Deckung perinealer und pelviner Defekte: die A. epigastrica inferior (DIEA) als Anschlussgefäß für die freie mikrochirurgische Rekonstruktion

Zusammenfassung

Hintergrund

Großflächige Defekte im perinealen oder vorderen/lateralen Beckenbereich können infolge tumorbedingter Resektionen, Infektionen oder aufgrund postoperativer Komplikationen entstehen. In Fällen, in denen lokale oder gestielte Lappenplastiken nicht ausreichen, ist eine mikrochirurgische Rekonstruktion mittels freier Lappen notwendig. Die A. epigastrica inferior (DIEA) kommt aufgrund ihrer Lage und ihres Kalibers als Anschlussgefäß für einen mikrovaskulären Gewebetransfer infrage.

Patienten/Materialien und Methoden

In einer retrospektiven Fallstudie wurden zwischen Juni 2024 und März 2025 Patienten mit perinealen oder pelvinen Defekten mikrochirurgisch versorgt. Die Defektdeckung erfolgte mit freien Lappenplastiken (muskulokutane Vastus-lateralis- (MVL), Latissimus-dorsi- (LD) und Paraskapularlappen) und End-zu-End-Gefäßanschluss an die DIEA. Die präoperative Planung beinhaltete eine CT-Angiografie zur Beurteilung der Gefäßsituation. Die mikrochirurgischen Anastomosen wurden standardisiert durchgeführt, wobei die arteriellen Anastomosen von Hand geknüpft wurden, die venösen Anastomosen mittels Venenkoppler erfolgten. Die Perfusion der Anastomosen und der Lappenplastik wurde mittels ICG-Fluoreszenz kontrolliert. Postoperativ erfolgten eine strukturierte Entlastung und Mobilisation.

Ergebnisse

Im untersuchten Zeitraum wurden 5 Patienten (Durchschnittsalter 64,6 Jahre, ASA-Score 2,8) mit perinealen oder pelvinen Defekten von durchschnittlich 413,4 cm² behandelt. Zugrunde liegende Ursachen waren Tumoren (3) und ausgedehnte Infektionen (2). Die DIEA konnte in allen Fällen als zuverlässiges Anschlussgefäß verwendet werden. Die venösen Anastomosen erfolgten im Durchschnitt mit 2,5-mm-Kopplern (Range: 2–3 mm). Es traten keine Lappenverluste oder -nekrosen auf.

Schlussfolgerung

Die Ergebnisse bestätigen die Eignung der DIEA als konstantes, oberflächliches und gut präparierbares Anschlussgefäß mit stabilem Kaliber und ausreichendem Fluss auch für große Lappen. Sie ermöglicht sichere mikrochirurgische Rekonstruktionen im vorderen und lateralen Beckenbereich und stellt damit eine valide Alternative zur A. femoralis dar, ohne die Durchblutung der Extremität zu kompromittieren. Die Studie unterstreicht den hohen Stellenwert der DIEA in der plastisch-rekonstruktiven Chirurgie komplexer Becken- und Perinealdefekte.

Abstract

Purpose

Extensive defects in the perineal or anterior/lateral pelvic region can occur as a result of tumour-related resections, infections, or postoperative complications. In cases where local or pedicled flap reconstructions are insufficient, microsurgical reconstruction using free flaps becomes necessary. Due to its location and calibre, the inferior epigastric artery (DIEA) is a suitable recipient vessel for microsurgical tissue transfer.

Patients/Materials and Methods

In a retrospective case study conducted between June 2024 and March 2025, patients with perineal or pelvic defects underwent microsurgical reconstruction. Defect coverage was achieved using free flap techniques (musculocutaneous vastus lateralis [MVL], musculocutaneous latissimus dorsi [LD] and parascapular flaps) with end-to-end anastomosis to the DIEA. Preoperative planning included CT angiography to assess the vascular situation. Microsurgical anastomoses were performed in a standardised manner, with arterial anastomoses hand-sewn and venous anastomoses carried out using venous couplers. The perfusion of the anastomoses and the flap was assessed using ICG fluorescence. Postoperative care included structured offloading and mobilisation.

Results

During the study period, five patients (average age 64.6 years, ASA score 2.8) with perineal or pelvic defects averaging 413.4 cm² were treated. The underlying causes were tumours (3) and extensive infections (2). The DIEA was successfully used as a reliable recipient vessel in all cases. Venous anastomoses were performed using venous couplers with an average diameter of 2.5 mm (range: 2–3 mm). No flap losses or necroses occurred.

Conclusion

The results confirm the suitability of the DIEA as a consistent, superficial, and easily dissectible recipient vessel with stable calibre and sufficient flow, even for large flaps. It enables safe microsurgical reconstructions in the anterior and lateral pelvic region and represents a valid alternative to the femoral artery, without compromising extremity perfusion. The study highlights the significant role of the DIEA in plastic and reconstructive surgery of complex pelvic and perineal defects.

Schlüsselwörter

A. epigastrica inferior - DIEA - perineale Defekte - pelvine Defekte - Mikrochirurgie - freie Lappenrekonstruktion

Keywords

deep inferior epigastric artery - DIEA - perineal defects - pelvic defects - microsurgery - free flap reconstruction

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