Perineal hernia repair after abdominoperineal excision or extralevator abdominoperineal excision: a systematic review of the literature

Oncologic outcomes of intersphincteric resection versus abdominoperineal resection for lower rectal cancer: a systematic review and meta-analysis

BACKGROUND

The efficacy of intersphincteric resection (ISR) surgery for patients with lower rectal cancer remains unclear compared to abdominoperineal resection (APR). The aim of this study is to compare the oncologic outcomes for lower rectal cancer patients after ISR and APR through a systematic review and meta-analysis.

MATERIALS AND METHODS

A systematic electronic search of the Cochrane Library, PubMed, EMBASE, and MEDLINE was performed through January 12, 2022. The primary outcomes included 5-year disease-free survival (5y-DFS) and 5-year overall survival. Secondary outcomes included circumferential resection margin involvement, local recurrence, perioperative outcomes, and other long-term outcomes. The pooled odds ratios, mean difference, or hazard ratios (HRs) of each outcome measurement and their 95% CIs were calculated.

RESULTS

A total of 20 nonrandomized controlled studies were included in the qualitative analysis, with 1217 patients who underwent ISR and 1135 patients who underwent APR. There was no significant difference in 5y-DFS (HR: 0.84, 95% CI: 0.55-1.29; P =0.43) and 5-year overall survival (HR: 0.93, 95% CI: 0.60-1.46; P =0.76) between the two groups. Using the results of five studies that reported matched T stage and tumor distance, we performed another pooled analysis. Compared to APR, the ISR group had equal 5y-DFS (HR: 0.76, 95% CI: 0.45-1.30; P =0.31) and 5y-LRFS (local recurrence-free survival) (HR: 0.72, 95% CI: 0.29-1.78; P =0.48). Meanwhile, ISR had equivalent local control as well as perioperative outcomes while significantly reducing the operative time (mean difference: -24.89, 95% CI: -45.21 to -4.57; P =0.02) compared to APR.

CONCLUSIONS

Our results show that the long-term survival and safety of patients is not affected by ISR surgery, although this result needs to be carefully considered and requires further study due to the risk of bias and limited data.

Transperineal Repair of Secondary Perineal Hernia Using a Mesh with a Memory-recoil Ring

Objectives

The aim of this study was to evaluate the effectiveness of transperineal repair of secondary perineal hernia (SPH) using a mesh with a memory-recoil ring.

Methods

Seven patients with SPH who underwent transperineal repair (TPR) between July 2010 and May 2022 were retrospectively analyzed. TPR was performed using a mesh with a memory-recoil ring.

Results

All SPHs developed after abdominoperineal resections in patients with anorectal malignancies. The median longitudinal and transverse diameters of the hernia orifice were 8 (7-10) cm and 6 (5-7) cm, respectively. In all cases, the mesh was fixed to the ischial tuberosity, residual levator muscle, coccygeus muscle, and coccyx after thorough dissection of the sac. The median operation time was 154 (142-280) min. Perioperative complications occurred in 2 cases (29%). One was enterotomy, which caused postoperative mesh infection requiring extraction of the mesh. The other was vaginal injury, which resulted in vaginal fistula but closed spontaneously. The median postoperative length of stay was 9 (5-14) days. No recurrence was observed during a median follow-up of 35 (9-151) months.

Conclusions

TPR using a mesh with a memory-recoil ring is safe, feasible and promising technique for SPH repairs.

Perineal Hernia Mesh Repair Using Only the Perineal Approach: How We Do It

Perineal hernia is a rare complication of rectal surgery. Different types of surgical approach have been described, but none of them have proven their superiority. Although there are many methods of closing the defect, we selected two cases to present from a series of five cases, in which the perineal hernia was successfully resolved surgically using only the perineal approach. The reconstruction of the perineal floor and closure of the defect were performed using a synthetic polypropylene mesh. The significance of this Technical Note article lies in the fact that we describe, step by step, a surgical technique for perineal hernia using just a perineal approach.

Laparoscopic repair of an anterior perineal hernia: a video presentation

BACKGROUND

The perineal hernia is a condition that occurs as a result of a defect in the pelvic diaphragm. It is classified as anterior or posterior, and as either a primary or secondary hernia. The best management of this condition remains controversial.

OBJECTIVES

To demonstrate the surgical steps of a laparoscopic repair with mesh of a perineal hernia.

MATERIALS AND METHODS

A video presentation showing the laparoscopic repair of a recurrent perineal hernia.

MAIN OUTCOME MEASURES

A 46-year-old woman with a prior history of a primary perineal hernia repair had complaints of a symptomatic vulvar bulge. Pelvic magnetic resonance imaging showed a 5 cm hernia sac at the right anterior pelvic wall containing adipose tissue. A laparoscopic perineal hernia repair was performed by dissection of the space of Retzius, reduction of the hernial sac, closure of the defect and mesh fixation.

RESULTS

The laparoscopic repair with mesh of a recurrent perineal hernia is demonstrated.

CONCLUSION

We showed that the laparoscopic approach can be an effective and reproducible treatment for perineal hernia.

LEARNING OBJECTIVE

Understanding of the surgical steps involved in the laparoscopic repair with mesh of a recurrent perineal hernia.

Robotic repair of perineal hernias: a video vignette and review of the literature

BACKGROUND

Perineal hernias can be secondarily acquired following abdominoperineal resection of the rectum. While transabdominal minimally invasive techniques have traditionally used laparoscopy, there are few studies published on the robotic platform, which has been gaining popularity for other types of hernia repairs. We review the existing literature, share a video vignette, and provide practical tips for surgeons interested in adopting this approach.

METHODS

A literature search in Pubmed was performed to include all articles in English describing robotic repair of perineal hernias with identification of variables of interest related to repair. A case presentation with an accompanying video vignette and lessons learned from the experience are provided.

