Technical noteBiological mesh used to repair perineal hernias following abdominoperineal resection for anorectal cancerCure d’éventration périnéale par prothèse biologique après amputation abdominopérinéale pour 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.
Section snippets
Methods
All patients with a PerH who had received surgical treatment between January 2015 and April 2018 were identified retrospectively in one specialized cancer surgery center. This study was carried out in accordance with the recommendations of local ethics committee and conducted in accordance with the Helsinki declaration with written informed consent from all subjects. All subjects gave written informed consent in accordance with the Declaration of Helsinki. The protocol was approved by the
Results
Between January 2015 and April 2018, six patients underwent surgery for a symptomatic perineal hernia. Perineal reconstruction was performed with the use of a biological mesh via a perineal approach in a supine position for five patients and in a prone position for one patient.
The patient characteristics are shown in Table 1.
The median interval from APE to perineal hernia repair was 31 months (IQR, 13–49). The median follow-up after hernia repair was 11 months (IQR, 6–35). Perineal hernia
Discussion
We report a limited cohort of patients who underwent a biological mesh reconstruction for PerH following APE or ELAPE. Only patients who had experienced severe symptoms such as pain or discomfort underwent surgical repair. The 50% recurrence rate that we report is high, and comparable to other studies reporting the use of biological mesh [5], [7]. Therefore, we cannot recommend this technique; however, the low rate of postoperative complications was noteworthy.
Some authors have reported using
Disclosure of interest
The authors declare that they have no competing interest.
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Techniques of perineal hernia repair: A systematic review and meta-analysis
2023, Surgery (United States)Citation Excerpt :The interval between index surgery and PH development was extremely heterogeneous, ranging from 1 month to 15 years. Symptoms were mentioned in 17 studies.4,12,14,16–19,21,23,25–27,31–33,35,37 The most common were perineal discomfort and sensation of painful bulging.
Postoperative perineal hernia repair: what is the evidence?
2023, Surgery TodayPerineal hernia after abdominoperineal resection – a systematic review
2022, Polski Przeglad Chirurgiczny/ Polish Journal of Surgery