Perineal Hernia Research Articles

A Comparison of Perineal Myocutaneous Flaps Following Abdominoperineal Excision of the Rectum for Anorectal Pathology.

Flap-based reconstruction following abdominoperineal resection has been used to address the resultant soft tissue defect and reduce postoperative wound complications. Vertical rectus abdominis myocutaneous flaps have been the traditional choice, but locoregional flaps have attracted attention in minimally invasive resection because they avoid additional abdominal dissection. However, few data exist comparing flap types. To compare outcomes for different types of perineal reconstruction in patients undergoing abdominoperineal resection exclusively for anorectal pathology. This was a retrospective comparative study. This study was conducted at a large, tertiary referral institution. Following Institutional Review Board approval, prospectively maintained clinical and financial databases were interrogated and cross-referenced for patients undergoing proctectomy or abdominoperineal resection with flap reconstruction from 2007 to 2018. Patients with primary gynecological or urological pathology were excluded. The primary outcome was flap complication rate. Secondary outcomes included perineal hernia rate, donor site complications, emergency department consult after discharge, readmission <90 days, and length of stay. Data were analyzed using univariate and multivariate techniques. A total of 135 patients (79 female, median age 58 years) were included: 68 rectus, 52 gluteal, and 15 gracilis flap reconstructions. Median follow-up was 46 months. Rates of both major and minor flap complications were similar for rectus and gluteal flaps, even when controlling for differences between groups via multivariate analysis ( p > 0.9), including extent of resection and use of mesh. For all flaps, American Society of Anesthesiology score ≥3 was the only independent predictor of major, but not minor, flap complications. For rectus and gluteal flaps, smoking, female sex, and American Society of Anesthesiology score ≥3 were independent predictors of major flap complications ( p < 0.05). This study was limited by its retrospective nature and potential selection bias associated with flap choice; it was also impossible to quantify defect size. Gluteal flaps have similar complication rates to rectus flaps and may be considered for patients who are otherwise suitable for minimally invasive abdominoperineal resection. See Video Abstract at http://links.lww.com/DCR/B866 .Una comparación de los colgajos miocutáneos perineales después de la escisión abdominoperineal del recto para patología anorectal. La reconstrucción con colgajo después de la resección abdominoperineal se ha utilizado para abordar el defecto de tejido blando resultante y reducir las complicaciones postoperatorias de la herida. Los colgajos miocutáneos verticales del recto abdominal han sido la elección tradicional, pero los colgajos locorregionales han atraído la atención en la resección mínimamente invasiva porque evitan la disección abdominal adicional. Sin embargo, existen pocos datos que comparen los tipos de colgajos.

Measuring morphological parameters of the pelvic diaphragm muscles using computed tomography in healthy dogs.

Evaluation of pelvic diaphragm muscles in dogs merits clinical attention because of the anatomical importance and their involvement in perineal hernia. This study aimed to evaluate the normal pelvic diaphragm muscles (levator ani and coccygeus muscles) using the computed tomography (CT) scan. For this purpose, 10 male and 10 female clinically normal, adult intact mixed-breed dogs weighing 15.00 to 20.00 kg were selected randomly. All animals underwent CT examination under general anesthesia and positioned in sternal recumbency. All the CT images were taken and reconstructed with a same protocol. The measurements of the pelvic diaphragm muscles were performed based on the presented guideline to the observer. The results were presented descriptively. The mean lengths of the coccygeus muscle in CT images were evaluated 4.60 cm for males and 4.30 cm for females. The mean lengths of levator ani muscle in CT images were measured 4.90 cm in males and 4.50 cm in females. In conclusion, the results of the present study can be beneficial to clinicians and researchers for further evaluation of the supporting muscles in pelvic cavity and underlying anatomical changes in perineal hernia in dogs.

