Perineal Hernia Research Articles

Fascia lata flap to repair perineal hernia in dogs: a preliminary study

Perineal hernia (PH) in dogs normally requires surgical reconstruction of the pelvic diaphragm. The use of fascia lata grafts has been reported and described in previous studies for the correction of PH after failure of the conventional herniorrhaphy. The purpose of this report is to describe a modified technique of fascia lata flap (FLP) for PH repair in dogs. Six client-owned male dogs with PH were included in the study. PH was repaired with a FLP obtained from the dog's ipsilateral thigh and sutured directly into the perineal defect. Caudal scrotal orchiectomy was performed in all dogs that were not castrated. Clinical outcome including postoperative complications and recurrence rates were evaluated. PH did not recur in any of the dogs included in this study. The mean follow-up time was 24 months (range: 18-34). Mild postoperative complications were observed. One dog presented partial skin dehiscence at the PH repair site and one had mild lameness. Complications were completely resolved within 20 postoperative days. FLP is a simple surgical technique that can be used for perineal herniorrhaphy in dogs without long-term recurrence.

Biological mesh reconstruction of the pelvic floor following abdominoperineal excision for cancer: A review.

Extralevator abdominoperineal excision and pelvic exenteration are mutilating operations that leave wide perineal wounds. Such large wounds are prone to infection and perineal herniation, and their closure is a major concern to most surgeons. Different approaches to the perineal repair exist, varying from primary or mesh closure to myocutaneous flaps. Each technique has its own associated advantages and potential complications and the ideal approach is still debated. In the present study, we reviewed the current literature and our own local data regarding the use of biological mesh for perineal wound closure. Current evidence suggests that the use of biological mesh carries an acceptable risk of wound complications compared to primary closure and is similar to flap reconstruction. In addition, the rate of perineal hernia is lower in early follow-up, while long-term hernia occurrence appears to be similar between the different techniques. Finally, it is an easy and quick reconstruction method. Although more expensive than primary closure, the cost associated with the use of a biological mesh is at least equal, if not less, than flap reconstruction.

Methods of reconstruction of perineal wounds after abdominoperineal resection. Literature review

The problem of wound closure after abdominoperineal resection to treat oncological diseases remains unsolved. Formation of a primary suture in the perineal wound can lead to multiple postoperative complications: seroma, abscess, wound disruption with subsequent perineal hernia. Chemoradiation therapy as a standard for locally advanced rectal or anal cancer doesn’t improve results of treatment of perineal wounds and increases duration of their healing. Currently, surgeons have several reconstructive and plastic techniques to improve both direct and long-term functional treatment results. In the article, the most common methods of allo- and autotransplantation are considered, benefits and deficiencies of various techniques are evaluated and analyzed.

Retrospective Study (2009-2014): Perineal Hernias and Related Comorbidities in Bitches

Retrospective study based on data extracted from medical records of dogs diagnosed with perineal hernia between 2009 and 2014; medical records of bitches were selected for further analysis to determine the prevalence of perineal hernias in bitches and to investigate potential comorbidities. Perineal hernia was diagnosed in 182 dogs (174 males and 8 females; 96% and 4%, respectively). Surgical correction was performed in 6 bitches. Surgical procedures corresponded to internal obturator muscle transposition with or without polypropylene mesh reinforcement (n = 5) and semitendinosus muscle transposition flap (n = 1). Major comorbidities associated with perineal hernias in adult bitches were trauma (n = 3; 7.3 ± 1.5 years; 7.1 ± 8.5kg) and persistent cough secondary to conditions such as bronchitis, tracheal collapse, and cardiopathy in aged, small-sized patients (n = 3; 13.6 ± 2.0 years; 2.3 ± 0.1kg). Perineal hernias are uncommon in bitches and tend to be associated with comorbidities in these patients. Aged female dogs suffering from uncontrolled chronic cough secondary to cardiopathy or bronchitis are at risk of developing perineal hernia. Previous trauma to the pelvis is another potential risk factor for perineal hernia development in female dogs.

Extralevator abdominoperineal excision for rectal cancer with biological mesh for pelvic floor reconstruction.

