Complex Reconstruction with Flaps After Abdominoperineal Resection and Groin Dissection for Anal Squamous Cell Carcinoma: A Difficult Case Involving Many Specialities

Abstract

Patient: Male, 49

Final Diagnosis: Anal squamo cell carcinoma

Symptoms: Inguinal mass • inflammation • perineal tumor

Medication: —

Clinical Procedure: Abdominoperineal resection (APR) • groin dissection and closure of the inguinal defect with oblique rectus abdominis myocutaneous (ORAM) flap

Specialty: Surgery

Objective:

Unusual setting of medical care

Background:

Anal squamous cell carcinoma accounts for about 2–4% of all lower gastrointestinal malignancies, with a distant disease reported in less than 5%. Although surgical treatment is rarely necessary, this often involve large dissections and difficult reconstructive procedures.

Case Report:

We present a complex but successful case of double-flap reconstruction after abdominoperineal resection and groin dissection for anal squamous cell carcinoma (cT3N3M0) with metastatic right inguinal lymph nodes and ipsilateral threatening of femoral vessels. A multi-specialty team was involved in the operation. A vascular and plastic surgeon performed the inguinal dissection with en bloc excision of the saphenous magna and a cuff of the femoral vein, while colorectal surgeons carried out the abdominoperineal excision. The 2 large tissue gaps at the groin and perineum were covered with an oblique rectus abdominis myocutaneous flap and a gluteal lotus flap, respectively. A partially absorbable mesh was placed at the level of the anterior sheath in order to reinforce the abdominal wall, whereas an absorbable mesh was used as a bridge for the dissected pelvic floor muscles. The post-operative period was uneventful and the follow-up at 5 months showed good results.

Conclusions:

An early diagnosis along with new techniques of radiochemotherapy allow patients to preserve their sphincter function. However, a persistent or recurrent disease needs major operations, which often involve a complex reconstruction. Good team-work and experience in specialized fields give the opportunity to make the best choices to perform critical steps during the management of complex cases.