Abdominal and perineal hernia rates following vertical rectus abdominis myocutaneous (VRAM) flap reconstruction – a supraregional experience

BackgroundVertical rectus abdominis myocutaneous (VRAM) flap has proven to be a robust reconstruction method following radical pelvic surgery. Radical pelvic surgery is associated with high morbidity due to pelvic complications and non-healing perineal wounds, as a result of non-collapsible pelvic dead space and pre-operative adjuvant radiotherapy insult. VRAM flap reconstruction addresses both issues by obliterating the dead space and introducing healthy non-radiated tissue. However, flap reconstruction complications can include donor site hernias (abdominal wall), perineal hernias, and flap-specific complications. This study aimed to evaluate the abdominal and perineal hernia rates as well as radiological evidence of flap vascularity post-operatively. MethodsWe conducted a retrospective analysis of patients who underwent a VRAM flap reconstruction following radical pelvic surgery at Christchurch hospital over a 10-year period. We identified the presence of donor site hernias (abdominal wall hernias), perineal hernias, and flap vascularity on post-operative radiological imaging performed within 48 months. ResultsSeventy-seven patients underwent a VRAM flap reconstruction of which 60 patients met the inclusion requirements for the study (mean age was 60.3 years [range 26–89]; 31 were male and 29 were female). Eighteen patients underwent an APR and 42 underwent a partial or a complete pelvic exenteration and the majority of them (75.0%) were for rectal cancers. Available imaging was on average 21.6 months post-operatively (IQR 11.8–31.3 months). The donor site hernia rate was 16.7%, and the perineal hernia rate was 3.3%. VRAM flap appeared to have DIEA flow in 98.3% of the patients. ConclusionVRAM flap reconstruction of complex pelvic defects remains a robust method of choice in complex pelvic reconstruction with little morbidity.

Empty pelvis syndrome: a systematic review of reconstruction techniques and their associated complications.

Empty pelvis syndrome is a major contributor to morbidity following pelvic exenteration. Several techniques for filling the pelvis have been proposed; however, there is no consensus on the best approach. We evaluated and compared the complications associated with each reconstruction technique with the aim of determining which is associated with the lowest incidence of complications related to the empty pelvis. The systematic review protocol was prospectively registered with PROSPERO (CRD42021239307). PRISMA-P guidelines were used to present the literature. PubMed and MEDLINE were systematically searched up to 1 February 2021. A dataset containing predetermined primary and secondary outcomes was extracted. Eighteen studies fulfilled our criteria; these included 375 patients with mainly rectal and gynaecological cancer. Only three studies had a follow-up greater than 2years. Six surgical interventions were identified. Mesh reconstruction and breast prosthesis were associated with low rates of small bowel obstruction (SBO), entero-cutaneous fistulas and perineal hernia. Findings for myocutaneous flaps were similar; however, they were associated with high rates of perineal wound complications. Omentoplasty was found to have a high perineal wound infection rate (40%). Obstetric balloons were found to have the highest rates of perineal wound dehiscence and SBO. Silicone expanders effectively kept small bowel out of the pelvis, although rates of pelvic collections remained high (20%). The morbidity associated with an empty pelvis remains considerable. Given the low quality of the evidence with small patient numbers, strong conclusions in favour of a certain technique and comparison of these interventions remains challenging.

Biological mesh versus primary closure for pelvic floor reconstruction following extralevator abdominoperineal excision: a meta-analysis

