Purse string closure of perineal defects after abdominoperineal excision

PURPOSE

The aim of this study was to describe a new technique of perineal closure following abdominoperineal excision (APE) using purse-string perineal skin closure (PSPC).

MATERIAL AND METHODS

Between January 2016 and May 2021, 15 consecutives patients who had an APE procedure were included in this retrospective single-center study. All indications of APE were considered, as well as all types of APE. We analyzed the patient characteristics and peri-operative features, including overall (Clavien 1 to 5) and severe (Clavien 3 and 4) postoperative morbidity, length of stay (LOS), and long-term results (median time to perineal wound closure and rate of perineal incisional hernia).

RESULTS

The patients included 11 men and four women, with a mean age of 64 ± 13 [33-80] years. The indication of APE was an epidermoid carcinoma of the anal canal (n = 5) or an adenocarcinoma of the rectum (n = 10). The mean operating time was 220 ± 88.64 [70-360] min. The overall morbidity rate was 60%, the severe morbidity rate 26%, and reoperation rate 26%. The median length of stay was 9 ± 6.5 days. After a mean follow-up of 23.5 ± 20.3 months, the median time to perineal wound closure was 96 ± 60 days, the persistent perineal sinus rate was 6% (n = 2), and one patient developed a perineal incisional hernia.

CONCLUSION

Purse-string closure of perineal wounds is a safe and effective technique for perineal wound closure after APE. The short LOS allowed an early return home.

Meta-analysis of biological mesh reconstruction versus primary perineal closure after abdominoperineal excision of rectal cancer

BACKGROUND

Extralevator abdominoperineal excision (ELAPE) of rectal cancer has been proposed to achieve better oncological outcomes. The resultant wide perineal wound, however, presents a challenge for primary closure and subsequent wound healing. This meta-analysis compared the outcomes of primary perineal closure with those of biological mesh reconstruction.

METHODS

The Medline and Embase search was performed for the publications comparing primary perineal closure to biological mesh reconstruction. Early perineal wound complications (seroma, infection, dehiscence) and late perineal wound complications (perineal hernia, chronic pain, and chronic sinus) were analyzed as primary endpoints. Intraoperative blood loss, operation time, and hospital stay were compared as secondary endpoints.

RESULTS

There was no significant difference in the overall early wound complications after primary closure or biological mesh reconstruction (odds ratio (OR) of 0.575 with 95% confidence interval (CI) of 0.241 to 1.373 and a P value of 0.213). The incidence of perineal hernia after 1 year was significantly high after primary closure of the perineal wounds (OR of 0.400 with 95% CI of 0.240 to 0.665 and a P value of 0.001). No significant differences were observed among other early and late perineal wound complications. The operation time and hospital stay were shorter after primary perineal closure (p 0.001).

CONCLUSION

A lower incidence of perineal hernia and comparable early perineal wound complications after biological mesh reconstruction show a relative superiority over primary closure. More randomized studies are required before a routine biological mesh reconstruction can be recommended for closure of perineal wounds after ELAPE.