Small Bowel Seromuscular Flap as a Novel Technique for Intrapelvic Filling.

This video demonstrates the use of a pedicled small bowel seromuscular flap for intrapelvic filling in two patients who developed chronic enterocutaneous fistulas to the perineum after a pelvic exenteration / abdominoperineal resection and pelvic radiotherapy. It is a strategic method to fill an empty pelvic cavity when conventional tissue flaps such as vertical rectus abdominis muscle, gracilis or omental flaps are not feasible due to patient anatomical or technical limitations. A segment of pedicled ileum was isolated with transverse linear cutter staplers in the same manner as when creating an ileal conduit. The length of ileum isolated was tailored to the volume of soft tissue filling required. Mesenteric vessels supplying the isolated ileal segment were protected to ensure vascular viability. An enterotomy was made longitudinally along the length of the antimesenteric border and the small bowel mucosa excised. Mucosal stripping was facilitated by submucosal injection of dilute epinephrine and electrocautery or sharp scissor dissection. Where radiation changes made this ineffective, mucosectomy was performed with scissor excision and argon plasma coagulation for hemostasis. The seromuscular flap was positioned in the pelvic cavity and the remaining small bowel anastomosed. In one case the flap was secured in the pelvis with sutures whilst in the other, the flap comfortably filled the cavity and fixation was not required. One patient developed a perineal wound collection, managed by surgical drainage and negative pressure dressing. He was readmitted 4 weeks post initial procedure with surrounding cellulitis. No collection was found on CT or exploration. Simple gauze dressings were used and he was discharged home 10 days later after rehabilitation. The other patient had an uneventful recovery. There were no perineal hernias or recurrent enterocutaneous fistulas in our two cases at 2 and 5 months follow up respectively. In conclusion, a small bowel seromuscular flap has the advantages of the use of the pre-existing laparotomy wound, preservation of abdominal wall musculature, tailored volume of vascularized tissue and resourceful use of the small bowel segment affected by the enterocutaneous fistula. See Video Abstract at http://links.lww.com/DCR/B438.