Annales de chirurgie plastique esthétique (2020) 65, e15—e21

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TECHNICAL NOTE

Biological mesh used to repair perineal

hernias following abdominoperineal
resection for anorectal cancer
Cure d’éventration périnéale par prothèse biologique après
amputation abdominopérinéale pour cancer anorectal

M. Jafari a,*, L. Schneider-Bordat a, B. Hersant b

a
Service de chirurgie oncologique, centre Oscar-Lambret, 3, rue Combemale, 59020 Lille cedex, France
b
Service de chirurgie plastique, reconstructrice, esthétique, et maxillo-faciale, hôpitaux universitaires
Henri-Mondor, 51, avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France

Received 25 July 2019; received in revised form 20 November 2019; accepted 2 December 2019

KEYWORDS Summary
Abdominoperineal Purpose. — This study aimed to determine the outcome for patients who had undergone perineal
excision; hernia repair, via a perineal approach, using a biological mesh post-abdominoperineal excision
Perineal hernia; (APE) for anorectal cancer.
Biological mesh Method. — All consecutive patients having undergone perineal hernia repair involving an
extracellular matrix of porcine small intestinal submucosa at our hospital between 2015 and
2018 were included. Follow-up clinical examinations and computed tomography scans were
performed.
Results. — Six patients were treated surgically for symptomatic perineal hernia after a median
of 31 months from APE. The median follow-up after hernia repair was 11 months (interquartile
range [IQR], 6—35 months). Three patients (50%) developed a recurrent perineal hernia after a
median interval of 6 months.
Conclusion. — Perineal hernia repair using a biological mesh resulted in a high recurrence rate in
patients who had undergone APE for anorectal cancer.
# 2020 Elsevier Masson SAS. All rights reserved.

* Corresponding author.
E-mail address: m-jafari@o-lambret.fr (M. Jafari).

https://doi.org/10.1016/j.anplas.2019.12.004
0294-1260/# 2020 Elsevier Masson SAS. All rights reserved.
e16 M. Jafari et al.
Résumé
MOTS CLÉS Objectif. — Le but de cette étude était de déterminer les résultats de cure d’éventration
Amputation périnéale par voie périnéale et par prothèse biologique après amputation abdominopérinéale
abdominopérinéale ; (AAP) pour un cancer anorectal.
Éventration périnéale ; Méthode. — Tous les patients ayant été opérés d’une cure d’éventration périnéale à l’aide une
Prothèse biologique matrice extracellulaire de sous-muqueuse intestinale porcine dans notre hôpital entre 2015 et
2018 ont été inclus. Les patients ont été suivis par examens cliniques et scanner abdomino-
pelvien.
Résultats. — Six patients ont été opérés d’une d’éventration périnéale après un intervalle
médian de 31 mois post-AAP. Le suivi médian après cure d’éventration périnéale était de 11 mois
(intervalle interquartile [IQR], 6—35 mois). Trois patients (50 %) ont développé une récidive
d’éventration périnéale après un intervalle médian de 6 mois.
Conclusion. — La cure d’éventration périnéale par prothèse biologique a entraîné un taux de
récidive élevé chez les patients ayant été opérés d’une AAP pour un cancer anorectal.
# 2020 Elsevier Masson SAS. Tous droits réservés.

