The “Pelvic Bowl” Framework

Perineal and pelvic reconstruction after abdominoperineal resection or pelvic exenteration is challenging due to high rates of wound complications, perineal hernia, and empty pelvis syndrome. Morbidity arises from residual dead space, poor vascularity, and inadequate pelvic floor support. We performed a narrative review synthesizing evidence on perineal and pelvic reconstruction following extirpative pelvic surgery, critically appraising existing decision-making algorithms through the lens of 3 core reconstructive objectives: pelvic floor support, dead space obliteration, and perineal resurfacing. We identified 4 categories of existing frameworks: defect morphology, operative context, multifactorial, and flap-specific, that effectively match techniques to defects but do not systematically ensure all mechanistic objectives are addressed. To bridge this gap, we developed a conceptual framework, the "Pelvic Bowl" model, organizing reconstruction around 3 essential layers: pelvic floor support (preventing hernia and bowel descent), dead space obliteration (preventing fluid accumulation and infection), and perineal resurfacing (providing durable wound coverage). This objective-centered approach enables systematic evaluation of whether chosen techniques address all failure modes, facilitating individualized reconstructive planning and potentially reducing complication rates.