GoalTo share our experience of extra-levator abdominoperineal excision (ELAPE) for low rectal cancer, focusing on perineal repair with biological mesh.MethodsWe retrospectively analyzed medical records of all patients with low rectal cancer who underwent the ELAPE procedure using biological mesh for perineal repair at the Gastrointestinal Surgery of Nanjing Drum Power Hospital between January 2013 and September 2015. All patients were closely followed up to now.ResultsA total of 17 patients underwent ELAPE for low rectal cancer was screened. Of these, 15 patients had primary rectal cancer, 1 had local recurrent rectal cancer, and 1 had malignant melanoma. All patients underwent ELAPE successfully without intestinal perforation and got stage I healing in perineum wound without incision infection, dehiscence, cystocele perinealis, urethral dysfunction or intestinal obstruction. Perineum wound hematoma developed in just one patient and had successful percutaneous drainage in one week. During the follow-up, there was no recurrence, perineal hernia, sexual dysfunction, urinary retention, or bowel obstruction. Two patients described slight pain in the sacrococcygeal region without special handling.ConclusionELAPE is applicable to low rectal cancer. Biological mesh reconstruction of perineal defect seems to be safe and effective, with high patient compliance.

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

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.

Herniorrafia perineal em cães – revisão de literatura

A hérnia perineal ocorre com maior frequência em cães machosnão castrados com idade superior a cinco anos. As técnicas cirúrgicasde reparação do diafragma pélvico são diversas, sendoempregadas de forma isolada ou associadas e incluem técnica desutura padrão, transposição do músculo obturador interno, transposiçãodo músculo glúteo superficial, transposição do músculosemitendinoso, reparação com uso de implantes sintéticos ou biológicos,colopexia e cistopexia. As complicações pós-operatóriasassociadas são: lesão do nervo isquiático ou pudendo, incontinênciafecal ou urinária, prolapso retal, infecção, deiscência de suturae recidiva da hérnia. Por ser uma enfermidade que apresentaelevados índices de complicações e recidivas, decidiu-se realizara presente revisão abordando os aspectos gerais e as principaistécnicas de tratamento da referida afecção.

Laparoscopy combined with transperineal extralevator abdominoperineal excision for locally advanced low rectal cancer

To evaluate the laparoscopy combined with transperineal extralevator abdominoperineal excision (TP-ELAPE) for locally advanced low rectal caner. Clinical data of 12 patients with locally advanced low rectal cancer undergoing laparoscopy combined with TP-ELAPE in our department from May 2013 to March 2015 were retrospectively analyzed. There were 8 male and 4 female patients with median aged of 63 (46 to 72) years. The median distance from tumor lower margin to anal verge was 3.5(2.0 to 4.0) cm. A self-made transanal suit for minimally invasive operation was used to make a sealed lacuna outside the sphincter, thus laparoscope can be applied to perform transperineal operation. All the patients underwent operations successfully without conversion to open abdominal operation. The median operating time was 206 (180 to 280) minutes with perineal operating time 95(80 to 120) minutes. The median intraoperative blood loss was 120(50 to 200) ml. The median postoperative hospital stay was 12(9 to 18 ) days. Postoperative pathology revealed that all circumferential margins (CRM) were negative. The area of sample horizontal section was (2 824±463) mm(2), and of outer muscularis propria was(2 190±476) mm(2). Postoperative complications included chronic sacrococcygeal region pain in 2 cases, urinary retention in 3 cases, perineal wound infection in 1 case. No perineal seroma, perineal hernia, wound dehiscence and sinus tract formation were observed. Among 8 patients with preoperative normal sexual function, sexual dysfunction occurred in 2 patients. There was no local recurrence and metastasis during a median follow-up of 21(12 to 34) months. Laparoscopy combined with TP-ELAPE has the potential to simplify the operation procedure for low rectal cancer, can ensure the radical treatment and safety of operation, and may be carried out in experienced centers.

Perineal herniorrhaphy in a dog using a cone-shaped polypropylene mesh implant

A 10-year-old neutered male shih tzu was presented due to a history of rectal tenesmus, dyschezia and constipation for the previous two months. Physical assessment disclosed swelling on the left...

Is there a place for a biological mesh in perineal hernia repair?

