A novel method of minimally invasive rectus abdominis muscle flap harvest: Laparoscopic surgeons take note.

The rectus abdominis muscle (RAM) is a workhorse flap to fill or repair abdominal defects. A drawback of an open RAM harvest is donor site morbidity, and minimally invasive techniques for flap harvesting have been previously proposed but involve vertical division of the rectus fascia. We present a case of a 52-year-old woman with a recurrent rectovaginal fistula in a radiated field treated with a laparoscopic low anterior resection with simultaneous RAM flap harvest utilising a single Pfannenstiel incision. Our novel modified laparoscopic-assisted RAM harvest technique prevents longitudinal violation of the anterior and posterior rectus sheaths, thereby promoting a quick recovery, improved cosmesis and decreased post-operative morbidity.

INTRODUCTION

The rectus abdominis muscle (RAM) flap is traditionally harvested by a longitudinal abdominal and rectus sheath incision with significant morbidity including hernia formation, pain, infection, unpleasing scar and morbidity with future laparotomies.

Several minimally invasive (MIS) techniques have been proposed to minimise this morbidity which includes four reports of laparoscopic and robotic techniques.[1234] The Pfannenstiel incision has been previously described once but required an incision through the entire length of the anterior rectus sheath. We report the first case of a RAM flap harvest using an MIS technique through a small Pfannenstiel incision without longitudinal division of the anterior or posterior rectus sheaths.

CASE REPORT

A previously healthy 52-year-old female was diagnosed with a partially obstructing rectal cancer 8 cm from the anal verge. The patient underwent neoadjuvant chemoradiation followed by a robotic ultra-low anterior resection with a stapled anastomosis and proximal diversion. At 2-month post-operatively, a rectovaginal fistula was noted. The patient underwent a perineal repair of the fistula with gracilis muscle interposition flap. The loop ileostomy was reversed after endoscopic and radiological evidence of fistula healing. The fistula recurred 1 month later necessitating another ileostomy. Four weeks later, the fistula was repaired trans-abdominally as described below.

A 5 cm Pfannenstiel incision was made and extended down to the anterior rectus sheath which was divided transversely. Flaps were created superiorly and inferiorly separating the rectus muscle from the anterior fascia followed by division of the peritoneum in the midline to enter the abdomen. Three 5-mm trocars were placed at the umbilicus, the right and left lower quadrants. After laparoscopic resection of the previous anastomosis and take down/repair of the fistula, a redo ultra-low anterior resection was performed with a transanal inter-sphincteric resection, coloanal pull-through and a hand-sewn anastomosis.

The left rectus muscle was then harvested in a laparoscopic-assisted fashion through the Pfannenstiel incision without longitudinal division of either anterior or posterior rectus sheaths [Figure 1]. The rectus muscle was divided superiorly at the level of the costal margin and inferiorly at the pubis while preserving the deep inferior epigastric vessels. The flap was then rotated and transposed between the rectum and the vagina and held by interrupted sutures. The transverse anterior rectus sheath incision was closed primarily. The total operative time was 4 h while the rectus harvest time was less than 45 min. The patient's post-operative course was uneventful with minimal pain, and the patient was discharged home after 6 days. The patient continued to do well at 4-month follow-up without any evidence of fistula recurrence or hernia formation.

Figure 1

Depiction of port and incision sites with magnified view of the minimally invasive dissection planes for the flap harvest from the Pfannenstiel incision

DISCUSSION

Previously described transabdominal MIS approach for RAM harvest have several benefits over the open method which include less post-operative pain, shorter hospital stay, faster recovery and improved cosmesis due to avoidance of a vertical skin incision.[234] However, this approach still leads to vertical division of the posterior rectus sheath which continues to pose a risk of hernia formation and increased post-operative pain.

Our method is different from all previous reports of laparoscopic, robotic and Pfannenstiel approaches[23] as no longitudinal violation of either anterior or posterior rectus sheath was necessary which reduces or eliminates the risk of hernia formation. Our harvest time was much shorter (45 min) than previously reported MIS harvest time (78–125 min).[23] Longer operative time and a steep learning curve which have been cited as reasons for slow adaptation of these techniques can be overcome with our technique with a potential for widespread adaptation.[5] Other potential benefits include prevention of intra-abdominal adhesions and bypassing the need to address adhesions from previous surgeries as we remain extra-peritoneal.

Based on our early experience, this approach is feasible with optimal results and likely leads to less post-operative pain, shorter hospital stay and rapid recovery while maintaining the cosmetic benefit afforded by other MIS techniques. Moreover, it likely leads to potentially lower hernia rates with preservation of both anterior and posterior rectus sheaths. Further prospective studies and long-term follow-up will be needed to better elucidate the advantages of this novel technique.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.