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

Summary

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.

Résumé

Objectif

Le but de cette étude était de déterminer les résultats de cure d’éventration périnéale par voie périnéale et par prothèse biologique après amputation abdominopérinéale (AAP) pour un cancer anorectal.

Méthode

Tous les patients ayant été opérés d’une cure d’éventration périnéale à l’aide une matrice extracellulaire de sous-muqueuse intestinale porcine dans notre hôpital entre 2015 et 2018 ont été inclus. Les patients ont été suivis par examens cliniques et scanner abdominopelvien.

Résultats

Six patients ont été opérés d’une d’éventration périnéale après un intervalle médian de 31 mois post-AAP. Le suivi médian après cure d’éventration périnéale était de 11 mois (intervalle interquartile [IQR], 6–35 mois). Trois patients (50 %) ont développé une récidive d’éventration périnéale après un intervalle médian de 6 mois.

Conclusion

La cure d’éventration périnéale par prothèse biologique a entraîné un taux de récidive élevé chez les patients ayant été opérés d’une AAP pour un cancer anorectal.

Introduction

Perineal hernia (PerH) is a known and late complication of abdominoperineal excision (APE) of the rectum. Extralevator abdominoperineal excision (ELAPE) has been reported to improve oncological outcomes [1], [2], [3] compared with standard APE; however, this technique has been found to create a large defect at the level of the pelvic floor which, in turn, may increase the risk of PerH, with a reported incidence rate of up to 26% [4].

PerH is defined as a protrusion of intra-abdominal viscera through the pelvic floor into the perineal region (Fig. 1). For asymptomatic patients, treatment is typically conservative. However, some patients may experience discomfort, pain, urinary dysfunction, skin disorders and, more rarely, bowel obstruction, and surgical repair is challenging. Several criteria may complicate the operation, namely, the extent of adhesiolysis, tissues weakened due to radiotherapy, a large defect, and comorbidities which may affect healing.

There is no consensus concerning the optimal treatment of PerH [5]. Various techniques have been reported using synthetic mesh, biological mesh, and a myocutaneous flap [6], [7], [8].

Anterolateral thigh, rectus abdominis, gluteal, and gracilis muscle flaps have been reported to be the most widely used, whether alone or in combination with a mesh [9].

Biological mesh has been reported as inducing tissue regeneration rather than scars and as suitable for use within a potentially contaminated field [10], [11].

Biological mesh has previously been used for primary pelvic floor closure after APE and has been shown to provide additional benefits compared to that of myocutaneous flap reconstruction, such as shorter operating times, low morbidity, absence of donor-site morbidity, and reduced length of hospital stay [12]. Moreover, it has been reported to decrease the rate of PerH development [13]. The use of biological mesh has progressed significantly in abdominal wall reconstruction surgery, but recent data have not confirmed the benefits of its use over synthetic mesh, and routine use has not been recommended [14].

We aimed to determine the rate of recurrence of perineal hernias after surgical reparation using biological mesh via a perineal approach.