PurposeThis study aimed to determine the outcome of perineal hernia repair with a biological mesh after abdominoperineal resection (APR).MethodAll consecutive patients who underwent perineal hernia repair with a porcine acellular dermal mesh between 2010 and 2014 were included. Follow-up was performed by clinical examination and MRI.ResultsFifteen patients underwent perineal hernia repair after a median of 25 months from APR. Four patients had a concomitant contaminated perineal defect, for which a gluteal fasciocutaneous flap was added in three patients. Wound infection occurred in three patients. After a median follow-up of 17 months (IQR 12–24), a clinically recurrent perineal hernia developed in 7 patients (47 %): 6 of 11 patients after a non-cross-linked mesh and 1 of 4 patients after a cross-linked mesh (p = 0.57). Routine MRI at a median of 17 months revealed a recurrent perineal hernia in 7 of 10 evaluable patients, with clinical confirmation of recurrence in 5 of these 7 patients. No recurrent hernia was observed in the three patients with combined flap reconstruction for contaminated perineal defects.ConclusionA high recurrence rate was observed after biological mesh repair of a perineal hernia following APR.

Circumferential resection margins and perineal complications after neoadjuvant long-course chemoradiotherapy followed by extralevator abdominoperineal excision of the rectum: Five years of activity at a single institution.

Prone extralevator abdominoperineal excision of the rectum (ELAPE) has been introduced to improve the circumferential resection margins (CRM) compared with traditional APER. We present short-term results achieved with prone ELAPE preceded by neoadjuvant chemoradiotherapy during the last 5 years of activity. A retrospective review was conducted. Prone ELAPE operations performed between September 2010 and August 2014 at Leicester Royal Infirmary preceded by neoadjuvant chemoradiotherapy. Data regarding demographics, staging, neoadjuvant therapies, intraoperative perforations, and perineal complications were collected. Seventy-two patients were included. Pretreatment radiological T4 were 25.0%, histological T4 2.8%. Intraoperative perforations occurred in 2.8%, CRM was involved in 11.1%. Perineal complications consisted of superficial wound infections (20.8%), full thickness dehiscences (16.7%), hematomas (9.7%), pelvic collections (6.9%), and perineal hernias (5.6%). In our experience, prone ELAPE preceded by long-course chemoradiotherapy has been successfully used in the last 5 years to resect low rectal tumors. Perineal wound complications rates are similar to those presented in series using direct perineal closures. J. Surg. Oncol. 2016;114:86-90. © 2016 Wiley Periodicals, Inc.

The Spatial Relationship and Surface Projection of Canine Sciatic Nerve and Sacrotuberous Ligament: A Perineal Hernia Repair Perspective.

Sciatic nerve entrapment can occur as post-operative complication of perineal hernia repair when sacrotuberous ligament is incorporated during hernia deficit closure. This results in sciatic sensory loss and paralysis of the hind leg. This study investigated the spatial relationship of sciatic nerve and sacrotuberous ligament and their surface topographic projection of 68 cadavers (29 Beagles and 39 Taiwanese mongrels) with various heights (25–56 cm). By gross dissection, the sacrotuberous ligament and sciatic nerve were exposed and their distance in between was measured along four parts (A, B, C, D) of sacrotuberous ligament. The present study revealed that the C was the section of sacrotuberous ligament where the sciatic nerve and the sacrotuberous ligament are closest to each other. Furthermore, a positive correlation was observed between C and height of the dogs. From the present study, we found that the C in smaller dogs has the shortest distance between the sciatic nerve and the sacrotuberous ligament, and thus the most vulnerable to sciatic nerve entrapment, and needs to be avoided or approached cautiously during perineal hernia repair.

Biologic Mesh Reconstruction of the Pelvic Floor after Extralevator Abdominoperineal Excision: A Systematic Review.

