recipient area and the abdominal donor area without obvious scar hyperplasia or hyperpigmentation; no complications such as incisional rupture, incisional infection, intestinal adhesion, intestinal obstruction, or weakening of the abdominal wall strength occurred in the abdominal donor area, and the abdominal appearance was good with no localized bulge or formation of abdominal hernia; there was no local recurrence of tumor or metastasis in any patient. Conclusions The surgical approach of using the modified vertical rectus abdominis myocutaneous flap to repair the skin and soft tissue defects after abdominoperineal resection for rectal cancer is relatively simple in operation, can achieve good postoperative appearances of the donor and recipient areas with few complications, and is worthy of clinical promotion.
- Wounds and injuries /
- Surgical flaps /
- Rectal neoplasms /
- Vertical rectus abdominis myocutaneous flap /
- Abdominoperineal resection /
- Wound repair
黄覛韬：酝酿和设计研究、实施手术、采集数据、分析/解释数据、撰写文章、获取研究经费；屈展：酝酿和设计研究、实施研究、采集数据、分析/解释数据、对文章的知识性内容作批评性审阅；梁鹏飞、刘蔚东：酝酿和设计研究、实施手术、对文章的知识性内容作批评性审阅；何志友、崔旭、郭乐、陈杰：实施手术、采集数据；李梦娟：撰写文章、制图；黄晓元：指导手术；张丕红：酝酿和设计研究、指导手术、分析/解释数据、对文章的知识性内容作批评性审阅

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1 采用改良垂直腹直肌肌皮瓣修复患者直肠癌经腹会阴联合切除术后皮肤软组织缺损的效果。1A.低位直肠癌肛周溃疡，已行放射治疗待手术；1B.术前设计垂直腹直肌肌皮瓣；1C.经腹会阴联合切除术后继发会阴部皮肤软组织缺损；1D.术中保留腹壁下动脉穿支（箭头所示）；1E.术中切取垂直腹直肌肌皮瓣；1F.在耻骨肌止点上方2~3 cm处切开腹横筋膜和腹膜；1G.术后会阴部即刻观；1H.术后14 d腹部供瓣区愈合良好；1I.出院后8个月随访，会阴部外观良好

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