RESULTS

Seven case reports (four containing video) published between 2019 and 2022 were included. Most articles (n = 5) utilized the Da Vinci Si or Xi, and most patients (n = 5) had undergone abdominoperineal resection with neoadjuvant chemotherapy to treat rectal cancer. Patients were positioned in Trendelenburg with rightward tilt (n = 2), modified lithotomy (n = 1), or a combination of the two (n = 1). All articles (n = 7) reported closing the defect and using mesh. Three articles describe placing five ports (one camera, three robotic, one assistant). There were no significant intraoperative or postoperative complications reported, and no recurrence noted at 3-27 months follow-up. Based on our experience, as shown in the video vignette, we recommend lithotomy positioning, using porous polypropylene mesh anchored to the periosteum of the sacrum and peritoneum overlying the bladder and side wall, and placing a drain above the mesh.

CONCLUSIONS

A robotic transabdominal approach to perineal hernia repair is a viable alternate to laparoscopy based on low complication rates and lack of recurrence. Prospective and longer duration data are needed to compare the techniques.

Techniques of perineal hernia repair: A systematic review and meta-analysis

BACKGROUND

Perineal hernias are rare, underreported and poorly studied complications of extensive pelvic surgeries. Their management is challenging, with currently no treatment algorithm available.

METHOD

MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were searched. Studies comprising at least 3 patients who underwent surgical perineal hernia repair were included. The primary outcome was perineal hernia recurrence. The secondary outcomes were overall complications and surgical site occurrences.

RESULTS

Twenty-nine studies were included, comprising 325 patients undergoing 347 repairs. Overall complications were 33% (95% confidence interval 24%-43%) in the entire cohort, 31% (19%-44%) after perineal repair, 39% (14%-67%) after abdominal repair, and 36% (19%-53%) after mesh repair (20% with biological, 46% with synthetic mesh). The surgical site occurrence rate was 18% (8%-29%). The overall recurrence rate was 22% (15%-29%). Recurrence after perineal repair was 19% (10%-29%): 20% with mesh (25% with biological, 19% with synthetic), 24% with primary repair, and 39% with flap repair. Recurrence after an abdominal repair was 18% (11%-26%): 16% with laparoscopic, 12% with open, 16% with mesh (24% with biological, 16% with synthetic), 30% with primary, and 25% with flap repair. No significant differences could be found in the meta-analysis regarding overall complications and recurrence.

CONCLUSION

Synthetic mesh repair seems to be associated with a lower recurrence rate than other techniques, especially after an abdominal approach. The perineal and abdominal approaches appear to be safe, with similar recurrence rates. The combined approach seems promising, but more evidence is needed.

Mesh, flap or combined repair of perineal hernia after abdominoperineal resection - A systematic review and meta-analysis

AIM

The aim of this systematic review was to analyse recurrence rates after different surgical techniques for perineal hernia repair.

METHOD

All original studies (n ≥ 2 patients) reporting recurrence rates after perineal hernia repair after abdominoperineal resection (APR) were included. The electronic database PubMed was last searched in December 2021. The primary outcome was recurrent perineal hernia. A weighted average of the logit proportions was determined by the use of the generic inverse variance method and random effects model.

RESULTS

A total of 19 studies involving 172 patients were included. The mean age of patients was 64 ± 5.6 years and the indication for APR was predominantly cancer (99%, 170/172). The pooled percentage of recurrent perineal hernia was 39% (95% CI: 27%-52%) after biological mesh closure, 29% (95% CI: 21%-39%) after synthetic mesh closure, 37% (95% CI: 14%-67%) after tissue flap reconstruction only and 9% (95% CI: 1%-45%) after tissue flap reconstruction combined with mesh.

CONCLUSION

Recurrence rates after mesh repair of perineal hernia are high, without a clear difference between biological and synthetic meshes. The addition of a tissue flap to mesh repair seemed to have a favourable outcome, which warrants further investigation.

Transanal total mesorectal excision port-assisted perineal hernia repair: A case report

Perineal hernia after abdominoperineal resection (APR) is a troublesome problem, and severe cases require surgical treatment. However, perineal hernia repair is challenging, especially when combined with intestinal adhesions. The difficulty of the operation lies in performing adhesiolysis and mesh placement under poor visibility. While there are traditional, laparoscopic and even robotic methods of performing this procedure, no easy and minimally-invasive approach has been reported. Here, we report the case of a patient with perineal hernia, who underwent transanal total mesorectal excision (TaTME) port-assisted laparoscopic perineal hernia repair. The operation was successful, the postoperative recovery was uneventful, the patient’s symptoms improved significantly, and no recurrence was found during the 4-month follow-up. The availability and safety of TaTME port-assisted perineal hernia repair provide a promising approach for hernia repair. Compared with traditional perineal or laparoscopic abdominal approaches, this procedure is less invasive and results in a better field of vision.

Management of Perineal Wounds Following Pelvic Surgery

Despite advancements in understanding and technique, there remain significant challenges in the management of a complex perineal wound following pelvic surgery. Complications including wound sepsis, fistulation, persistent sinus, and herniation produce additional morbidity and health care costs. This article details the methods of optimizing patient and operative factors to mitigate this risk, alongside strategies to deal with sequelae of wound failure.

Surgical Repair of Postoperative Perineal Hernia: A Case for the Perineal Approach

BACKGROUND

Perineal hernia is a well-known, rare complication following abdominoperineal resection for rectal cancer. Due to its rarity, the literature on its surgical repair is comprised of case reports and small case series, and not one surgical approach has been established as superior.

OBJECTIVE

This study aimed to identify the repair methods used at our institution and their outcomes. We hypothesized that a perineal approach would have a similar recurrence rate to a transabdominal repair with shorter hospital length of stay.

DESIGN

This study was a retrospective case series.

SETTINGS

This study was conducted in a large, single institution setting.

PATIENTS

Patients who underwent surgical repair for perineal hernia from January 2009 to December 2019 were included.

MAIN OUTCOME MEASURES

The primary outcomes were perineal hernia recurrence, surgical approach to repair, and length of stay.

