Evolution of Perineal and Pelvic Reconstruction

Surgical repair of defects in the perineal region, which can be caused by trauma, infection, or cancer, has been a challenging issue from the very beginning. The history of perineal, vaginal, and pelvic reconstruction is closely related to the development of oncological surgery for rectal, anal, and vulvar tumors with the invention of multimodal neoadjuvant therapies, creating central perineal and pelvic defects from the resection for oncological clearance of these cancers. Adjacent perineal defects mostly stem from extensive metastases to the regional lymph pathways from these tumors. Necrotizing fasciitis (such as Fournier’s gangrene), injury from radiation, thermal, and combat-related trauma, as well as congenital abnormalities or the consequences of gender reassignment surgeries are less frequent causes for perineal reconstruction and do not always involve flap surgery. A number of various surgical techniques, such as local flaps, free flaps, and grafts, that can be used for perineal, vaginal, and pelvic reconstruction, depending on the size, location, and complexity of the defects, have been developed over the last few decades. The necessity for flap reconstruction in colorectal radical surgery has a high morbidity rate of up to 66%, with the creation of a surgical dead space in the pelvis and pelvic floor created by a wide resection, followed by potential fluid and hematoma accumulation, risk of wound infection, pelvic abscess, anastomotic dehiscence, adhesions, and the development of fistulae and sinus tracts and perineal herniae.