Soft Tissue Reconstruction After Sacral Neoplasm Resection: The University of California San Francisco Experience.

PURPOSE: Resection of sacral neoplasms such as chordoma and chondrosarcoma with subsequent reconstruction of large soft tissue defects is a complex multidisciplinary process. Radiotherapy and prior abdominal surgery play a role in reconstructive planning; however, there is no consensus on how to maximize outcomes. In this study, we present our institution's experience with the reconstructive surgical management of this unique patient population. METHODS: We conducted a retrospective review of patients who underwent reconstruction after resection of primary or recurrent pelvic chordoma or chondrosarcoma between 2002 and 2019. Surgical details, hospital stay, and postoperative outcomes were assessed. Patients were divided into 3 groups for comparison based on reconstruction technique: gluteal-based flaps, vertical rectus abdominus myocutaneous (VRAM) flaps, and locoregional fasciocutaneous flaps. RESULTS: Twenty-eight patients (17 males, 11 females), with mean age of 62 years (range, 34-86 years), were reviewed. Twenty-two patients (78.6%) received gluteal-based flaps, 3 patients (10.7%) received VRAM flaps, and 3 patients (10.7%) were reconstructed with locoregional fasciocutaneous flaps. Patients in the VRAM group were significantly more likely to have undergone total sacrectomy (P < 0.01) in a 2-stage operation (P < 0.01) compared with patients in the other 2 groups. Patients in the VRAM group also had a significantly greater average number of reoperations (2 ± 3.5, P = 0.04) and length of stay (29.7 ± 20.4 days, P = 0.01) compared with the 2 other groups. The overall minor and major wound complication rates were 17.9% and 42.9%, respectively, with 17.9% of patients experiencing at least 1 infection or seroma. There was no association between prior abdominal surgery, surgical stages, or radiation therapy and an increased risk of wound complications. CONCLUSIONS: Vertical rectus abdominus myocutaneous flaps are a more suitable option for patients with larger defects after total sacrectomy via 2-staged anteroposterior resections, whereas gluteal myocutaneous flaps are effective options for posterior-only resections. For patients with small- to moderate-sized defects, local fasciocutaneous flaps are a less invasive and effective option. Paraspinous flaps may be used in combination with other techniques to provide additional bulk and coverage for especially long postresection wounds. Furthermore, mesh is a useful adjunct for any reconstruction aimed at protecting against intra-abdominal complications.

Abdominal Mesh Use in Pedicled Rectus Abdominis Flaps for Pelvic Reconstruction.

Background: Rectus abdominis flap coverage of high-risk perineal wounds following extirpative pelvic procedures can result in improved perineal outcomes. However, rectus abdominis flap harvest has morbidity associated with the donor site, including hernia or bulge development. The risk-benefit profile of mesh use in this scenario is not well-defined in the literature. Methods: We performed a retrospective chart review of all patients who underwent rectus abdominis flap coverage of pelvic defects at our institution during July 2012-January 2021. Patient characteristics and postoperative outcomes were assessed. Patients were stratified into groups based on whether mesh was used and whether primary fascial closure was achieved. Donor site outcomes were analyzed between groups. Results: One hundred consecutive patients were included. When considering all patients in whom primary fascial closure was achieved, the use of mesh did not significantly decrease rates of hernia development. Mesh use in this setting was associated with significantly greater rates of infection, requiring procedural intervention (12% versus 0%, P = 0.044). When considering all patients in whom mesh was used, primary fascial closure was associated with decreased rates of hernia development, and this trended toward significance (16.1% versus 0.0%, P = 0.058). Conclusions: When closing a pedicled rectus abdominis flap donor site, if primary fascial closure is achievable, the addition of mesh to reinforce the repair does not have an added benefit. Mesh use in this setting was not shown to prevent hernia or bulge development, and was found to be associated with significantly greater rates of infection, requiring procedural intervention.

Comparing Peer and Faculty Feedback for Asynchronous Laparoscopic Skill Acquisition.

OBJECTIVE: Traditionally, expert surgeons have provided surgical trainees with feedback about their simulation performance, including for asynchronous practice. Unfortunately, innumerable time demands may limit experts' ability to provide feedback. It is unknown whether and how peer feedback is an effective mechanism to help residents acquire laparoscopic skill in an asynchronous setting. As such, we aimed to assess the effect of peer feedback on laparoscopic performance and determine how residents perceive giving and receiving peer feedback. DESIGN: We conducted a convergent mixed methods study. In the quantitative component, we randomized residents to receive feedback on home laparoscopic tasks from peers or faculty. We then held an end-of-curriculum, in-person laparoscopic assessment with members from both groups and compared performance on the in-person assessment between the groups. In the qualitative component, we conducted interviews with resident participants to explore experiences with feedback and performance. Three authors coded and rigorously reviewed interview data using a directed content analysis. SETTING: We performed this study at a single tertiary academic institution: the University of California, San Francisco. PARTICIPANTS: We invited 47 junior residents in general surgery, obstetrics-gynecology, and urology to participate, of whom 37 (79%) participated in the home curriculum and 25 (53%) participated in the end-of-curriculum assessment. RESULTS: Residents in the peer feedback group scored similarly on the final assessment (mean 70.7%; SD 16.1%) as residents in the faculty feedback group (mean 71.8%; SD 11.9%) (p = 0.86). Through qualitative analysis of interviews with 13 residents, we identified key reasons for peer feedback's efficacy: shared mental models, the ability to brainstorm and appreciate new approaches, and a low-stakes learning environment. CONCLUSIONS: We found that peer and faculty feedback led to similar performance in basic laparoscopy and that residents engaged positively with peer feedback, suggesting that peer feedback can be used when residents learn basic laparoscopy.