RESULTS

We identified 36 patients who underwent surgical repair of perineal hernia at our institution. Twenty patients received neoadjuvant chemoradiation therapy. Most patients (29) had previously undergone abdominoperineal resection; 5 were robotic, 15 were laparoscopic, 1 was robotic converted to open, and 8 were open. Patients were repaired through a perineal approach (22) or transabdominally (14). The median length of stay was 4 days (1-12) after a perineal approach and 8 days (3-18) after a transabdominal approach. At a median follow-up of 12.7 months (1-72), there were 4 recurrences after perineal repair and 3 recurrences after transabdominal repair.

LIMITATIONS

This study was limited by its small sample size (36), the retrospective and nonrandomized nature of the case series, and a lack of routine postoperative imaging. A median follow-up length of 12.7 months may not be adequate to detect all recurrences.

CONCLUSIONS

This case series supports the perineal approach for surgical repair; it should be the first approach considered, as it is less invasive and may be associated with shorter length of stay compared to an open transabdominal approach. Male gender and neoadjuvant chemotherapy may be possible risk factors for the development of perineal hernia after abdominoperineal resection. See Video Abstract at http://links.lww.com/DCR/B856.

REPARACIN QUIRRGICA DE HERNIA PERINEAL POSOPERATORIA UN CASO PARA EL ABORDAJE PERINEAL

ANTECEDENTES:La hernia perineal es una complicación rara y bien conocida después de la resección abdominoperineal por cáncer de recto. Debido a su rareza, la literatura sobre su reparación quirúrgica se compone de informes de casos y pequeñas series de casos, y ningún abordaje quirúrgico se ha establecido como superior.OBJETIVO:El presente estudio tuvo como objetivo identificar los métodos de reparación utilizados en nuestra institución y sus resultados. Presumimos que un abordaje perineal tendría una tasa de recurrencia similar a una reparación transabdominal, con una estancia hospitalaria más corta.DISEÑO:Ésta es una serie de casos retrospectiva.AJUSTES:El escenario fue una gran institución única.PACIENTES:Los pacientes que se sometieron a reparación quirúrgica por hernia perineal desde enero del 2009 hasta diciembre del 2019 se incluyeron en la revisión.PRINCIPALES MEDIDAS DE RESULTADO:Los resultados primarios fueron la recurrencia de la hernia perineal, el abordaje quirúrgico para la reparación y la duración de la estadía.RESULTADOS:Identificamos 36 pacientes que fueron sometidos a reparación quirúrgica de hernia perineal en nuestra institución. La mayoría de los pacientes recibieron quimiorradioterapia neoadyuvante (n = 20). La mayoría de los pacientes (n = 29) se habrían sometido previamente a una resección abdominoperineal (n = 5 robótica, n = 15 laparoscópica, n = 1 robótica convertida a abierta, n = 8 abierta). Los pacientes fueron reparados mediante un abordaje perineal (n = 22) o transabdominal (n = 14). La mediana de la estancia hospitalaria fue de 4 días (rango, 1-12) después de un abordaje perineal y de 8 días (rango 3-18) después de un abordaje transabdominal. En una mediana de seguimiento de 12,7 meses (rango, 1-72) hubo 4 recurrencias después de la reparación perineal y 3 recurrencias después de la transabdominal.LIMITACIONES:El tamaño de la muestra pequeño (n = 36), la naturaleza retrospectiva y no aleatorizada de la serie de casos, la falta de imágenes posoperatorias de rutina, la mediana de seguimiento de 12,7 meses puede no ser adecuada para detectar todas las recurrencias.CONCLUSIONES:Esta serie de casos apoya el abordaje perineal para la reparación quirúrgica; debe ser el primer abordaje considerado, ya que es menos invasivo y puede estar asociado con una estadía más corta en comparación con el abordaje transabdominal abierto. El sexo masculino y la quimioterapia neoadyuvante podrían ser posibles factores de riesgo para el desarrollo de hernia perineal después de la resección abdominoperineal. Consulte Video Resumen en http://links.lww.com/DCR/B856. (Traducción- Dr. Francisco M. Abarca-Rendon).

Perineal wound healing after abdominoperineal resection for rectal cancer: a retrospective cohort study

PURPOSE

Delayed perineal wound healing is a common complication after abdominoperineal resection (APR) in rectal cancer. The primary aim of this study was to evaluate the number of patients with delayed wound healing after APR. Secondary aims were to identify risk factors, and describe treatment.

METHODS

Prospectively collected data from the Swedish Colorectal Cancer Registry (SCRCR) was used for retrospective analysis of APR performed at Skåne University Hospital Malmö between 2013 and 2018. Medical charts were retrospectively reviewed. Delayed healing was defined as non-healed perineal wound 30 days postoperatively. Patients undergoing extralevator APR requiring reconstruction were excluded. Statistical analysis was made using SPSS. Risk factors for impaired wound healing were analyzed using a multivariable model.

RESULTS

A total of 162 patients were included, of which 114 underwent standard APR (sAPR) and 48 patients intersphincteric APR (isAPR). In the total population, 69% (111/162) were male, with median age 71 (26-87). The overall healing rate was 52% (85/162); 44% (50/114) in sAPR vs 73% (35/48) in isAPR (P < 0.001). Risk factors for impaired healing after multivariable analysis were BMI > 30 (OR 7.0; CI 95% 1.8-26.2, P = 0.004), reoperation (OR 7.9; CI 95% 1.6-39.8, P = 0.013), neoadjuvant radiotherapy (OR 5.2; CI 95% 1.02-25.1, P = 0.047) and sAPR (OR 2.598; CI 95% 1.05-6.41, P = 0.038). Eight percent (13/162) required an intervention (Clavien-Dindo ≥ 3).

CONCLUSION

Delayed perineal wound healing is a frequent complication after APR but the majority could be treated conservatively. Several risk factors were identified. Further studies aiming at interventions reducing delayed perineal wound healing after APR are warranted.

