In patients who have undergone proctectomy for inflammatory bowel disease, the main problem may be a deep presacral cavity with only a small skin

Table 1. Comparison of VRAM flap use for perineal primary closure and for PPS repair

Author Primary perineal PPS repair Major flap- Healed at repair with with related 3 months

VRAM VRAM complications

[*], unreported date defect. Use of a pedicled omental graft to fill this cavity is a simple solution which does not compromise skeletal muscle bulk or function and can be more readily applied by general and colorectal surgeons than the more specialised myocutaneous flap [42, 43]. It is particularly appropriate in Crohn's disease where the rectus muscle may already have been damaged because of multiple stoma sites. The omentum may be based on the right gastroepiploic artery, in which case the left gastroepiploic close to the short gastric vessels is divided and the left side of the omentum is mobilised in order to bring the apex down to the perineum (Fig. 5).

In some cases, to allow a longer pedicle, the omental flap can be obtained on the left gastroepiploic artery, dividing the right gastroepiploic at the level of the second portion of the duodenum [16]. For Bell et al. [34], primary closure over a pedicled omentoplas-ty is the standard practice for perineal wound repair following APR. Radice et al. [41] employed primary perineal wound closure with or without an omental pedicle graft for pelvic space obliteration, followed by delayed myocutaneous flap advancement as required for wound complications, after resection of locally advanced pelvic malignancies. Pujol [44], in a multicentre study, reported 100% success utilising epiploonplasty in 28 abdominoperineal resections and 32 pelvectomies. Brough et al. [45], in a series of ten cases with a persistent sinus after previous proc-tectomy, used a plug of greater omentum (two cases), a muscle plug using the rectus abdominis muscle (two cases) and a full myocutaneous flap based on the rectus abdominis muscle where there was considerable loss of perineal skin (six cases). Complications of omentoplasty include haemorrhage, infarction, causing peritonism, intestinal obstruction and per-ineal hernia. Reoperation for omentoplasty-related complications is required in 0-7% of patients [42,43, 46].

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