Objective: To compare the morbidity of perineum-related complication between biological mesh and primary closure in closing pelvic floor defects following extralevator abdominoperineal excision (ELAPE). Methods: A literature search was performed in PubMed, Embase, Cochrane Library, Web of Science, Wanfang database, Chinese National Knowledge Infrastructure, VIP database, and China Biological Medicine database for published clinical researches on perineum-related complications following ELAPE between January 2007 and August 2020. Literature inclusion criteria: (1) study subjects: patients undergoing ELAPE with rectal cancers confirmed by colonoscopy pathological biopsy or surgical pathology; (2) study types: randomized controlled studies or observational studies comparing the postoperative perineum-related complications between the two groups (primary perineal closure and reconstruction with a biological mesh) following ELAPE; (3) intervention measures: biological mesh reconstruction used as the treatment group, and primary closure used as the control group; (4) outcome measures: the included literatures should at least include one of the following postoperative perineal complications: overall perineal wound complications, perineal wound infection, perineal wound dehiscence, perineal hernia, chronic sinus, chronic perineal pain (postoperative 12-month), urinary dysfunction and sexual dysfunction. Literature exclusion criteria: (1) data published repeatedly; (2) study with incomplete or wrong original data and unable to obtain original data. Two reviewers independently performed screening, data extraction and assessment on the quality of included studies. Review Manager 5.3 software was used for meta-analysis. The mobidities of perineum-related complications, including overall perineal wound (infection, dehiscence, hernia, chronic sinus) and perineal chronic pain (postoperative 12-month), were compared between the two pelvic floor reconstruction methods. Finally, publication bias was assessed, and sensitivity analysis was used to evaluate the stability of the results. Results: A total of five studies, including two randomized controlled studies and three observational controlled studies, with 650 patients (399 cases in the biological mesh group and 251 cases in primary closure group) were finally included. Compared with primary closure, biological mesh reconstruction had significantly lower ratio of perineal hernia (RR=0.37, 95%CI: 0.21-0.64, P<0.001). No significant differences in ratios of overall perineal wound complication, perineal wound infection, perineal wound dehiscence, perineal chronic sinus and perineal chronic pain (postoperative 12-month) were found between the two groups (all P>0.05). Conclusion: Compared with primary closure, pelvic floor reconstruction following ELAPE with biological mesh has the advantage of a lower incidence of perineal hernia.

Robotic-Assisted Repair of Peritoneal-Perineal Hernia: A Case Report

Study Objective Peritoneal perineal hernia is a rare prolapse without an established gold standard treatment. In this video, we present a unique technique in repairing this condition. Design Case report. Setting Patient was positioned in low lithotomy. The DaVinci™ Xi robot was docked on the left side and set up for pelvic surgery. Patients or Participants The patient is a 68-year-old female with surgical history of total vaginal hysterectomy and laparoscopic sigmoidectomy who presented for evaluation of a vaginal bulge. MR Defecography demonstrated tissue distortion concerning for peritoneal perineal hernia with marked small bowel decent. Interventions Robotic assisted synthetic mesh placement to obliterate the space between the rectum and vagina to promote visceral adherence. The peritoneum overlying the vaginal apex was dissected off the vagina into the rectovaginal plane and taken down all the way to the perineal body. Synthetic mesh was attached posteriorly to the vaginal wall with delayed absorbable suture. The rectum was then sutured to the posterior vaginal mesh using absorbable suture. In this way, the mesh was “sandwiched” between the two viscera. Care was taken to avoid full-thickness suture placement long the rectal serosa. Excellent obliteration of the Pouch of Douglas was achieved. The mesh was then attached to the sacral promontory using permanent suture. Complete reperitonealization of the mesh was performed using absorbable suture. Measurements and Main Results At her postoperative visit, she reported resolution of her symptoms of pelvic pressure and vaginal bulge. Postoperative MR Defecography revealed the resolution of small bowel decent into the perineal space. Conclusion Our approach was unique in that we reduced the hernia and obliterated the posterior cul-de-sac by suturing the mesh to both posterior vagina and anterior colon. Robotic approach provided minimally invasive care, excellent intraoperative visualization over laparotomy, and better dexterity over laparoscopy. Peritoneal perineal hernia is a rare prolapse without an established gold standard treatment. In this video, we present a unique technique in repairing this condition. Case report. Patient was positioned in low lithotomy. The DaVinci™ Xi robot was docked on the left side and set up for pelvic surgery. The patient is a 68-year-old female with surgical history of total vaginal hysterectomy and laparoscopic sigmoidectomy who presented for evaluation of a vaginal bulge. MR Defecography demonstrated tissue distortion concerning for peritoneal perineal hernia with marked small bowel decent. Robotic assisted synthetic mesh placement to obliterate the space between the rectum and vagina to promote visceral adherence. The peritoneum overlying the vaginal apex was dissected off the vagina into the rectovaginal plane and taken down all the way to the perineal body. Synthetic mesh was attached posteriorly to the vaginal wall with delayed absorbable suture. The rectum was then sutured to the posterior vaginal mesh using absorbable suture. In this way, the mesh was “sandwiched” between the two viscera. Care was taken to avoid full-thickness suture placement long the rectal serosa. Excellent obliteration of the Pouch of Douglas was achieved. The mesh was then attached to the sacral promontory using permanent suture. Complete reperitonealization of the mesh was performed using absorbable suture. At her postoperative visit, she reported resolution of her symptoms of pelvic pressure and vaginal bulge. Postoperative MR Defecography revealed the resolution of small bowel decent into the perineal space. Our approach was unique in that we reduced the hernia and obliterated the posterior cul-de-sac by suturing the mesh to both posterior vagina and anterior colon. Robotic approach provided minimally invasive care, excellent intraoperative visualization over laparotomy, and better dexterity over laparoscopy.