Perineal hernia after abdominoperineal resection – a systematic review

<b>Introduction:</b> Perineal hernia (PH), also termed pelvic floor hernia, is a protrusion of intraabdominal viscera into the perineum through a defect in the pelvic floor. </br></br> <b>Aim:</b> The study was conducted to evaluate the cases of perineal hernia resulting as a complication of abdominoperineal resection (APR) of rectal cancer. </br></br> <b> Material and methods:</b> 30 cases from 24 articles published in reputable peer reviewed journals were evaluated for eight variables including [I] patient age, [II] gender, [III] time since APR, [IV] clinical presentation, [V] approach to repair, [VI] type of repair, [VII] presence/absence of pelvic adhesions [VIII] complications. </br></br> <b>Results:</b> There was a total of 30 cases (18 males and 12 females) with a mean age of 71.5 years. The time of onset of symptoms ranged from 6 days to 12 years. Perineal lump with pain was the chief presenting feature followed by intestinal obstruction. Different approaches were adopted to repair by various methods. </br></br> <b>Conclusions:</b> Perineal hernia as a complication of abdominoperineal resection is reported increasingly nowadays, as the approach to management of rectal cancer has gradually got shifted from open to minimally invasive in recent years. There is a need to spread awareness about this condition, so that it is actively looked for, during the postoperative follow-up. Management is surgical repair; the approach and type of repair should be individualized.

Repair of a perineal hernia with a bladder patch after abdominoperineal resection: A case report and literature review

Perineal hernia is the protrusion of the intra-abdominal viscera through the pelvic floor. It rarely occurs after abdominoperineal resection but has increasingly occurred after surgical treatment for rectal cancer. A patient was diagnosed as having perineal hernia 10 days after laparoscopic abdominoperineal resection with preoperative radiotherapy and chemotherapy. He presented with epigastric discomfort and perineal wound dehiscence. Perineal hernia was confirmed by computed tomography scan and treated with a semi-emergency surgery. The surgical field was contaminated because of the perineal wound dehiscence. The levator muscle at the pelvic floor was not sufficient, so we used a bladder patch to cover the pelvic inlet. The surgery was performed without any adverse events. To our best knowledge, this is the first case report to present the usefulness of a bladder patch for the treatment of a perineal hernia using a laparoscopic transabdominal approach in emergency situations.

Diagnosis and Management of Perineal Hernias

A 72-year-old male patient presented to our outpatient clinic complaining with a perineal bulge one year after abdominoperineal excision for rectal cancer. He described a progressively enlarging bulge in the perineum causing a dull pain that was worse when sitting. On examination, the skin was intact, and a soft 7-cm hernia was identified that could be reduced into the pelvis but recurred immediately. Treatment options were discussed.

A case of successful laparoscopic intraperitoneal onlay mesh plus technique repair for perineal hernia after laparoscopic abdominoperineal resection

The frequency of secondary perineal hernia after abdominoperineal resection has been reported as 0.83%-26%. The optimal surgery for secondary perineal hernia and surgical indication remains controversial. An 87-year-old woman diagnosed with lower rectal cancer underwent laparoscopic abdominoperineal resection. Follow-up computed tomography at 6 months postoperatively revealed secondary perineal hernia. She reported no discomfort and no incarceration was apparent, but she complained of perineal discomfort 3 months later. Laparoscopic repair surgery was performed using an intraperitoneal onlay mesh plus technique with VENTRALIGHT® ST mesh (Medicon, Osaka, Japan), a non-absorbable mesh with a biodegradable coating. No recurrence of peritoneal hernia was seen as of 3 months postoperatively. A time lag can exist between imaging findings and symptom appearance. This laparoscopic intraperitoneal onlay mesh plus technique might become the optimal treatment for perineal hernia.

Short-term outcomes following beyond total mesorectal excision and reconstruction using myocutaneous flaps: A retrospective cohort study

INTRODUCTION

Beyond total mesorectal excision (bTME) offers long-term survival in patients with advanced pelvic malignancy. At Skåne University Hospital (SUS) Malmö in Sweden, the vertical rectus abdominis musculocutaneous (VRAM) and gluteal maximus (GM) flap have been used for perineal reconstruction to promote healing and functional outcomes after significant tissue loss. This study aims to examine 90-day overall and flap-specific complications in patients with advanced pelvic cancer treated with bTME and perineal flap reconstruction.

METHOD

This retrospective study conducted at SUS included patients undergoing surgery between January 01, 2010 and August 01, 2016. Patients' data were gathered through medical chart reviews. The Clavien-Dindo (CD) classification system was used to classify surgical and medical postoperative complications. Flap-specific complications were evaluated regardless of CD classification.

RESULTS

One hundred five patients (51 men, 54 women) underwent bTME surgery with perineal reconstruction, with VRAM flaps used in 27 (26%) patients, GM flaps in 51 (49%) patients and GM flaps with vaginal reconstruction in 27 (26%) patients. The 90-day mortality rate was one (1%), despite surgical CD ≥ III and/or medical CD ≥ II complications affecting 51 (48%) patients. Partial perineal dehiscence was noted in 45 (43%) patients, mostly treated conservatively. At the first outpatient postoperative visit (median, 42 days), flap healing was complete in 47 (45%) patients.

CONCLUSION

bTME surgery in pelvic cancer patients with perineal flap reconstruction using VRAM or GM flaps results in high overall and flap complication rates, but low mortality. Most complications can be conservatively treated.

Laparoscopic perineal hernia repair following pelvic exenteration: a case report

Background

Acquired perineal hernia is a rare complication following extensive pelvic surgery. Radiotherapy is also a predisposing factor. Perineal hernia can cause chronic perineal pain, bowel obstruction, urinary disorders and a cosmetically disfiguring defect. The treatment of perineal hernia is surgical, usually consisting of mesh repair via an abdominal or perineal approach.

