Background: Significant morbidity can result from perineal wounds, particularly after radiotherapy and extensive resection for cancer. Myocutaneous flaps have been used to improve healing. The purpose of this study was to evaluate the morbidity and results of primary rectus abdominis myocutaneous flap reconstruction of the vagina and perineum after extended abdominoperineal resection. Methods: Thirty-one consecutive patients undergoing one-stage rectus abdominis myocutaneous flap reconstruction of extensive perineal wounds were studied prospectively. Twenty-six patients had surgery for recurrent or persistent epidermoid anal cancer or low rectal cancer, and 21 had high-dose preoperative radiotherapy. Results: Three weeks after the operation, complete healing of the perineal wound was seen in 27 of the 31 patients. There were nine flap-related complications including three patients with partial flap necrosis, two with vaginal stenosis, one with vaginal scarring, one with small flap disunion and two with weakness of the anterior abdominal wall. There were no unhealed wounds at the completion of follow-up (median 9 months). Conclusion: The transpelvic rectus abdominis myocutaneous flap for the reconstruction of large perineal and vaginal wounds achieves wound healing with only moderate morbidity in the majority of patients after extensive abdominoperineal resection with or without radiotherapy.

Background: The technical difficulty an operation creates for a surgeon is difficult to measure. Current measures are poor surrogates. In both research and teaching settings it would be valuable to be able to accurately measure this degree of difficulty. The National Aeronautics and Space Administration Task Load Index (NASA TLX) is a multi‐dimensional scale designed to obtain workload estimates relating to a task. This study aimed to evaluate the NASA TLX as an objective measure of technical difficulty of an operation.Methods: Seven surgeons performed 127 pre‐defined operations (minimally invasive right hemicolectomy & re‐do bariatric surgery) and recorded a NASA TLX score after each operation. These scores were compared to numerous clinical parameters and the score was correlated with the subjective measure of whether the surgeon categorized the operation as “easy”, “moderate” or “difficult”.Results: The NASA TLX score was significantly correlated with operative duration, blood loss, previous abdominal surgery and the surgeons' assessment of difficulty. It did not correlate with intra‐operative or post‐operative complications, conversion to open surgery or length of stay.Conclusions: The NASA TLX score provides a graded numerical score that that correlated significantly with the surgeon's assessment of the technical difficulty, and with operative duration, intra‐operative blood loss and previous abdominal surgery. This novel application of this tool could be employed in both research and teaching settings to score surgical difficulty and monitor a trainee's proficiency over time.