867 A Novel Use for Silicone Expanders: Reducing Pelvic Dead Space and Preventing Bowel Herniation When Managing Radical Exenterative Surgery Complications

Abstract Aim To date, there is no clear consensus regarding the best way to obliterate the pelvic dead space, as seen in patients treated for recurrent perineal herniation and entero-cutaneous fistuli following total pelvic exenteration (TPE) for locally advanced rectal cancer. We present a novel technique using saline-filled breast expander to fill the dead space and create an artificial pelvic floor using the implant capsule, thus preventing intestinal herniation and fistuli formation in the multi-operated and irradiated pelvis scenario. Method We present 2 patients who initially had TPE, IGAP flap perineal reconstruction and neoadjuvant chemoradiotherapy. Patient 1 had 2 laparotomies for persistent enteroperineal fistulae in the 2-year postoperative period. Patient 2 had persistent wound discharge 2 years post TPE and underwent an enterocutaneous fistula repair and wound debridement. Both cases were complicated by perineal herniation and re-presented with persistent fistulation. A Becker 25 breast expander was placed into the pelvis and inflated with 150 ml of saline, to help contain the small bowel in the abdomen and reduce the risk of perineal re-herniation and fistulae. Results The silicone device was removed at 7-12 months, preserving its capsule, by the time the wound had healed. The wounds remained healed at post-operative follow up without any further perineal wound complications, herniation or fistuli Conclusions Addressing the dead pelvic space by using a breast expander may treat this particular TPE complication. The capsule created following placement of breast implant, facilitates artificial pelvic floor.

Expert Commentary on Diagnosis and Management of Perineal Hernia.

Expert Commentary on Diagnosis and Management of Perineal Hernia.

V01-06 ROBOTIC ASSISTED REPAIR OF A PERINEAL BLADDER HERNIA

You have accessJournal of UrologyIncontinence & Female Pelvic Medicine/Reconstructive Surgery (V01)1 Sep 2021V01-06 ROBOTIC ASSISTED REPAIR OF A PERINEAL BLADDER HERNIA Dmitry Volkin, and Christopher Tarnay Dmitry VolkinDmitry Volkin More articles by this author , and Christopher TarnayChristopher Tarnay More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001970.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Perineal hernias are relatively uncommon but certainly may be encountered by the urologist or pelvic reconstructive surgeon. Diagnosis and management of these unusual hernias is limited to case reports in the literature. Our aim was to provide a video guide demonstrating our technique of how to successfully repair such a hernia. METHODS: This is a video presentation of a 70 year old female patient who developed lower urinary tract symptoms and a palpable mass in her right buttocks. Imaging confirmed a bladder hernia in the right ischiorectal fossa. She underwent repair of her hernia via a robotic assisted abdominal approach, which confirmed a large defect in the levator muscle bordered medially by the vagina and bladder. We also perform a brief review of the literature on perineal hernias and review possible sites of herniation of the bladder. RESULTS: The patient underwent a patch repair of the hernia with soft polypropylene mesh cut to approximately the size of the defect but she recurred 6 weeks later. Repeat operation revealed a medial detachment of her mesh patch. A second repair was performed utilizing a larger piece of mesh, anchoring it more broadly to the levator musculature laterally and pubic bone anteriorly. The patient’s immediate post-operative course was complicated by a retroperitoneal hematoma that was managed conservatively. She was free of hernia recurrence 1 year after her second operation. CONCLUSIONS: Perineal hernias are within the scope of practice of the urologist and pelvic reconstructive surgeon. They can successfully be repaired with reduction of the hernia and application of a broad mesh patch. Source of Funding: Not applicable © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e63-e63 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dmitry Volkin More articles by this author Christopher Tarnay More articles by this author Expand All Advertisement Loading ...