Case presentation

We present a case report and a surgical video of a 42-year-old woman with history of a squamous cell carcinoma. This patient had 3 recurrences since the diagnosis and a symptomatic perineal hernia. Complete regression of the recurrent malignancy allowed us to treat the perineal hernia. We performed laparoscopic repair with prosthetic mesh in this patient who had undergone multiple surgeries and radiotherapy, while preserving the omental flap that was used to reconstruct the posterior part of the vagina.

Conclusion

There is no consensus concerning the preferred surgical approach, perineal or laparoscopic, as no study has demonstrated the superiority of either of these approaches. Laparoscopic repair for an acquired perineal hernia is safe and feasible. However, further studies including randomized trials are required to precisely evaluate the best surgical approach and type of mesh.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01237-9.

Flap Reconstruction of Perineal Defects after Pelvic Exenteration: A Systematic Description of Four Choices of Surgical Reconstruction Methods

BACKGROUND

The treatment of locally advanced or recurrent anorectal cancer requires radical surgery such as extralevator abdominoperineal resection and pelvic exenteration. Larger defects require flap reconstruction. The authors evaluated outcomes of different perineal reconstruction techniques.

METHODS

A systematic search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting outcomes on perineal flap reconstruction in patients with anal or colorectal cancer were included. Data on patient characteristics, surgical details, perineal and donor-site complications, revision surgery, mortality, and quality of life were extracted. Articles were assessed using the Group Reading Assessment and Diagnostic Evaluation approach.

RESULTS

The authors included 58 mainly observational studies comprising 1988 patients. Seventy-three percent of patients had rectal cancer. The majority of 910 abdominoperineal resection patients underwent reconstruction with rectus abdominis flaps (91 percent). Dehiscence (15 to 32 percent) and wound infection (8 to 16 percent) were the most common complications. Partial flap necrosis occurred in 2 to 4 percent and flap loss occurred in 0 to 2 percent. Perineal herniation was seen in 6 percent after gluteal flap reconstruction and in 0 to 1 percent after other types of reconstruction. Donor-site complications were substantial but were reported inconsistently.

CONCLUSIONS

Clinical outcome data on perineal reconstruction after exenterative surgery are mostly of very low quality. Perineal reconstruction after pelvic exenteration is complex and requires a patient-tailored approach. Primary defect size, reconstruction aims, donor-site availability, and long-term morbidity should be taken into account. This review describes the clinical outcomes of four flap reconstruction techniques. Shared clinical decision-making on perineal reconstruction should be based on these present comprehensive data.

Comparison of perineal morbidity between biologic mesh reconstruction and primary closure following extralevator abdominoperineal excision: a systematic review and meta-analysis

AIM

Extralevator abdominoperineal excision (ELAPE) for rectal cancer leaves a greater perineal defect which might result in significant perineal morbidity, and how to effectively close perineal defects remains a challenge for surgeons. This study aimed to comparatively evaluate the perineal-related complications of biologic mesh reconstruction and primary closure following ELAPE.

METHOD

The electronic databases PubMed, EMBASE, Cochrane Library, and Web of Science were searched to screen out all eligible studies, which compared biologic mesh reconstruction with primary closure for perineal-related complications following ELAPE. Pooled data of perineal-related complications including overall wound complications, hernia, infection, dehiscence, chronic sinus, and chronic pain (12 months after surgery) were analyzed.

RESULTS

A total of four studies (one randomized controlled trial and three cohort studies) involving 544 patients (346 biologic mesh vs 198 primary closure) were included. With a median follow-up of 18.5 months (range, 2-71.5 months). Analysis of the pooled data indicated that the perineal hernia rate was significantly lower in biologic mesh reconstruction as compared to primary closure (OR, 0.38; 95% CI, 0.22-0.69; P = 0.001). There were no statistically significant differences between the two groups in terms of total perineal wound complications rate (P = 0.70), as well as rates of perineal wound infection (P = 0.97), wound dehiscence (P = 0.43), chronic sinus (P = 0.28), and chronic pain (12 months after surgery; P = 0.75).

CONCLUSION

Biologic mesh reconstruction after extralevator abdominoperineal excision appears to have a lower hernia rate, with no differences in perineal wound complications.

Extra-Levator AbdominoPerineal excision (eLAPE): a complicated postoperative perineal hernia

A 75-year-old woman presented with perineal wound dehiscence and small bowel prolapse of a perineal hernia, 6 years after extra-Levator AbdominoPerineal Excision (eLAPE) procedure for rectal cancer. She underwent emergency wound refashioning and perineal hernia repair with Parmacol mesh. Her postoperative recovery was complicated by long-standing ileus, wound infection, and she was discharged to community palliative care services. In this case report, we raise awareness of postoperative eLAPE complications and describe an unfortunate case where a postoperative perineal hernia was not repaired in a patient with multiple comorbidities.

Closed loop obstruction and adhesive intestinal obstruction in perineal hernia

Perineal hernia with bowel gangrene is uncommon but known complication of laparoscopic extralevator abdominoperineal excision (ELAPE). We present a rare case of closed loop small bowel obstruction with bowel gangrene secondary to an incarcerated perineal hernia that developed 7 years after an ELAPE. Intraoperatively, we found a definitive transition point due to adhesions in pelvis and a closed loop obstruction of the distal small bowel at different site with gangrenous intestine. She was managed successfully surgically with adhesiolysis and fixation of defect with biological mesh. Prevalence of perineal hernias will rise in future because of the increasing cases of ELAPE, in which no repair of pelvic floor is performed. The need of follow-up of these operations and more reporting of such cases are important in increasing awareness of these complications. Patients should be made aware of such complications and should seek urgent medical care.

