Repair of Perineal Hernia Following Abdominoperineal Excision with Biological Mesh: A Systematic Review.

Sunil K Narang,Neil J Smart,Nasra N Alam,Ferdinand Köckerling,Ian R Daniels

doi:10.3389/fsurg.2016.00049

Abstract

Perineal hernia (PerH) following abdominoperineal excision (APE) procedure is a recognized complication. PerH was considered an infrequent complication of APE procedure; however, PerH rates of up to 45% have been reported in recent publications following a laparoscopic APE procedure. Various methods of repair of PerH with the use of synthetic meshes or myocutaneous flap have been described, although there is no general agreement on an optimal strategy. The use of biological meshes for different operations is growing in popularity, and these have been promoted as being superior and safer when compared to synthetic meshes. Although the use of biologics is becoming popular claims of better outcomes are largely unsupported by evidence. The aim of this systematic review is to evaluate the currently available evidence supporting the use of biologic or biosynthetic meshes for the repair of PerH that develop following an APE. A systematic review of all English language literature relevant to repair of PerH following APE with biologic or biosynthetic mesh published between January 1, 2000 and July 31, 2016 was carried out using MEDLINE, EMBASE, and the Cochrane Library of Systematic Reviews for relevant literature. Searches were performed using a combination of Medical Subject Headings (MeSH) terms and text words "PerH," "APE," "morbidity," "biologics," "biosynthetic," and "hernia." Studies in which the use of biological meshes was not reported were excluded from the review. Various outcome measures, including operative technique, complication rates, recurrence rates, type of mesh, management of recurrences, and risk factors, were extracted. Oxford Centre for Evidence-based Medicine - Levels of Evidence (March 2009) was used to assess the quality of evidence. The systematic review of the literature identified three case reports, four case series, and one pooled analysis that were included in the final review. Overall, these studies were of poor quality providing level 4 evidence. Various different approaches and techniques of repair of PerH were described; however, it was difficult to extract information with regard to the primary and secondary outcome measures. There is no general agreement to the optimal operative strategy to repair PerH following an APE. There is insufficient evidence to recommend any specific operative approach or repair technique for PerH following an APE.

Highlights

The finding of a perineal hernia (PerH) following an abdominoperineal excision (APE) is a recognized complication; it is unclear as to how frequently this occurs
A systematic review of all English language literature relevant to the repair of a PerH following an APE with biologic or biosynthetic mesh published between January 1, 2000 and July 31, 2016 was carried out using MEDLINE (PubMed and Ovid), EMBASE (Ovid), and the Cochrane Library of Systematic Reviews/ Controlled Trials for relevant literature
Searches were performed using a combination of Medical Subject Headings (MeSH) terms and text words “perineal hernia,” “abdominoperineal excision,” “morbidity,” “biologics,” “biosynthetic,” and “hernia.” All randomized/non-randomized, controlled/non-controlled clinical trials, prospective observational studies, clinical registry data, retrospective case series, and case reports that reported on repair of PerH following APE were included for analysis

Summary

Introduction

The finding of a perineal hernia (PerH) following an abdominoperineal excision (APE) is a recognized complication; it is unclear as to how frequently this occurs. The surgical management of rectal cancer has evolved over the recent years with the acceptance of the principle of total mesorectal excision (TME) and the recognition of the importance of a clear surgical resection and avoidance of tumor perforation during an APE [7] This procedure has evolved into the extra levator abdominoperineal excision (eLAPE) with the potential surgical resection margin information being identified through MRI staging [7, 8]. An eLAPE creates a wider defect in the pelvic floor leaving only the ischioanal fat and skin for closure of the defect as the entire pelvic floor muscle complex has been excised surrounding the distal rectum Perineal herniation in this group of patients is increasingly recognized and a recent publication has reported an overall PerH rate of 26% and this can be as high as 45% in those having a laparoscopic eLAPE procedure [10]

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Conclusion