A comparative multicentre study evaluating gluteal turnover flap for wound closure after abdominoperineal resection for rectal cancer

BackgroundThe aim of this study was to compare perineal wound healing between gluteal turnover flap and primary closure in patients undergoing abdominoperineal resection (APR) for rectal cancer.MethodsPatients who underwent APR for primary or recurrent rectal cancer with gluteal turnover flap in two university hospitals (2016–2021) were compared to a multicentre cohort of primary closure (2000–2017). The primary endpoint was uncomplicated perineal wound healing within 30 days. Secondary endpoints were long-term wound healing, related re-interventions, and perineal herniation. The perineal hernia rate was assessed using Kaplan Meier analysis.ResultsTwenty–five patients had a gluteal turnover flap and 194 had primary closure. The uncomplicated perineal wound-healing rate within 30 days was 68% (17/25) after gluteal turnover flap versus 64% (124/194) after primary closure, OR 2.246; 95% CI 0.734–6.876; p = 0.156 in multivariable analysis. No major wound complications requiring surgical re-intervention occurred after flap closure. Eighteen patients with gluteal turnover flap completed 12-month follow-up, and none of them had chronic perineal sinus, compared to 6% (11/173) after primary closure (p = 0.604). The symptomatic 18-month perineal hernia rate after flap closure was 0%, compared to 9% after primary closure (p = 0.184).ConclusionsThe uncomplicated perineal wound-healing rate after the gluteal turnover flap and primary closure after APR is similar, and no chronic perineal sinus or perineal hernia occurred after flap closure. Future studies have to confirm potential benefits of the gluteal turnover flap.

Efficacy of Pelvic Peritoneum Closure After Laparoscopic Extralevator Abdominoperineal Excision for Rectal Cancer

BackgroundThe descent of the small bowel into the pelvic dead space after extralevator abdominoperineal excision (ELAPE) presents a higher risk for postoperative complications. The aim of the present study was to evaluate the efficacy of pelvic peritoneum closure in preventing the small bowel from descending into the pelvic dead space and the potential consequences of this approach. MethodsPatients with rectal cancer undergoing laparoscopic ELAPE from March 2014 to January 2019 were retrospectively investigated. Closure of the pelvic peritoneum (CPP) was routinely performed unless it was not feasible. All patients with pelvic peritoneum reconstruction were included in the CPP group, and patients without pelvic peritoneum reconstruction were included in the no-CPP group. The main outcomes included the incidences of the small bowel descending into the retro-urogenital space (space between the bladder/uterus and the sacrum on axial CT scans), perineal wound complications, perineal hernia, and small bowel obstruction (SBO). ResultsOf the 100 patients included, 79 received CPP, and 21 did not. Fewer patients with pelvic peritoneum closure had small bowels residing in the retro-urogenital space than patients without closure (17.7% vs 42.9%, p=0.014). The incidence of SBO was also lower in the CPP group (7.6% vs. 23.8%, p=0.034). Multivariable analysis showed that no-CPP (p=0.014) was an independent risk factor for the small bowel descending into the retro-urogenital space. ConclusionCPP may prevent the small bowel from descending into the retro-urogenital dead space in patients undergoing laparoscopic ELAPE without increasing the incidence of perineal wound complications. Prospective studies are warranted to confirm the efficacy of CPP in preventing SBO and perineal hernia.

