Optimizing Postoperative Mobility: A Review of Enhanced Recovery after Surgery Protocols for Pedicled Flap-Based Pelvic Reconstructions

Background Surgical reconstruction of pelvic defects aims to restore pelvic floor anatomy and function after oncological resection, infection, or trauma. The functional demands of the pelvis and proximity to anogenital flora can complicate wound healing, often necessitating locoregional flap reconstruction. While enhanced recovery after surgery (ERAS) protocols have shown benefits in other surgeries, they lack standardization for pedicled flap-based pelvic and perineal reconstructions. Methods PubMed and Embase were queried for articles from January 2000 to January 2025 reporting pedicled flap-based pelvic and perineal reconstruction. Single case reports were excluded. Data regarding postoperative mobility protocols, including bed rest, mobilization, sitting, drain management, discharge timing, and complication rates, were extracted and categorized by the flap donor site region. Results Out of 536 articles identified, 42 met inclusion criteria. Remobilization protocols varied across different flap types. The median out-of-bed remobilization times for vertical rectus abdominis myocutaneous, inferior gluteal artery perforator, internal pudendal artery perforator, anterolateral thigh, and gracilis flaps were 5, 2, 5, 2, and 1 days postoperatively, respectively, with an overall range of 0 to 36 days. Sitting was allowed at 15, 6, 14, 14, and 2 days postoperatively for these flaps. Conclusion The findings advocate for standardized ERAS protocols with early mobilization and graded sitting, challenging traditional prolonged bed rest practices. We propose specific guidelines for pedicled flap reconstruction of the pelvic and perineal areas, including 1 to 2 days of strict bed rest followed by short-distance ambulation. Gradual sitting protocols should start in the second week with attention to cushioning and offloading. For more vulnerable perineal-based flaps, 4 to 5 days of bed rest and sitting beginning in the third week are recommended. Continuing recovery at a rehabilitation center is also advised. Future studies are needed to examine and modify these protocols, taking into consideration patient factors, disease severity, such as radiation exposure, and the type of reconstruction performed.