Case series of in situ pelvic floor reconstruction combining levator ani suture and negative pressure wound therapy for abdominoperineal resection

Abstract

Background Abdominoperineal resection (APR) is a standard surgical technique for low rectum cancer with a low recurrence rate. There are some problems associated with APR such as perineal hernia and perineal surgical site infection. Recently, the prophylactic efficacy of negative pressure wound therapy (NPWT) for surgical site infection has been reported. Herein, we analyzed the efficacy of in situ pelvic floor reconstruction combining levator ani suture and NPWT after APR for perineal hernia and perineal surgical site infection. Methods We analyzed six patients treated by laparoscopic APR with NPWT combined with levator ani suture retrospectively. The primary endpoints were surgical site infection within 30 days and perineal hernia within 1 year after surgery. The day following surgery, we performed NPWT for the perineal wound using the VAC ® abdominal wound management system (KCI, San Antonio, TX, USA). Results There were four male and two female patients ranging in age from 69 to 86 years (mean: 76 years). The mean NPTW duration was 17 days (13–20 days). The length of the postoperative hospital stay was 14–22 days (median: 18 days). There was no patient with surgical site infection within 30 days or with perineal hernia within 1 year after surgery. Conclusion We experienced the in situ pelvic floor reconstruction combining levator ani suture and NPWT after laparoscopic APR for perineal hernia and perineal surgical site infection. This combination treatment was safe and may be effective for preventing surgical site infection and perineal hernia.

Surgical Repair of Postoperative Perineal Hernia: A Case for the Perineal Approach

“…14 No factors have been strongly established to increase the risk of PH, although multiple factors have been identified as potential risk factors; these include obesity, diabetes, chemoradiotherapy, and extensive pelvic floor resections (eg, ELAPR). 4,5,7,10 In our series, most patients had received neoadjuvant CRT, suggesting that it may be a risk factor contributing to the development of PH; however, our study is underpowered with no controls. This finding was similar to McKenna et al 11 , Martijnse et al 10 , and Abbas & Garner 5 in that the majority of their patients had received neoadjuvant CRT; this may indicate an effect on wound healing, or it may be that most patients undergoing APR for rectal cancer receive neoadjuvant CRT.…”

“…P erineal hernia (PH), although rare, is a well-known complication following abdominoperineal resection (APR) for rectal cancer and has been defined as a defect in the pelvic floor through which abdominal and/ or pelvic viscera protrude. [1][2][3][4][5][6][7][8] The reported incidence varies from less than 1% to 13%; [3][4][5][6][8][9][10][11] in our previous study, we found an incidence of 1%. 12 Due to its rarity, the literature on surgical PH repair is comprised of case reports and small case series, and not one surgical approach has been established as superior.…”

“…Following their index operation, 3 patients had a pelvic abscess, and 1 had a MRSA infection of the buttock. Pelvic procedures prior to APR included hysterectomy (7), appendectomy (1), bladder suspension (1), and tubal ligation postpartum (1).…”

“…Drains were used in 22 patients (10 transabdominal and 12 perineal repairs) for a range of 2 days to 9 weeks, and a median of 10 days. The median LOS after a perineal approach was 4 days (1-12) and after a transabdominal approach was 8 days (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18).…”

Retrospective analysis of risk factors for postoperative perineal hernia after endoscopic abdominoperineal excision for rectal cancer

“…Various pelvic reinforcements as alternatives to PPC have been performed after APE: suture of levator ani muscle, bladder peritoneal flaps, hysteropexy, omentoplasty and synthetic mesh. Levator ani muscle suturing [25] could not be applied to rectal cancer surgery because of wide excision of the muscle. A randomized trial revealed that omentoplasty did not reduce the incidence of PPH [26].…”