Soft-tissue reconstruction of external hemipelvectomy defects

BACKGROUND: External hemipelvectomy is the ultimate salvage procedure for locally advanced pelvic tumors, infections, and failed revascularizations. It is associated with high wound morbidity requiring surgical management. In this study, the authors analyzed their experience with primary and secondary reconstruction of hemipelvectomy wounds. METHODS: The records of 160 consecutive hemipelvectomy patients from the authors' institution were reviewed to identify the incidence of soft-tissue coverage problems and approaches to their management. RESULTS: At the time of hemipelvectomy, a musculocutaneous hemipelvectomy flap was sufficient for closure in 159 patients, one patient needed a free lower leg fillet flap, and none required pedicle flaps. No hemipelvectomy hernias were observed, although abdominal wall reconstruction was performed in three patients. Wound complications were encountered in 62 patients (39 percent), and 51 patients required operative débridement. Thirty-three patients healed by secondary intention, and 25 underwent delayed reconstruction with local tissue rearrangements (n = 15), split-thickness skin grafting (n = 6), and pedicled flaps (n = 6). All pedicled flaps were contralateral inferiorly based rectus abdominis muscle (n = 2) and musculocutaneous (n = 4) flaps. CONCLUSIONS: Hemipelvectomy is associated with high wound morbidity. When the hemipelvectomy flap has a musculocutaneous design, hernias are exceedingly rare. Although immediate reconstruction is accomplished with a hemipelvectomy flap in the vast majority of cases, secondary reconstructions are often required for management of wound complications. For large defects, a contralateral inferiorly based rectus abdominis muscle or musculocutaneous flap is the reconstruction of choice. The rectus abdominis muscle should therefore always be preserved in hemipelvectomy patients by careful preoperative planning, especially when creation of an ostomy is considered.