In patients with a persistent perineal sinus after LAR with permanent colostomy, is vertical rectus abdominis myocutaneous flap or gracilis muscle flap reconstruction preferred

What is known

- The retrieved literature favors the rectus abdominis (VRAM/muscle) flap over gracilis for persistent perineal sinus, reporting healing rates over 90% with rectus abdominis versus more variable, often inferior results with gracilis, which is criticized for inconsistent blood supply and insufficient bulk to fill a deep pelvic dead space ^1–3. - A prior abdominal operation with a stoma (permanent colostomy) is specifically cited as a relative difficulty/contraindication for the rectus abdominis flap, since it may jeopardize the colostomy, complicate future laparotomy, and cause abdominal-wall weakness/incisional hernia ².

What is unknown / caveats

- Gracilis healing rates range from 33% to 100% across small series, so its true efficacy is unresolved - Evidence is small retrospective cohorts, case series and narrative reviews — no head-to-head randomized comparison of VRAM vs gracilis - Most series involve proctocolectomy/APR for IBD, not specifically prior LAR with permanent colostomy - Prior stoma and abdominal surgery specifically complicate the rectus abdominis harvest — a factor not resolved by the retrieved data - No retrieved study directly compares VRAM and gracilis outcomes in patients with a pre-existing colostomy.

## References

1. Collie MH, Potter MA, Bartolo DC. Myocutaneous flaps promote perineal healing in inflammatory bowel disease. Br J Surg. 2005;92(6):740-1. PMID: 15838906.

2. Lohsiriwat V. Persistent perineal sinus: incidence, pathogenesis, risk factors, and management. Surg Today. 2009;39(3):189-93. PMID: 19280276.

3. PMID: 1825193. (metadata not in corpus)

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_Draft — generated by the IBDology RAG and not yet clinician-reviewed. Answers are grounded in the retrieved literature listed above; a high faithfulness score means the answer matches its sources, not that the sources are correct._