JSUR Journal

The study was approved by the local Danish ethics committee. Written informed consent was obtained from all patients for publication and accompanying images according to the World Medical Association Declaration of Helsinki.

Results

A total number of 13 patients were admitted for surgery. Major symptoms of the perineal hernia were bulging and swelling (77%), pain (69 %), sensation of weight (31%), urinary symptoms (23 %), and general discomfort (23 %). Average time from primary surgery for rectal cancer to admission for hernia surgery was 20,8 months (4.3-121.6), and 360 months in one patient with colitis. The primary surgical procedure was EAPE with mesh (Permacol) reconstruction in 3 patients, gluteal flap in 2 patients, conventional APE in 7 patients and intersfincteric APE in 1 patient. The mean operation time was 48 minutes (32-63). No complications were observed during the surgical procedure or during the stay at hospital. No patients had complications of the perineal wound. The median hospital stay was 4.2 days (1-11).

One patient had pain in the perineal region after 3 months but he had the same symptoms as before surgery and had physical performance as before surgery. 73% of the patients had no symptoms at the 3 months postoperative control (1 had pain, 1 had discomfort, and 2 did not answer the questionary). Clavien Dindo postoperative medical complications were observed in two patients: one had an urinary tract infection, and one had dyspnea caused by atrial fibrillation. The follow-up period by QoL questionary was 70.1 months (12.7-109). Two patients (15%) out of 13 patients had a recurrent perineal hernia in the observation period and underwent new surgery, one with re-suturing of the mesh (technical failure) and one with implantation of a new Permacol mesh. The data on QoL after 70.1 months (12.7-109 months) are listed in Table 2. Eleven out of 13 patients (85 %) answered the questionary (1 dead and 1 had loss of memory). As shown, the sensation of weight and/or foreign object in the body was reported to be worst when sitting, while pain was most present when exercising. Reduced movement was most present when doing everyday life activities. Thirty percentage had sensory disturbances in the perineal area. Seventy-five percentage would recommend the procedure to other patients.

Table 2: Symptomatic score of quality of life using the Carolina Comfort Scale in patients after open surgery for perineal hernia.

Discussion

The use of more extended surgical procedures for low rectal cancer could result in increasing numbers of perineal hernias, especially after the implementation of EAPE, since this technique includes resection of the pelvic floor to achieve free surgical margins. Implementation of this new operation technique leads to new challenges in primary reconstruction of the pelvic floor. The development of 6-26% perineal hernias after EAPE with mesh reconstruction (Jensen [10]: 6%, Musters [11]: 8%, Han [12]: 14% and Sayers [5]: 26%) rises questions such as: could reconstruction be performed as a primary procedure, or may it be performed secondary if the patient develops a symptomatic perineal hernia? This has not yet been investigated in a randomized trial. Primary closure seems to be logic from a patient point of view. Against this is, that it has economic consequences caused by the price of the mesh. This study shows than secondary reconstruction in patients with a hernia can performed with no major perioperative risk. Flap reconstruction procedures, either primary or secondary, often require the presence of a plastic surgeon. This increases the opportunity costs and with functional drawbacks for the patient according to physical performance, donor site morbidity, and QoL. Since 1997 we have used the VRAM flap as a safe method for reconstruction after salvage surgery for anal cancer in patients having previous irradiation of the pelvis. We have shown low rate of perineal complications after this method [6]. However, we only use this method in patients after wide ischioanal and wide perineal skin resections, and for vaginal reconstruction since it has a high donor-site morbidity [7]. Holm et al. preferred to use the gluteal muscle flap for pelvic floor reconstruction after eAPE [4]. Reconstruction of the perineum with a fasciocutaneous gluteal flap was safe when looking on wound healing whereas the risk of perineal hernia development was unacceptable high (21%). Consequently, if a gluteus flap is used for reconstruction of the perineum, it must be performed as a rotational musculocutaneous flap alone [4,13] , or in combination with a mesh beneath the flap.

When using a mesh for reconstruction the length of hospital stay is reduced [14] and the patients can be mobilized immediately after surgery. One study showed no difference between the frequence of secondary perineal hernias between flap and mesh reconstructed patients [15]. Historical, perineal wound healing problems is a significant problem after primary closure of the pelvic floor and perineum after APE [13]. Infection is a risk of developing a hernia and wound healing complications are increased after implementation of preoperative neoadjuvant irradiation [8]. A Danish study showed 26% wound complications after standard APR without radiotherapy and 71% in patients given preoperative radiotherapy [10]. The incidence of symptomatic perineal hernia following conventional APE is estimated to be from 0.2% to 0.6% and 6% after more extensive surgery on the pelvis, like EAPE.

Diminished healing of the perineal wound may also increase the risk of perineal hernia development, and both smoking, and chemo irradiation are shown to be significant factors in hernia development [16,17]. Previous results showed that extensive resection with removal of the pelvic floor in EAPE imposes the need for reconstructive procedures to prevent later development of hernia, and that all hernias was observed within the first 12 months [8]. However, mesh reconstructed patients might develop hernias over time due to weakening or dissolving of the biological mesh [18], and studies with a longer observation period after surgery are needed. There are referrals in the literature with high recurrence rate when using biological mesh in up to half of the patients in different type of hernias. One reason of this differences between our results and other studies on biological mesh for hernia repair might be, that no infections were seen in this relative small study, and in order to have final conclusions about the efficiency of biological meshes, more series are required, preferable in a randomized study. The present method was implemented in our department after having seen two late mesh infections (> 1 year) after laparoscopically repair of a perineal hernia using a conventional mesh type. Randomized studies on trans-perineal versus laparoscopic repair and on the different mesh types are needed. Furthermore, the costs and higher infection rate of primary reconstruction after EAPE could argue to perform studies on primary versus secondary reconstruction.

The optimal surgical technique must minimize complications such as failure of the sutured mesh, which may lead to a hernia. We used interrupted, monofilament absorbable sutures to fix the mesh, both when doing the primary and the secondary reconstruction. Moreover, care was taken to spare skin and to minimize the dead- space between the mesh and the skin. Several advantages were observed: the implantation is easy to learn, it can be performed without plastic surgical assistance [18,19] and the operating time is short. It is useful in patients where laparoscopic repair is technical challenging or contraindicated. Some of the biologic mesh types available have elastin fibers with natural cross-links in the mesh which can be considered beneficial to tissue integration and may preserve the mechanical strength of the mesh after surgery. The risk of infection is significant, but the consequences of infection are not serious when using a biological mesh compared to non- biologic mesh types. The risk of developing a fistula between the mesh and skin is an obvious risk, but this complication was not seen in this study. The disintegration of the biological mesh may lead to reduced tensile strength and higher risk of recurrence compared to a traditional mesh type. One study on 29 patients reconstructed with a high-tension repair of a non-resorbable mesh showing relapse in 5% (1 out of 20 patients) [20], compared with 15 % (2 out of 13 patients) in this paper. Finally, the cost of a biological mech is much higher compared to a traditional mesh.

QoL for the patient is dependent on factors as perioperative morbidity and pain, physical behavior, and possible development of a recurrent perineal hernia. However, approximately half of the patients had reduction in QoL, however 75% still would recommend the operation method to other patients. This could be taken as an important parameter for effect of the procedure. The question: “Will you recommend the operation to other patients with the same disorder?” the answer was yes in 75% of the patients. The 25% who answer no or maybe to the question was not surprisingly linked to the patients with relapse. It is not likely that there are no significant difference in QoL between a biological mech and a traditional mesh type.