Partial myocutaneous gluteal flap for perineal reconstruction of extralevator abdominoperineal defects. A single surgeon series of 49 cases in 8 years, and a modification of the technique

Extralevator abdominoperineal excision (ELAPE) for low rectal tumours necessitates a reliable method of reconstructing the perineum. The senior author developed the partial myocutaneous gluteal (PMG) flap. We present 49 consecutive reconstructions with the refinement of the original procedure. We conducted a retrospective observational review of patients undergoing ELAPE and PMG reconstruction from 2012 to 2019, with at least 1 year follow-up. The procedure was modified iteratively following our original series, to minimise perineal herniation, specifically by greater mobilisation of the inferior gluteus maximus muscle and separation of the muscle and fasciocutaneous components, allowing closure of the defect around the coccygeal remnant. Perineal herniation and wound complications were recorded. Laparoscopic and open resection techniques were compared, as were outcomes before and after modification of the flap. There were no flap failures in our cohort of 49 patients. Two patients (4%) required return to theatre acutely for perineal wound complications: one wound dehiscence and one flap-related haematoma. Five patients had evidence of perineal hernia, three prior to any modification of the flap and two following. Three had symptoms of which two required elective repair. The flap modifications were made in response to these cases. There were no significant differences in perineal outcomes for laparoscopic versus open, and before and after flap modification. Over the last 8 years, we have refined our perineal reconstruction technique following instances of perineal herniation and major wound dehiscence. We believe that the PMG flap provides robust and reliable option for the reconstruction of perineal extralevator abdominoperineal defects.

Perineal reconstruction after extralevator abdominoperineal resection: Differences among minimally invasive, open, or open with a vertical rectus abdominis myocutaneous flap approaches

BackgroundPerineal wound complications after extralevator abdominoperineal resection for cancer are common with no consensus on optimal reconstructive technique. We compared short- and long-term results of laparoscopic abdominoperineal resection with open surgery ± vertical rectus abdominis myocutaneous flap. MethodsThis is a single-institution retrospective observational study of 204 consecutive patients with advanced low rectal cancer who underwent extralevator abdominoperineal resection from January 2010 to August 2020. Main outcome measures were short-term results, wound complications, and incisional, parastomal, and perineal hernia rates. ResultsFifty-five (27%) patients had a laparoscopic approach, 80 (39%) open, and 69 (33%) open + vertical rectus abdominis myocutaneous flap. The groups had similar median length of follow up (P = .75). Patients’ age and radiation, intraoperative and postoperative complications, mortality, and readmission rates were similar among the 3 groups. Perineal wound infection and dehiscence rates were not influenced by surgical approach. Laparoscopy resulted in higher perineal (7.3 vs 2.5 vs 0%; P = .047) and parastomal (23.6 vs 13.8 vs 5.8%; P = .016) hernia rates than did open or open + vertical rectus abdominis myocutaneous flap. Patients who underwent an open approach had a higher body mass index and rate of prior surgeries and preoperative ostomies. Laparoscopic and open approaches had significantly shorter operative times (300 vs 303 vs 404 minutes, respectively; P < .001) and shorter length of stay (7.6 vs 10.8 vs 11.12, respectively; P = .006) compared to open with a flap approach. ConclusionOpen and open + vertical rectus abdominis myocutaneous flap approaches for reconstruction after abdominoperineal resection had lower parastomal and perineal hernias rates but similar postoperative morbidity as did the laparoscopic approach.

Perineal hernia repair using polypropylene mesh in three female Jaffarabadi buffaloes - a short communication

This study reports a rare unilateral perineal hernia in three mature female Jaffarabadi buffaloes. The buffaloes presented with a unilateral swelling lateral to the vulvar lip. Upon palpation, the swelling was painless, soft and reducible. Ultrasonography revealed a hyperechoic hernia sac containing the urinary bladder and or motile intestine, with homogenous hypoechoic contents. The perineal hernia was repaired using polypropylene mesh after the repositioning of the retroflexed urinary bladder and/or large intestine. The clinical outcome, including postoperative complications and hernia recurrence, was found via periodic examination and telephone calls. No complications were observed for 6 months of follow-up and all the buffaloes had excellent outcomes.

