Reoperative Pelvic Surgery

Reoperative pelvic surgery is technically challenging and carries with it significant potential risk. Pelvic pathology that requires reoperative surgery typically involves recurrent malignancies, complications from ileal pouch-anal anastomoses (IPAA) for inflammatory bowel disease, complications from low pelvic anastomoses, and palliative situations. The goals of reoperative pelvic surgery are resection/repair of the primary indication and reconstruction whenever possible. This review describes pelvic anatomy and operative management for recurrent rectal cancer. Complications following IPAA, low anastomotic complications, and palliative reoperative pelvic surgery are also detailed. Tables outline prognostic factors negatively impacting outcomes following surgery for recurrent rectal cancer, absolute and relative contraindications for exenterative surgery, survival following exenteration for recurrent rectal cancer, intraoperative radiotherapy doses related to resection margin, indications for reoperative pouch surgery, and mobilization techniques for difficult reconstructions. Figures show anterior and posterior exenteration; the anatomy of presacral space after rectal mobilization; vascular exposure and dissection; unicortical transverse osteotomy; placement of Silastic mesh; division of the sacrospinous and sacrotuberous ligaments and piriformis muscle; posterior sacral osteotomy; transperineal delivery of pedicled myocutaneous rectus flap; vertical rectus abdominis myocutaneous flap; gracilis flap; total thigh fillet flap; sacropelvic resection classification; and increasing colon length with primary, secondary, and tertiary maneuvers. This review contains 18 figures, 6 tables, and 89 references.