Robotic Rectus Muscle Flap for Reconstruction in the Pelvis



Robotic surgery has gained widespread use in several surgical specialties when working in the deep pelvis. The improved visualization, ability to use multiple arms, and precise maneuverability have made the robot increasingly valuable for surgery in this area. With this increased use, plastic surgeons are challenged to reconstruct defects after robotic pelvic tumor extirpation, abdominoperineal resection, and rectovaginal/colovesicular fistula takedown. These patients often have a history of pelvic irradiation, and primary closure is associated with increased rates of wound complications and fistula recurrence. In these cases, reconstruction of the defect with a muscle flap can significantly improve healing and decrease the risk of major complications by bringing in well-vascularized tissue to fill the defect and/or bolster the repair. Given that these procedures are now being performed robotically, plastic surgeons have adopted robotic surgery for a minimally invasive approach to muscle flap harvest. This chapter presents the novel technique of robotically harvesting the rectus abdominis muscle flap from an intraperitoneal approach to reconstruct these defects. The technique, recommended postoperative care, and potential complications are described.


Pelvic reconstruction Perineal reconstruction Rectus abdominis Muscle flap Robotic reconstruction Robotic rectus Abdominoperineal resection 

Supplementary material

Video 14.1

Isolation of the pedicle (MP4 16338 kb)

Video 14.2

Identification of the lateral border of the rectus muscle, dissection to the costal margin (MP4 28505 kb)

Video 14.3

Identification of the medial border of the rectus muscle, dissection to the costal margin (MP4 28783 kb)

Video 14.4

Anterior rectus sheath dissection from muscle (MP4 18886 kb)

Video 14.5

Distal muscle division (MP4 23990 kb)

Video 14.6

Muscle dissection from distal to proximal (MP4 13024 kb)

Video 14.7

Rectus muscle isolation and placement in rectal vault (MP4 46908 kb)