RECURRENT PERINEAL HERNIA — LAPAROSCOPIC SURGICAL TREATMENT: CLINICAL CASE

Background: Recurrent postoperative perineal hernia is a rare complication of such operation as posterior pelvic evisceration. This condition can reduce the quality of life in the postoperative period and requires surgical restoration of the impaired pelvic anatomy.Clinical case: A 54-year old female patient applied to the MSU University clinic in July 2020 with the protrusion in the perineal area. She was diagnosed with recurrent perineal postoperative hernia. She was diagnosed with rectal cancer T4N1M0 and uterine dysplasia in 2017, 6 courses of neoadjuvant polychemoradiation therapy were performed; she underwent extralevator abdominal-perineal resection with uterine extirpation and the permanent colostomy formation in 2018. A perineal postoperative hernia was diagnosed in March 2020, perineal transabdominal plastic surgery was performed with a mesh implant. A recurrent perineal hernia was diagnosed in April 2020, the patient underwent laparoscopic alloplasty with a composite mesh implant. On the 9th postoperative day, she was discharged in a satisfactory condition without any complaints.Conclusion: Postoperative perineal hernia is a fairly rare complication in surgical practice. The recurrent rate is quite high. The insufficient number of patients, the short follow-up period and the wide range of surgical treatment methods do not allow evaluating the results adequately. It is necessary to conduct large randomized clinical trials to assess the efficacy of surgical interventions and to determine the indications for certain procedures.

Mine disaster survivor’s pelvic floor hernia treated with laparoscopic surgery and a perineal approach: A case report

BACKGROUND

A pelvic floor hernia is defined as a pelvic floor defect through which the intraabdominal viscera may protrude. It is an infrequent complication following abdominoperineal surgeries. This type of hernia requires surgical repair by conventional or reconstructive techniques. The main treatments could be transabdominal, transperineal or a combination.

CASE SUMMARY

In this article, we present the case of a recurrent perineal incisional hernia, postresection of the left side of the pelvis, testis and lower limbs resulting from a mine disaster 18 years ago. Combined laparoscopic surgery with a perineal approach was performed. The pelvic floor defect was repaired by a biological mesh and one pedicle skin flap. No signs of recurrence were indicated during the 2 years of follow-up.

CONCLUSION

The combination of laparoscopic surgery with a perineal approach was effective. The use of the biological mesh and pedicle skin flap to restructure the pelvic floor was effective.

Imaging Postoperative Abdominal Hernias: A Review with a Clinical Perspective

Postoperative internal hernia is a challenging but critical diagnosis in postoperative patients presenting with acute abdomen. Postoperative internal hernias are increasingly being recognized after Roux-en-Y gastric bypass (RYGB) and bariatric surgeries. These internal hernias have a high risk of closed-loop obstruction and bowel ischemia; therefore, prompt recognition is necessary. Computed tomography (CT) is the imaging modality of choice in cases of postoperative acute abdomen. Understanding the types of postoperative internal hernia and their common imaging features on CT is crucial for the abdominal radiologist. Postoperative external hernias are usually a result of defect or weakness of the abdominal wall created because of the surgery. CT helps in the detection, delineation, diagnosis of complications, and surgical planning of an external hernia. In this article, the anatomy, pathophysiology, and CT features of common postoperative hernias are discussed. Afterreading this review, the readers should be able to (1) enumerate the common postoperative internal and external abdominal hernias, (2) explain the pathophysiology and surgical anatomy of Roux-en-Y gastric bypass-related hernia, (3) identify the common imaging features of postoperative hernia, and (4) diagnose the complications of postoperative hernias.

Quality of Life, Sexual Functioning, and Physical Functioning Following Perineal Reconstruction with the Lotus Petal Flap

BACKGROUND

Lotus petal flaps (LPF) may be used for the reconstruction of extralevator abdominoperineal defects that cannot be closed primarily. Limited data are available on how perineal reconstruction with the LPF impacts on patients' quality of life (QoL), sexual functioning, and physical functioning.

METHODS

A cross-sectional study was performed following perineal reconstruction with the LPF. The QoL of patients having undergone LPF reconstruction was compared with a control group in which perineal defects were closed without flaps. Sexual and physical functioning (presence of perineal herniation and range of motion [ROM] of the hip joints) could only be evaluated in the LPF group. Psychometrically sound questionnaires were used. Physical functioning was evaluated subjectively with binary questions and objectively by physical examination.

RESULTS

Of the 23 patients asked to participate, 15 (65%) completed the questionnaires and 11 (47%) underwent physical examination. In the control group, 16 patients were included. There were no significant differences in QoL between the LPF and control groups. Within the LPF group, 33% of patients were sexually active postoperatively compared with 87% preoperatively. No perineal herniation was found. The ROM of the hip joints was bilaterally smaller compared with the generally accepted values.

CONCLUSIONS

Conclusions should be made with care given the small sample size. Despite a supposedly larger resection area in the LPF group, QoL was comparable in both groups. Nonetheless, reconstruction seemed to affect sexual function and physical function, not hampering overall satisfaction.

Biological mesh used to repair perineal hernias following abdominoperineal resection for anorectal cancer

PURPOSE

This study aimed to determine the outcome for patients who had undergone perineal hernia repair, via a perineal approach, using a biological mesh post-abdominoperineal excision (APE) for anorectal cancer.

METHOD

All consecutive patients having undergone perineal hernia repair involving an extracellular matrix of porcine small intestinal submucosa at our hospital between 2015 and 2018 were included. Follow-up clinical examinations and computed tomography scans were performed.

RESULTS

Six patients were treated surgically for symptomatic perineal hernia after a median of 31 months from APE. The median follow-up after hernia repair was 11 months (interquartile range [IQR], 6-35 months). Three patients (50%) developed a recurrent perineal hernia after a median interval of 6 months.

CONCLUSION

Perineal hernia repair using a biological mesh resulted in a high recurrence rate in patients who had undergone APE for anorectal cancer.

Further insights into the treatment of perineal hernia based on a the experience of a single tertiary centre

AIM

There is little evidence concerning the optimal surgical technique for the repair of perineal hernia. This study aimed to report on the evolution of a technique for repair of perineal hernia by analysing the experience in a tertiary referral centre.

METHOD

This was a retrospective review of consecutive patients who underwent perineal hernia repair after abdominoperineal excision in a tertiary referral centre. The main study end-points were rate of recurrent perineal hernia, perineal wound complications and related re-intervention.