The aim of this review is to provide an overview of the evidence for the use of biologic mesh in the reconstruction of the pelvic floor after extralevator abdominoperineal excision of the rectum (ELAPE). A systematic search of PubMed was conducted using the search terms: "ELAPE," "extralevator abdominoperineal excision of rectum," or "extralevator abdominoperineal resection." The search yielded 17 studies. Biologic mesh was used in perineal reconstruction in 463 cases. There were 41 perineal hernias reported but rates were not consistently reported in all studies. The most common complications were perineal wound infection (n = 93), perineal sinus and fistulae (n = 26), and perineal haematoma or seroma (n = 11). There were very few comparative studies, with only one randomized control trial (RCT) identified that compared patients undergoing ELAPE with perineal reconstruction using a biological mesh, with patients undergoing a conventional abdominoperineal excision of the rectum with no mesh. There was no significant difference in perineal hernia rates or perineal wound infections between the groups. Other comparative studies comparing the use of biologic mesh with techniques, such as the use of myocutaneous flaps, were of low quality. Biologic mesh-assisted perineal reconstruction is a promising technique to improve wound healing and has comparable complications rates to other techniques. However, there is not enough evidence to support its use in all patients who have undergone ELAPE. Results from high-quality prospective RCTs and national/international collaborative audits are required.

Successful Surgical Management of Recurrent Perineal Hernia Using Colopexy and Cystopexy in a Dog

The aim of this report is to describe the successful management of long standing and recurrent perineal hernia with transposition of internal obturator muscles, colopexy, cystopexy and castration in a non- descript dog.

The Great Spay/Neuter Debate: Does Early Gonadectomy Prevent or Cause Disease in Dogs?

Traditionally, veterinarians have recommended that dogs be spayed or neutered at approximately 6 months of age. For most pet owners and veterinarians, this is a convenient time. It allows pets to complete their initial vaccine series while still performing the procedure prior to sexual maturity. After all, it is common to recommend spaying prior to a pet’s first estrus period to help protect against mammary cancer. Likewise, it is common to recommend castration prior to the onset of undesirable behaviors, such as aggression and urine marking, which can be associated with male sexual maturity. It is also widely accepted that castration can prevent conditions such as perineal hernias, perianal adenomas, and prostatic diseases (other than neoplasia) in male dogs. So why have these long-standing recommendations become controversial?

Laparoscopic repair of perineal hernia after abdominoperineal excision.

Perineal hernia is a challenging complication after abdominoperineal excision (APE) of the rectum. Surgical repair can be accomplished using challenging abdominal or transperineal approaches. A laparoscopic repair using a Proceed mesh might be an easy and effective alternative. We describe a multi-center case-series of twelve patients with a symptomatic perineal hernia treated by laparoscopic mesh repair. A cone-shaped 10×15cm Proceed Mesh was tacked to the promontory or sacrum and sutured to the pelvic sidewalls and the anterior peritoneum. Twelve patients underwent laparoscopic repair of their perineal hernia. Four men and eight women presented with a symptomatic perineal hernia after abdominoperineal excision between 2008 and 2013 and underwent a laparoscopic repair with a Proceed mesh. The median age at presentation was 53years (range 39-68years). The mean total theater time was 119min (range 75-200min). No conversion to an open procedure was needed. No early complications where seen. The mean hospital stay was 2.25days (range 1-4days). Three patients showed recurrence, of whom two had a defect in the middle of the proceed mesh, one had a defect anterior to the previous perineal hernia. All 3 patients underwent a redo-laparoscopic repair with mesh. In this case series we present an alternative approach for the surgical repair of perineal hernias. Based on our experience, perineal hernia after APE can be repaired safely and effectively using the described laparoscopic technique.

Transabdominal–pelvic–perineal (TAPP) anterolateral thigh flap: A new reconstructive technique for complex defects following extended abdominoperineal resection

Abdominoperineal resection (APR) following radiotherapy is associated with a high rate of perineal wound complications. The anterolateral thigh (ALT) flap, combined with the vastus lateralis (VL) muscle, can cover complex perineal and pelvic anteroposterior defects. This is used for the first time transabdominally through the pelvis and the perineum (TAPP) in the infero-posterior directions; this technique has been described and illustrated in this study. Among over 90 patients who underwent perineal reconstruction between May 2004 and June 2011, six patients presented high-grade tumours invading perineum, pelvis and sacrum, thereby resulting in a continuous anteroposterior defect. ALT+VL TAPP reconstructions were performed after extended APR and, subsequently, sacrectomy. Patients were examined retrospectively to determine demographics, operative time, complications (general and flap-related), time to complete healing and length of hospital stay. Long-term flap coverage, flap volume stability and functional and aesthetic outcomes were assessed. Mean operating time of the reconstruction was 290min. No deaths occurred. One patient presented partial flap necrosis. Another patient presented a novel wound dehiscence after flap healing, due to secondary skin dissemination of the primary tumour. Following volumetric flap analysis on serial post-operative CT scans, no significant flap atrophy was observed. All flaps fully covered the defects. No late complications such as fistulas or perineal hernias occurred. Donor-site recovery was uneventful with no functional deficits. The use of the ALT+VL flap transabdominally is an innovative method to reconstruct exceptionally complex perineal and pelvic defects extending up to the lower back. This flap guarantees superior bulk, obliterating all pelvic dead space, with the fascia lata (FL) supporting the pelvic floor.