Laparoscopic perineal hernia repair following pelvic exenteration: a case report

BackgroundAcquired perineal hernia is a rare complication following extensive pelvic surgery. Radiotherapy is also a predisposing factor. Perineal hernia can cause chronic perineal pain, bowel obstruction, urinary disorders and a cosmetically disfiguring defect. The treatment of perineal hernia is surgical, usually consisting of mesh repair via an abdominal or perineal approach.Case presentationWe present a case report and a surgical video of a 42-year-old woman with history of a squamous cell carcinoma. This patient had 3 recurrences since the diagnosis and a symptomatic perineal hernia. Complete regression of the recurrent malignancy allowed us to treat the perineal hernia. We performed laparoscopic repair with prosthetic mesh in this patient who had undergone multiple surgeries and radiotherapy, while preserving the omental flap that was used to reconstruct the posterior part of the vagina.ConclusionThere is no consensus concerning the preferred surgical approach, perineal or laparoscopic, as no study has demonstrated the superiority of either of these approaches. Laparoscopic repair for an acquired perineal hernia is safe and feasible. However, further studies including randomized trials are required to precisely evaluate the best surgical approach and type of mesh.

Flap Reconstruction of Perineal Defects after Pelvic Exenteration: A Systematic Description of Four Choices of Surgical Reconstruction Methods.

The treatment of locally advanced or recurrent anorectal cancer requires radical surgery such as extralevator abdominoperineal resection and pelvic exenteration. Larger defects require flap reconstruction. The authors evaluated outcomes of different perineal reconstruction techniques. A systematic search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting outcomes on perineal flap reconstruction in patients with anal or colorectal cancer were included. Data on patient characteristics, surgical details, perineal and donor-site complications, revision surgery, mortality, and quality of life were extracted. Articles were assessed using the Group Reading Assessment and Diagnostic Evaluation approach. The authors included 58 mainly observational studies comprising 1988 patients. Seventy-three percent of patients had rectal cancer. The majority of 910 abdominoperineal resection patients underwent reconstruction with rectus abdominis flaps (91 percent). Dehiscence (15 to 32 percent) and wound infection (8 to 16 percent) were the most common complications. Partial flap necrosis occurred in 2 to 4 percent and flap loss occurred in 0 to 2 percent. Perineal herniation was seen in 6 percent after gluteal flap reconstruction and in 0 to 1 percent after other types of reconstruction. Donor-site complications were substantial but were reported inconsistently. Clinical outcome data on perineal reconstruction after exenterative surgery are mostly of very low quality. Perineal reconstruction after pelvic exenteration is complex and requires a patient-tailored approach. Primary defect size, reconstruction aims, donor-site availability, and long-term morbidity should be taken into account. This review describes the clinical outcomes of four flap reconstruction techniques. Shared clinical decision-making on perineal reconstruction should be based on these present comprehensive data.

Combined Robotic-Assisted Bio-absorbable Mesh Placement and Gluteal Fasciocutaneous Flap Reconstruction: a Novel Technique for the Repair of a Symptomatic Perineal Hernia Following Extralevator Abdominoperineal Resection for Rectal Cancer

Extralevator abdominoperineal resection for rectal cancer has predominated over the common technique during recent years providing better oncologic results. However, extralevator abdominoperineal resection has been associated to a higher incidence of wound complications and perineal hernia. Several risk factors including preoperative pelvic radiotherapy, laparoscopic abdominoperineal resection, women, previous hysterectomy, obesity, coccygectomy, long small bowel mesentery, postoperative wound infection, and open pelvic peritoneum have been correlated to increased perineal hernia rate. Despite the minor clinical manifestation of a perineal hernia, its effect on the quality of life remains remarkable. Therefore, the surgical management of a perineal hernia after abdominoperineal resection is still a challenge for colorectal surgeons. Several techniques have been used including biologic meshes and myocutaneous flaps. Nevertheless, the ideal technique has not yet been proved. During last years, colorectal surgeons have utilized minimally invasive techniques such as robotic repair of perineal hernias. We presented the first case in the literature of a combined approach of robotic-assisted repair using a bio-absorbable mesh and a gluteal fasciocutaneous flap reconstruction.

