# Robotic Rectus Muscle Flap Reconstruction After Pelvic Exenteration in Gynecological Oncology: Current and Future Perspectives—A Narrative Review

## TL;DR

This review discusses the use of robotic-assisted rectus muscle flap reconstruction after pelvic exenteration for gynecological cancers, highlighting its potential benefits and the need for further research.

## Contribution

The paper introduces robotic rectus flap reconstruction as a novel minimally invasive approach to pelvic exenteration, emphasizing its potential to reduce complications and improve recovery.

## Key findings

- Robotic rectus flap reconstruction is technically feasible and allows successful flap harvest and pelvic defect coverage.
- Potential benefits include reduced wound morbidity and preservation of a minimally invasive surgical workflow.
- Current evidence is limited to case reports and small series, with no standardized protocols or comparative data.

## Abstract

Pelvic exenteration is a radical procedure performed for recurrent or locally advanced gynecologic cancers and requires advanced anatomical knowledge. While extensive tissue loss during this procedure can lead to high morbidity, the procedure offers long-term survival potential. Reconstruction using vascularized flaps, such as the vertical rectus abdominis musculocutaneous (VRAM) or the transverse rectus abdominis musculocutaneous (TRAM) flap, has become the gold standard in open surgery for restoring pelvic integrity, reducing complications, and improving quality of life. Following introduction of minimally invasive pelvic exenteration, the need for minimally invasive reconstructive surgery has emerged. Current data on robotic rectus flap reconstruction is insufficient and limited to case reports and small series. This review analyzes the current literature, summarizes surgical techniques, and highlights future research needs to guide the integration of robot-assisted rectus muscle-based flap reconstruction into modern reconstructive algorithms.

Background/Objectives: Pelvic exenteration is a radical procedure performed for recurrent gynecologic cancers. The goal of exenteration is to prolong survival, but this procedure also results in extensive tissue loss and consequently high morbidity. Reconstruction using vascularized flaps, particularly the VRAM flap, is crucial to restoring pelvic integrity and decreasing complications resulting from extensive tissue loss. With the rise of minimally invasive surgery, the traditionally open abdominal approach to exenteration and reconstruction can now be performed with the assistance of robotic platforms. This review aims to summarize available evidence, describe techniques, and propose future directions for robotic rectus flap reconstruction after pelvic exenteration. Methods: This narrative review was conducted following the SANRA guidelines for narrative synthesis. A comprehensive search of PubMed, Embase, Scopus, and Web of Science was conducted for studies published between January 2000 and November 2025 on pelvic exenteration followed by robotic rectus abdominis flap reconstruction in gynecologic oncology. Eligible studies were retrospective or prospective reports, technical descriptions, case series, or comparative analyses. Non-robotic techniques and animal studies were excluded. Although the primary focus was gynecologic oncology, technically relevant studies from other oncologic disciplines were included when the reconstructive approach was directly applicable to pelvic exenteration. Extracted data included patient demographics, surgical details, and perioperative and oncologic outcomes. Results: The literature search identified primarily case reports and small single-center series describing robot-assisted rectus muscle-based flap reconstruction after pelvic exenteration. Reported cases demonstrated technical feasibility and successful flap harvest using robotic platforms, with adequate pelvic defect coverage. Potential benefits, such as reduced wound morbidity and preservation of a minimally invasive workflow, have been described. However, patient numbers were small, techniques varied, and standardized outcome measures or comparative data with open approaches were lacking. Conclusions: Robotic rectus flap reconstruction represents a promising advancement in pelvic exenteration surgery, potentially reducing morbidity and improving recovery. Further research, including multicenter prospective studies, is needed to validate these findings and establish standardized protocols.