RESULTS

Thirty-four patients were included: in 18 patients a biological mesh was used followed by 16 patients who underwent synthetic mesh repair. Postoperative perineal wound infection occurred in two patients (11%) after biological mesh repair compared with four (25%) after synthetic mesh repair (P = 0.387). None of the meshes were explanted. Recurrent perineal hernia following biological mesh was found in 7 of 18 patients (39%) after a median of 33 months. The recurrence rate with a synthetic mesh was 5 of 16 patients (31%) after a median of 17 months (P = 0.642). Re-repair was performed in four (22%) and two patients (13%), respectively (P = 0.660). Eight patients required a transposition flap reconstruction to close the perineum over the mesh, and no recurrent hernias were observed in this subgroup (P = 0.030). No mesh-related small bowel complications occurred.

CONCLUSION

Recurrence rates after perineal hernia repair following abdominoperineal excision were high, and did not seem to be related to the type of mesh. If a transposition flap was added to the mesh repair no recurrences were observed, but this finding needs confirmation in larger studies.

A new method of robot-assisted laparoscopic repair of perineal hernia after abdominoperineal resection: a case report

INTRODUCTION

Perineal hernia is a protrusion of the pelvic floor which contains intra-abdominal viscera. The occurrence of perineal hernia after abdominoperineal resection (APR) is rare, but it has been reported in recent years that the incidence of perineal hernia after rectal cancer surgery has increased. This has been attributed to a shift towards extralevator abdominoperineal resection, together with more frequent and long-term use of neoadjuvant therapy.

PRESENTATION OF CASE

Here, we report a patient with perineal hernia 5 years after APR surgery for rectal cancer. We decided to perform robot-assisted laparoscopic surgery on this patient using the da Vinci Surgical System. The perineal hernia was repaired by primary closure with the placement of a non-absorbable synthetic mesh as reinforcement for the pelvic floor. No complications occurred during the operation, and the patient was discharged on the third day after the operation. Clinical follow-up proceeded at the designated time intervals without difficulties.

DISCUSSION

The recurrence rates of perineal hernia are still very high, and due to poor view, suturing, and mesh placement in the deep pelvis, surgeons face many challenges. Many methods have been described, but there is still no consensus as to the optimal repair technique for perineal hernia.

CONCLUSION

Perineal hernias can be repaired with robot-assisted laparoscopy. Furthermore, compared with the open and laparoscopic methods, suturing and mesh placement are easier with the robot approach.

Pelvic peritoneum closure reduces postoperative complications of laparoscopic abdominoperineal resection: 6-year experience in single center

BACKGROUND

To investigate feasibility of laparoscopic abdominoperineal resection with pelvic peritoneum closure (LAPR-PPC) for lower rectal cancer.

METHODS

LAPR-PPC has been used for lower rectal cancer in our institution since 2014. In this study, we retrospectively analyzed the data from 86 patients who underwent LAPR-PPC and compared with the data from 96 patients who underwent laparoscopic APR without PPC (LAPR) from January 2013 to December 2018.

RESULTS

The rate of perineal surgical site infection (SSI) (18.75% (18/96) vs. 5.81% (5/86), p < 0.01), delayed (> 4 weeks) perineal healing (12.50% (12/96) vs. 3.49% (3/86), p = 0.027), ileus (7.29% (7/96) vs 1.16% (1/86), p = 0.044), and postoperative perineal hernia (PPH, 5.21% (5/96) vs. 0% (0/86), p = 0.032) were significantly lower in LAPR-PPC group than LAPR group. The patients in LAPR-PPC group had shorter hospitalization time (21.32 ± 11.95 days vs. 13.93 ± 11.51 days, p < 0.01).

CONCLUSIONS

PPC procedure enabled the reduction in perineal wound complications, ileus, PPH, and consequently shortened hospitalization time. LAPR-PPC is beneficial for the patients with lower rectal cancer.

Long-term outcomes of biological mesh repair following extra levator abdominoperineal excision of the rectum: an observational study of 100 patients

Background

Current evidence suggests that pelvic floor reconstruction following extralevator abdominoperineal excision of rectum (ELAPER) may reduce the risk of perineal herniation of intra-abdominal contents. Options for reconstruction include mesh and myocutaneous flaps, for which long-term follow-up data is lacking. The aim of this study was to evaluate the long-term outcomes of biological mesh (Surgisis^®, Biodesign™) reconstruction following ELAPER.

Methods

A retrospective review of all patients having ELAPER in a single institution between 2008 and 2018 was perfomed. Clinic letters were scrutinised for wound complications and all available cross sectional imaging was reviewed to identify evidence of perineal herniation (defined as presence of intra-abdominal content below a line between the coccyx and the lower margin of the pubic symphysis on sagittal view).

Results

One hundred patients were identified (median age 66, IQR 59–72 years, 70% male). Median length of follow-up was 4.9 years (IQR 2.3–6.7 years). One, 2- and 5-year mortality rates were 3, 8 and 12%, respectively. Thirty three perineal wounds had not healed by 1 month, but no mesh was infected and no mesh needed to be removed. Only one patient developed a symptomatic perineal hernia requiring repair. On review of imaging a further 7 asymptomatic perineal hernias were detected. At 4 years the cumulative radiologically detected perineal hernia rate was 8%.

Conclusions

This study demonstrates that pelvic floor reconstruction using biological mesh following ELAPER is both safe and effective as a long-term solution, with low major complication rates. Symptomatic perineal herniation is rare following mesh reconstruction, but may develop sub clinically and be detectable on cross-sectional imaging.

A 25 year experience of perineal hernia repair

PURPOSE

Though perineal hernias remain rare, the incidence is reportedly rising. Secondary to the historical rarity, optimal method of repair and outcomes after repair remain poorly understood. Therefore, we reviewed the past 25 years of our institutional experience with perineal hernia repair.

METHODS

A retrospective review of an institution-maintained database was conducted from January 1, 1994 to January 31, 2018 for patients undergoing perineal hernia repair. Data were collected on patient characteristics, operative technique, and post-operative outcomes.