Hernia perineal. Presentación de un caso

Los autores presentan un caso de hernia perineal. La predisposición congénita es el factor principal. El diagnóstico clínico se hizo en este caso. El tratamiento quirúrgico se realizó mediante la técnica abdominal.

Comparison of caudal and pre-scrotal castration for management of perineal hernia in dogs between 2004 and 2014

AIMS: To compare peri- and post-operative complications associated with caudal scrotal castration (CSC) and perineal hernia repair with pre-scrotal castration (PSC) in conjunction with another surgical procedure.METHODS: Medical records were reviewed for 51 intact male dogs that were admitted to the Veterinary Emergency and Surgical Center, Levittown, PA, and underwent a CSC and perineal hernia repair using an internal obturator muscle flap (IOMF) between 2004 and 2014. Perioperative, and major and minor post-operative complications noted within the 2 week follow up period were reported and compared to 91 intact male dogs that underwent a PSC in conjunction with a second surgical procedure.RESULTS: There were no recorded perioperative or major post-operative complications in either group. There were 3/51 (6%) minor post-operative complications in the CSC group compared to 6/91 (7%) in the PSC group. There were 2/51 (4%) and 4/91 (4%) cases that developed heat, erythema and swelling associated with the incision site and 1/51 (2%) and 2/91 (2%) cases that developed scrotal swelling in the CSC and PSC groups, respectively. Overall, there was no difference in the prevalence of minor complications between the two groups (p=0.86).CONCLUSIONS AND CLINICAL RELEVANCE: Caudal scrotal castration was not associated with more perioperative or postoperative complications relative to PSC. Utilising the CSC approach eliminates the need to aseptically prepare and drape a second site when carrying out perineal hernia repair, as well as the need for patient repositioning. Thus, we recommend that CSC be the preferred surgical technique when performing orchiectomy in dogs concurrent with perineal hernia repair.

PWE-386 Development of perineal hernias following abdominoperineal excision for low rectal cancer

Introduction Previously, perineal herniation following abdominoperineal excision (APE) has been considered a rare complication affecting Method Retrospective data on patients who underwent APE between May 2006 and October 2014 in a single UK institution were collected. Analysis of Magnetic Resonance Imaging (MRI) and Computerised Tomography (CT) scans determined pelvic cavity dimensions and the presence of perineal herniation. Perineal hernias were defined as a defect containing bowel, uterus, bladder, vagina or omentum dropping below the pubococcygeal line. Consequently asymptomatic perineal hernias were included in this data. Perineal defects resolving naturally over time were not considered to be a hernia. Pelvic floor descent was measured from the pubococcygeal line to the lowest point of the descended material or matter. Data for gender and treatment with chemoradiotherapy (CRT) were extracted from patient notes. Data were tested for normality and appropriate t-tests used. Results Post-operative data were available for 63/73 patients, mean age 67 years (range 26–85), of which 67% were male. First postoperative scans presented 17/63 (27%) patients with a perineal hernia. Most recent scans showed 23/63 (37%) patients with a perineal hernia. No significant difference was found between post-operative pelvic outlet size and presence of a perineal hernia (9.8 v 10.3, P Conclusion Our data suggest that the size of the pelvic outlet and gender could be less important than previously thought in development of a perineal hernia. It could be suggested that patients at risk of perineal herniation present early after surgery and that increased survival time does not necessarily increase the risk of developing a perineal hernia. This may be due to improved surgical technique and closure with porcine mesh. Disclosure of interest None Declared.