title: Laparoscopic abdominoperineal resection with open posterior cylindrical excision and primary transpelvic VRAM flap.
abstract: BACKGROUND
  In our own experience over the last 15 years, the primary transpelvic vertical rectus abdominis myocutaneous (VRAM) flap is a reliable tool to prevent perineal wound complications after cylindrical excision in radical anorectal tumor surgery. To minimize the operative trauma in such patients, we performed a laparoscopic abdominoperineal resection combined with an open posterior cylindrical excision and a primary transpelvic vertical rectus abdominis myocutaneous (VRAM) flap via a minimal supraumbilical incision, which is described here for the first time.
  
  
  METHODS
  A 49-year-old patient with recurrent anal cancer received radiochemotherapy with curative intention and underwent laparoscopic abdominoperineal rectal excision with posterior cylindrical excision combined with a primary transpelvic vertical rectus abdominis myocutaneous (VRAM) flap. The rectal stump was clipped and pulled through the pelvis together with the VRAM flap, which was then placed into the sacral defect.
  
  
  RESULTS
  We found that the combined operative technical approaches with laparoscopy and minimal incisions for flap harvest and cylindrical excision were technically feasible, and no mesh was needed to close the small-sized laparotomies. We achieved complete tumor removal and flap perfusion, and healing was uneventful. The patient showed no relapse at 3 years postoperative.
  
  
  CONCLUSIONS
  Our report of the operative technique shows that the combination of minimally invasive methods together with transpelvic VRAM flap transposition is technically feasible, can be performed with operative efficiency, and may become a valuable tool to minimize perioperative complications in advanced colorectal tumor surgery.
authors.affiliation: Department of Plastic and Hand Surgery, University of Erlangen Medical Center, Erlangen, Germany. raymund.horch@uk-erlangen.de
authors.forename: R E
authors.initials: RE
authors.lastname: Horch
authors.forename: A
authors.initials: A
authors.lastname: D'Hoore
authors.forename: T
authors.initials: T
authors.lastname: Holm
authors.forename: U
authors.initials: U
authors.lastname: Kneser
authors.forename: W
authors.initials: W
authors.lastname: Hohenberger
authors.forename: A
authors.initials: A
authors.lastname: Arkudas
mesh_terms: D001005:Anus Neoplasms / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008875:Middle Aged; D010502:Perineum / Q000601:surgery; D012007:Rectum / Q000601:surgery; D017568:Rectus Abdominis / Q000601:surgery*; D013524:Surgical Flaps