RESULTS

Twenty-one patients (n = 12 male) underwent perineal hernia repair in the study period with two-thirds of the operations occurring in the most recent 7 years (since January 1, 2011). The median time to repair was 13 months (range 2-127) after index operation. The approach was transabdominal in nine, perineal in nine, and combined in three. Mesh, a tissue flap, or a combination of these was used in 19 of the cases and 6 additional abdominal wall hernias were repaired concurrently. Post-operative complications consisted of superficial surgical-site infection (n = 2), infected seroma (n = 1), and a missed enterotomy (n = 1). Follow-up ranged from 0 to 112 months (median 2 months) and only one recurrence was noted.

CONCLUSION

Presentation for repair of perineal hernia has increased at our instituion over the past 2 decades. Outcomes did not differ between the three repair approaches and the choice of mesh or tissue-based repair. Surgeons should base these decisions on hernia complexity and local tissue conditions.

Robot-assisted laparoscopic repair of perineal hernia after abdominoperineal resection: A case report and review of the literature

INTRODUCTION

Perineal hernia is a protrusion of the pelvic floor containing intra-abdominal viscera. The occurrence of postoperative perineal hernia after abdominoperineal resection (APR) is rare, but reports have indicated a recent increase in occurrence following surgical treatment for rectal cancer. This has been attributed to a shift towards extralevator abdominoperineal resection, together with more frequent and long-term use of neoadjuvant therapy.

PRESENTATION OF CASE

Here, we report the case of a patient who underwent APR for cancer. Twenty months postoperative, a perineal hernia was detected. The patient was electively scheduled for surgery. Robot-assisted laparoscopy was performed using the da Vinci Surgical System. The perineal hernia was repaired by primary closure with the placement of Symbotex Composite mesh as reinforcement for the pelvic floor. The surgery was performed without any adverse events, and the patient was discharged the day after surgery. Clinical follow-up proceeded at the designated time intervals without difficulties.

DISCUSSION

Recurrence rates of perineal hernia remain high, and surgeons face numerous challenges related to poor view, suturing and mesh placement in the deep pelvis. Numerous approaches have been described, but there is still no consensus as to the optimal repair technique for perineal hernia.

CONCLUSION

Symptomatic perineal hernias can feasibly be repaired with robot-assisted laparoscopy. Furthermore, suturing and mesh placement require less effort with the robot approach when compared to the open and laparoscopic approaches. These promising findings are demonstrated in the included video.

Laparoscopic repair with cone-shaped mesh implantation for perineal hernia occurred after laparoscopic abdominoperineal resection

INTRODUCTION

Perineal hernia after abdominoperineal resection (APR) is a rare complication, and no standard surgical procedures are established. We describe a simple laparoscopic mesh implantation technique utilizing a large synthetic flat mesh.

PRESENTATION OF CASE

We report a case of perineal hernia after APR. We performed laparoscopic repair using a soft and large synthetic mesh with simple technique. The essence of this technique is that mesh is inserted into the abdominal cavity without trimming and it forms in a conical shape to better adjust to the pelvic cavity.

DISCUSSION

The perineal and laparoscopic approaches for perineal hernia repair have been performed most commonly in recent years, but the recurrence rate after repair remains high (24.1%). Using a large mesh could cover the hernial orifice with a sufficient margin, reducing a risk of recurrence caused by shrinkage and slippage of the mesh.

CONCLUSION

Our technique utilizing a large, lightweight, synthetic mesh can be practical and useful for perineal hernia repair after laparoscopic APR.

Which Therapeutic Option Is Optimal for Surgery-Related Perineal Hernia After Abdominoperineal Excision in Patients with Advanced Rectal Cancer? A Report of 3 Thought-Provoking Cases

Case series

Patient: Male, 72 • Male, 71 • Male, 76

Final Diagnosis: Postoperative perineal hernia

Symptoms: Perineal discomfort

Medication: —

Clinical Procedure: Hernia repair

Specialty: Surgery

Peripartum Perineal Hernia: A Case Report and a Review of the Literature

OBJECTIVES

This article reviews the literature for the management and repair of perineal hernias and presents a previously undescribed case of perineal bladder herniation after intrapartum pubic symphysis rupture.

METHODS

A review of the literature was completed through the PubMed database using the search terms "bladder," "canal of Nuck," "labial hernia," "gynecology," "hernia," "obstetrics," "perineal hernia," "postpartum," "pubic diastasis," "pubic symphysis," "vaginal delivery," "symphyseal rupture," and "symphyseal separation." The electronic medical record for the patient was reviewed and used with the consent of the patient.

RESULTS

There were no reports of peripartum perineal hernias in the English language literature on human subjects. Literature review with the previously mentioned search terms demonstrated that there is not a standardized approach to repair given the rarity of these defects. There are data to support the use of mesh as opposed to primary repair but no data to support abdominal versus perineal versus combined approach. We describe a successful repair of a complicated peripartum perineal hernia using a combined abdominal-perineal approach with mesh.

CONCLUSIONS

Obstetric trauma is a previously unreported cause of perineal hernias. Perineal hernias are rare conditions that must be considered in any patient who presents with a bulging perineal mass. Puerperal pubic symphysis rupture can lead to a large bladder hernia. Our combined abdominal-perineal approach of repair resulted in minimal perioperative morbidity and short-term resolution of the hernia.

Rare Enterorectal Pelvic Floor Hernia-A Cadaveric Study

We present a cadaveric case study of an 88-year-old woman with an unusual posterior perineal hernia containing small bowel, rectum, and mesentery. Dissection revealed several loops of the small bowel occupying the presacral space and displacement of the rectum into a large perineal evagination. The intestinal mucosa appeared to have been healthy at the time of death, and we did not find any indication of rectal prolapse. There was also no evidence of past surgery, suggestive of a primary hernia. We conclude this patient had a posterior enterorectal perineal hernia. Suggestions for surgical repair are described.