Laparoscopic-assisted extralevator abdominoperineal excision using a parastomal prophylactic mesh and a biological mesh for pelvic floor reconstruction

A three layered repair of a large perineal hernia: case report and review of the literature

BACKGROUND

A symptomatic perineal hernia is an uncommon complication after abdominoperineal resection (APR). Repairs of such hernias can be achieved by usage of autologous flaps, synthetic mesh, or biologic mesh, which reduce bowel adhesions. Studies have shown that prophylactic repair of the pelvic floor with biologic mesh during APR, can reduce the incidence of perineal hernia.

CASE PRESENTATION

A 71-year-old woman, after extended APR (eAPR) with primary closure of pelvic floor with absorbable mesh, presented to our outpatient clinic with a symptomatic, extensive perineal hernia. The patient underwent repair of the perineal hernia using a synthetic mesh and a bilateral gluteal flap procedure. In post operative care, signs of surgical site infection and a fluid collection demonstrated in a CT-scan, compelled a surgical drainage. A clear fluid negative for bacterial growth was drained and antibiotic treatment was initiated. After drainage, surgical site showed signs of significant improvement and patient was eventually discharged.

CONCLUSION

The rise in reported incidence of perineal hernia after eAPR coupled with the scarcity of data regarding the preferable repair technique suggests that there is a significant need for further prospective comparative studies.

Preliminary Outcome of Individualized Abdominoperineal Excision for Locally Advanced Low Rectal Cancer

Background:

The introduction of individualized abdominoperineal excision (APE) may minimize operative trauma and reduce the rate of complications. The purpose of this study was to evaluate the safety and efficacy of individualized APE for low rectal cancer.

Methods:

Fifty-six patients who underwent individualized APE from June 2011 to June 2015 were evaluated retrospectively in Beijing Chaoyang Hospital, Capital Medical University. The main outcome measures were circumferential resection margin (CRM) involvement, intraoperative perforation, postoperative complications, and local recurrence. Statistical analysis was performed using SPSS version 16.0.

Results:

Fifty (89%) patients received preoperative chemoradiotherapy: 51 (91%) patients were treated with the sacrococcyx preserved; 27 (48%) patients with the levator ani muscle partially preserved bilaterally; 20 (36%) patients with the levator ani muscle partially preserved unilaterally and the muscle on the opposite side totally preserved; 7 (13%) patients with intact levator ani muscle and part of the ischioanal fat bilaterally dissected; and 2 (4%) patients with part of the ischioanal fat and intact lavator ani muscle dissected unilaterally and the muscle on the opposite side partially preserved. The most common complications included sexual dysfunction (12%), perineal wound complications (13%), urinary retention (7%), and chronic perineal pain (5%). A positive CRM was demonstrated in 3 (5%) patients, and intraoperative perforations occurred in 2 (4%) patients. On multiple logistic regression analysis, longer operative time (P = 0.032) and more intraoperative blood loss (P = 0.006) were significantly associated with perineal procedure-related complications. The local recurrence was 4% at a median follow-up of 53 months (range: 30–74 months).

Conclusion:

With preoperative chemoradiotherapy, individualized APE may be a relatively safe and feasible approach for low rectal cancer with acceptable oncological outcomes.

Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma - ACPGBI Position Statement

BACKGROUND

Perineal wound morbidity is common following abdominoperineal excision of the rectum (APE). There is no consensus on the optimum perineal reconstruction method after APE, and in particular 'extra-levator APE' (ELAPE).

METHODS

A systematic review of the PubMed, Embase and Cochrane databases was performed. This position statement formulated clinical questions and graded the evidence to make recommendations.

RESULTS

Perineal wound complications may be higher following ELAPE compared to 'conventional APE (cAPE)' however there is insufficient evidence to recommend cAPE over ELAPE with regards to the impact upon perineal wound healing. The majority of cAPE studies have used primary closure with varying complication rates reported. Where concerns regarding perineal wound healing exist, myocutaneous flap closure may be considered as an alternative method. There is minimal available evidence on perineal mesh reconstruction following cAPE. Primary closure, mesh use and myocutaneous flap reconstruction following ELAPE has been reported although variations in definitions and low-quality of available evidence limit comparison. There is insufficient evidence to recommend one particular method of perineal closure after ELAPE. Primary perineal closure is likely to have a higher risk of perineal herniation. Myocutaneous flaps and biological mesh have been effectively used in ELAPE closure. There is insufficient evidence to support one particular type of flap or mesh. Perineal wound complication rates are significantly increased when neo-adjuvant radiotherapy is delivered, regardless of surgical technique. There is no evidence that laparoscopy reduces APE perineal wound complications.

CONCLUSION

This position statement updates clinicians on current evidence around perineal closure after APE surgery.