  1. 1.
    Davidge KM, et al. Impact of flap reconstruction on perineal wound complications following ablative surgery for advanced and recurrent rectal cancers. Ann Surg Oncol. 2014;21(6):2068–73.CrossRefGoogle Scholar
  2. 2.
    Young MR, Small JO, Leonard AG, McKelvey ST. Rectus abdominis muscle flap for persistent perineal sinus. Br J Surg. 1988;75(12):1228.CrossRefGoogle Scholar
  3. 3.
    McDonald MW, Elliott LF 2nd, Sullivan JW, Ortenberg J. Repair of vesicocutaneous fistula by rectus abdominis myocutaneous flap. Br J Urol. 1991;67(4):445.CrossRefGoogle Scholar
  4. 4.
    Brough WA, Schofield PF. The value of the rectus abdominis myocutaneous flap in the treatment of complex perineal fistula. Dis Colon Rectum. 1991;34(2):148–50.CrossRefGoogle Scholar
  5. 5.
    Cox MR, Parks TG, Hanna WA, Leonard AG. Closure of persistent post-proctectomy perineal sinus using a rectus muscle flap. Aust N Z J Surg. 1991;61(1):67–71.CrossRefGoogle Scholar
  6. 6.
    Salup RR, Julian TB, Liang MD, Narayanan K, Finegold R. Closure of large postradiation vesicovaginal fistula with rectus abdominis myofascial flap. Urology. 1994;179(3):344–6.Google Scholar
  7. 7.
    Krasniak CL. Retroperitoneal transfer of a transverse rectus abdominis musculocutaneous flap for closure of a sacral radiation ulcer. Ann Plast Surg. 1995;34(3):332–4.CrossRefGoogle Scholar
  8. 8.
    Viennas LK, Alonso AM, Salama V. Repair of radiation-induced vesicovaginal fistula with a rectus abdominis myocutaneous flap. Plast Reconstr Surg. 1996;97(2):455–9.CrossRefGoogle Scholar
  9. 9.
    Erdmann MW, Waterhouse N. The transpelvic rectus abdominis flap: its use in the reconstruction of extensive perineal defects. Ann R Coll Surg Engl. 1995;77(3):229–32.PubMedPubMedCentralGoogle Scholar
  10. 10.
    Loessin SJ, Meland NB, Devine RM, Wolff BG, Nelson H, Zincke H. Management of sacral and perineal defects following abdominoperineal resection and radiation with transpelvic muscle flaps. Dis Colon Rectum. 1995;38(9):940–5.CrossRefGoogle Scholar
  11. 11.
    De Haas WF, Miller MJ, Temple WJ, Kroll SS, Schusterman MA, Reece GP, Skibber JM. Perineal wound closure with the rectus abdominis musculocutaneous flap after tumor ablation. Ann Surg Oncol. 1995;2(5):400–6.CrossRefGoogle Scholar
  12. 12.
    Butler CE, Gundeslioglu AO, Rodriguez-Bigas MA. Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg. 2008;206(4):694–703.CrossRefGoogle Scholar
  13. 13.
    Chessin DB, Hartley J, Cohen AM, Mazumdar M, Cordeiro P, Disa J, Mehrara B, Minsky BD, Paty P, Weiser M, Wong WE, Guillem JG. Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study. Ann Surg Oncol. 2005;12(2):104–10.CrossRefGoogle Scholar
  14. 14.
    Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg. 2009;123(1):175–83.CrossRefGoogle Scholar
  15. 15.
    Mathes SJ, Bostwick J 3rd. A rectus abdominis myocutaneous flap to reconstruct abdominal wall defects. Br J Plast Surg. 1977;30(4):282–3.CrossRefGoogle Scholar
  16. 16.
    Parkash S, Bhandari M. Rectus abdominis myocutaneous island flap for bridging defect after cystectomy for bladder exstrophy. Urology. 1982;20(5):536–7.CrossRefGoogle Scholar
  17. 17.
    Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982;69(2):216–25.CrossRefGoogle Scholar
  18. 18.
    Giampapa V, Keller A, Shaw WW, Colen SR. Pelvic floor reconstruction using the rectus abdominis flap. Ann Plast Surg. 1984;13(1):56–9.CrossRefGoogle Scholar
  19. 19.
    Bunkis J, Walton RL, Mathes SJ. The rectus abdominis free flap for lower extremity reconstruction. Ann Plast Surg. 1983;11(5):373–80.CrossRefGoogle Scholar
  20. 20.
    Shukla HS, Hughes LE. The rectus abdominis flap for perineal wounds. Ann R Coll Surg Engl. 1984;66(5):337–9.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Logan SE, Mathes SJ. The use of a rectus abdominis myocutaneous flap to reconstruct a groin defect. Br J Plast Surg. 1984;37(3):351–3.CrossRefGoogle Scholar
  22. 22.
    Sbitany U, Wray RC Jr. Use of the rectus abdominis muscle flap to reconstruct an elbow defect. Plast Reconstr Surg. 1986;77(6):988–9.CrossRefGoogle Scholar
  23. 23.
    Robertson CN, Riefkohl R, Webster GD. Use of the rectus abdominis muscle flap in urological reconstructive procedures. J Urol. 1986;135(5):963–5.CrossRefGoogle Scholar
  24. 24.
    Ford TD. Rectus abdominis myocutaneous flap used to close a median sternotomy chest defect. A case report. S Afr Med J. 1985;68(2):115–6.PubMedGoogle Scholar
  25. 25.
    Tobin GR, Day TG. Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps. Plast Reconstr Surg. 1988;81(1):62–73.CrossRefGoogle Scholar
  26. 26.
    McCraw J, Kemp G, Given F, Horton CE. Correction of high pelvic defects with the inferiorly based rectus abdominis myocutaneous flap. Clin Plast Surg. 1988;15(3):449–54.CrossRefGoogle Scholar
  27. 27.
    Horton CE, Sadove RC, Jordan GH, Sagher U. Use of the rectus abdominis muscle and fascia flap in reconstruction of epispadias/exstrophy. Clin Plast Surg. 1988;15(3):393–7.CrossRefGoogle Scholar
  28. 28.
    Young WA, Wright JK. Scrotal reconstruction with a rectus abdominis muscle flap. Br J Plast Surg. 1988;41(2):190–3.CrossRefGoogle Scholar
  29. 29.
    Bunkis J, Fudem GM. Rectus abdominis flap closure of ischiosacral pressure sore. Ann Plast Surg. 1989;23(5):447–9.CrossRefGoogle Scholar
  30. 30.
    Kroll SS, Pollock R, Jessup JM, Ota D. Transpelvic rectus abdominis flap reconstruction of defects following abdominal-perineal resection. Am Surg. 1989;55(10):632–7.PubMedGoogle Scholar
  31. 31.
    Shepherd JH, Van Dam PA, Jobling TW, Breach N. The use of rectus abdominis myocutaneous flaps following excision of vulvar cancer. Br J Obstet Gynaecol. 1990;97(11):1020–5.CrossRefGoogle Scholar
  32. 32.
    Tobin GR, Pursell SH, Day TG Jr. Refinements in vaginal reconstruction using rectus abdominis flaps. Clin Plast Surg. 1990;17(4):705–12.CrossRefGoogle Scholar
  33. 33.
    Skene AI, Gault DT, Woodhouse CR, Breach NM, Thomas JM. Perineal, vulvar and vaginoperineal reconstruction using the rectus abdominis myocutaneous flap. Br J Surg. 1990;77(6):635–7.CrossRefGoogle Scholar
  34. 34.
    Kluger Y, Townsend RN, Paul DB, Diamond DL. Rectus muscle flap for the reconstruction of disrupted pelvic floor. J Am Coll Surg. 1994;179(3):344–6.PubMedGoogle Scholar
  35. 35.
    Patel NV, Pedersen JC. Robotic harvest of the rectus abdominis muscle: a preclinical investigation and case report. J Reconstr Microsurg. 2012;28(7):477–80.CrossRefGoogle Scholar
  36. 36.
    Ibrahim AE, Sarhane KA, Pedersen JC, Selber JC. Robotic harvest of the rectus abdominis muscle: principles and clinical applications. Semin Plast Surg. 2014;28(1):26–31.CrossRefGoogle Scholar
  37. 37.
    Pedersen JC, Song DH, Selber JC. Robotic, intraperitoneal harvest of the rectus abdominis muscle. Plast Reconstr Surg. 2014;134(5):1057–63.CrossRefGoogle Scholar
  38. 38.
    Singh P, Teng E, Cannon LM, Bello BL, Song DH, Umanskiy K. Dynamic article: tandem robotic technique of extralevator abdominoperineal excision and rectus abdominis muscle harvest for immediate closure of the pelvic floor defect. Dis Colon Rectum. 2015;58(9):885–91.CrossRefGoogle Scholar
  39. 39.
    Wu LC, Song DH. The rectus abdominis musculoperitoneal flap for the immediate reconstruction of partial vaginal defects. Plast Reconstr Surg. 2005;115(2):559–62.CrossRefGoogle Scholar
  40. 40.
    Goldman JJ, Francis A, Baynosa R. Robotic rectus harvest for perineal and posterior vaginal wall defects and for rectovaginal fistula repair: a case series and evolution of technique. American Society for Reconstructive Microsurgery Annual Meeting. Phoenix; 2017 Jan 15.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Plastic SurgeryUniversity of Nevada, Las Vegas School of MedicineLas VegasUSA

Personalised recommendations