Prophylaxis of parastomal, perineal and incisional hernias in colorectal surgery

This article gives an overview of the relevant evidence from the literature on the topic of prophylactic use of meshes to prevent incisional and parastomal hernias in colorectal surgery. In addition, based on a structured literature search the incidence of hernias in colorectal surgery over the past 5years was analyzed. Aslight majority (54%) of articles recommended the use of prophylactic mesh implantation in colorectal surgery. The prophylactic use of meshes appears to reduce the risk of hernias in colorectal surgery but is associated with aslightly increased perioperative wound infection rate. Parastomal hernias are associated with higher incidence rates compared with incisional hernias and also appear to benefit more from prophylactic mesh implantation. The evidence in the literature is still unclear regarding the use of synthetic or biological implants due to the lack of randomized controlled trials. Perineal hernias were excluded from the analysis due to the incomparability of the mainly casuistic literature. An overview is given in the discussion. The analysis of the literature and also in reflection of our own experience comes to the conclusion that the disrupted integrity of the abdominal wall due to the operation should be prophylactically reinforced with amesh after colorectal surgery. An evidence-based recommendation is not possible based on the current state of research on implantation techniques, e.g. onlay, sublay intraperitoneal onlay mesh (IPOM) and selection of the implant.

Chronic prostatitis in a dog infected with a smooth strain of Brucella spp.

Dogs may be occasionally infected by smooth strains of Brucella spp. The infection is usually associated with the ingestion of contaminated material from parturition or abortion, or other tissues from infected farm animals, particularly cattle and pigs. A 6-year-old, male mixed breed dog from a rural area was admitted at a veterinary clinic for clinical examination. The dog had bilateral perineal hernia with dysuria and dyschezia, as well as small firm testicles with scrotal adhesions. Serological tests, including buffered plate antigen, serum agglutination test, and 2-mercaptoethanol test, were positive for smooth Brucella spp. strains, whereas a rapid slide agglutination test was negative for B. canis. Blood and prostate tissue samples yielded no bacterial isolates. Histopathology demonstrated interstitial lymphoplasmacytic and histiocytic infiltration of the prostate gland, with fibrosis and occasional disruption of glandular architecture. Immunohistochemistry demonstrated abundant Brucella spp. antigens in the cytoplasm of macrophages. This report supports the notion that not only B. canis, but also smooth Brucella spp. must be considered in the differential diagnosis of prostatitis in dogs.

Outcomes Following Immediate Vertical Rectus Abdominis Myocutaneous (VRAM) Flap-Based Perineal Reconstruction Following Resectional Surgery For Pelvic Malignancies.

Increasingly radical surgery combined with neo-adjuvant radiotherapy present a challenge for the reconstructive surgeon. The study objective was to review outcomes of Vertical Rectus Abdominis Myocutaneous (VRAM) flap-based perineal reconstruction following resectional surgery for pelvic malignancies. Single-centre retrospective analysis of patients undergoing immediate VRAM flap reconstruction of a perineal/pelvic defect for pelvic malignancy between July 2009 and November 2017. Primary outcome was perineal morbidity (surgical site infection (SSI), flap loss or dehiscence and perineal hernia). Secondary outcomes were length of stay and donor site morbidity (SSI, full-thickness dehiscence and incisional hernia). A total of 178 patients (96 females) were included. Median age was 67years (range 28-88). The majority were performed for locally advanced rectal adenocarcinoma (n = 122; 68.5%) and 136 (76.4%) patients had received neoadjuvant radiotherapy. Four patients had complete flap loss (2.3%), and 40 had perineal dehiscence (22.5%); however, only, 18 patients required a return to theatre during the admission for perineal-related complications (10.1%). Abdominal dehiscence occurred in six patients (3.4%). Median length of post-operative stay was 15days (6-131). Sixty-day mortality rate was 1.1%. SSI at the midline and perineum occurred in 34 (19.1%) and 38 patients (21.3%), respectively. At 90-day post-operatively, 75.6% of perineal wounds were healed. During a median follow-up of 44.5months, twelve, eleven and 39 patients were diagnosed with perineal, midline and parastomal hernias, respectively (6.9%, 6.2% and 21.9%). It is important to have accurate knowledge of perineal and donor-site morbidity rates to allow an informed consent process.