Introduction We aimed to determine the rate of recurrence of perineal

Perineal hernia (PerH) is a known and late complication of
abdominoperineal excision (APE) of the rectum. Extralevator
abdominoperineal excision (ELAPE) has been reported to
improve oncological outcomes [1—3] compared with stan-
dard APE; however, this technique has been found to create a
large defect at the level of the pelvic floor which, in turn,
may increase the risk of PerH, with a reported incidence rate
of up to 26% [4].
PerH is defined as a protrusion of intra-abdominal viscera
through the pelvic floor into the perineal region (Fig. 1). For
asymptomatic patients, treatment is typically conservative.
However, some patients may experience discomfort, pain,
urinary dysfunction, skin disorders and, more rarely, bowel
obstruction, and surgical repair is challenging. Several cri-
teria may complicate the operation, namely, the extent of
adhesiolysis, tissues weakened due to radiotherapy, a large
defect, and comorbidities which may affect healing.
There is no consensus concerning the optimal treatment
of PerH [5]. Various techniques have been reported using
synthetic mesh, biological mesh, and a myocutaneous flap
[6—8].
Anterolateral thigh, rectus abdominis, gluteal, and gra-
cilis muscle flaps have been reported to be the most widely
used, whether alone or in combination with a mesh [9].
Biological mesh has been reported as inducing tissue
regeneration rather than scars and as suitable for use within
a potentially contaminated field [10,11].
Biological mesh has previously been used for primary
pelvic floor closure after APE and has been shown to provide
additional benefits compared to that of myocutaneous flap
reconstruction, such as shorter operating times, low mor-
bidity, absence of donor-site morbidity, and reduced length
of hospital stay [12]. Moreover, it has been reported to
decrease the rate of PerH development [13]. The use of
biological mesh has progressed significantly in abdominal
wall reconstruction surgery, but recent data have not
confirmed the benefits of its use over synthetic mesh, and
routine use has not been recommended [14].
hernias after surgical reparation using biological mesh via a
perineal approach.
Methods
All patients with a PerH who had received surgical treatment
between January 2015 and April 2018 were identified retro-
spectively in one specialized cancer surgery center. This
study was carried out in accordance with the recommenda-
tions of local ethics committee and conducted in accor-
dance with the Helsinki declaration with written informed
consent from all subjects. All subjects gave written
informed consent in accordance with the Declaration of
Helsinki. The protocol was approved by the Centre Oscar-
Lambret ethics committee.
We reviewed all included patients’ case notes and
obtained information concerning patient age, the surgical
approach, neoadjuvant radiotherapy, history of smoking,
time to repair, and type of reparation. Following surgical
repair, recurrence was assessed during oncological follow-up
through clinical examination and abdominopelvic computed
tomography (CT) scanning. Postoperative complications
were also noted. Data were described as medians with
interquartile ranges (IQR).
Surgical procedure
One senior colorectal surgeon had performed the operations
on all of the study patients (Fig. 2).
The procedure started with a resection of the cutaneous
scar and hernia sac. A dissection was conducted to display
the coccyx posteriorly, the remnants of the levator muscle
laterally, and the posterior wall of the vagina or the prostate
gland. A 7  10 cm extracellular matrix of the porcine small
intestinal submucosa (Surgisis Cook Biodesign1) was sutured
to the sacrococcygeal ligament, to the remnants of the
levator muscle, and to the posterior wall of the vagina or
the prostate gland, with interrupted 2.0 polypropylene
Biological mesh used to repair perineal hernias
Figure 1 Perineal hernia. a: patient with symptomatic pernieal hernia; b: sagittal section of CT scan of the patient showing the
extension of the small intestine underneath the pelvic floor.
sutures. The omentum or the peritoneum of the hernia sac
was used to cover the intestinal side of the mesh. A 14-
French vacuum drain was placed on the subcutaneous side of
the mesh. The skin was closed with no tension.
Results
Between January 2015 and April 2018, six patients underwent
surgery for a symptomatic perineal hernia. Perineal recon-
struction was performed with the use of a biological mesh via
a perineal approach in a supine position for five patients and
in a prone position for one patient.
The patient characteristics are shown in Table 1.
The median interval from APE to perineal hernia repair
was 31 months (IQR, 13—49). The median follow-up after
hernia repair was 11 months (IQR, 6—35). Perineal hernia
recurrence occurred in 3 patients (50%) after a median
interval of 6 months (Fig. 3). The only postoperative com-
plication was urinary retention in one female patient, who
recovered after 1 month. No postoperative infections or
inflammatory syndromes were reported following the pro-
cedures.
Patient characteristics at the time of perineal hernia
repair are shown in Table 2.
Figure 2 Surgical technique. a: patient in the prone position; b: dissection of the remnants of the levator muscle; c: the biological
mesh stitched with minimum tension.
e17
Discussion
We report a limited cohort of patients who underwent a
biological mesh reconstruction for PerH following APE or
ELAPE. Only patients who had experienced severe symptoms
such as pain or discomfort underwent surgical repair. The
50% recurrence rate that we report is high, and comparable
to other studies reporting the use of biological mesh [5,7].
Therefore, we cannot recommend this technique; however,
the low rate of postoperative complications was noteworthy.
Some authors have reported using biological mesh in
association with a local flap such as the gluteal V-Y flap or
the gracilis muscle flap. While reported recurrence rates
were low, data were limited [4,6,7,15].
Non-irradiated tissue could facilitate colonization of the
mesh. While application of this technique requires plastic
surgical expertise, it may be a viable alternative to recon-
struction alone using a mesh [4,7]. Furthermore, the use of a
flap enhances the strength of the repair, as the biological
mesh is too supple and flexible to replace the pelvic floor
alone.
In a systematic review of the literature involving 108
patients who had undergone PerH repair after APE, a recur-
rence rate of 24% was reported. Non-absorbable mesh,
e18 M. Jafari et al.

Table 1 Patient characteristics and primary tumor treat- In 2012, we performed our first PerH repair using a
ment. composite permanent synthetic mesh via a perineal
approach. After 11 months of follow-up, there was no recur-
Characteristics n=6
rence. We did not include this case in our study series
Sex because the focus in this study concerned biological mesh.
Female (n, %) 4 (67) Despite this first encouraging result, wound healing was a
Age concern, with subsequent infection of the synthetic mesh
Mean years  SD 59.5  8 placed in the immediate subcutaneous area. Moreover, all
Primary disease our patients had received radiotherapy, which can delay
Rectal cancer (n, %) 4 (67) wound healing [16,17].
Anal cancer (n, %) 2 (33) It has been reported that acellular biological tissues can
Radiotherapy (n, %) 6 (100) provide a natural microenvironment for host cell migration
Type of APE and may be used as a scaffold for tissue regeneration [18,19].
Standard APE (n, %) 1 (7) One patient, who had a recurrence, underwent a second
Extralevator APE (n, %) 5 (83) operation for PerH repair with a composite permanent mesh
Surgery via an abdominal approach. We observed neither regenera-
Laparoscopy (n, %) 6 (100) tive tissue nor biological mesh, whereas 2.0 interrupted
Omentoplasty (n, %) 6 (100) polypropylene sutures had remained intact in the area of
the first repair. This finding reinforced reported concerns
APE: abdominoperineal excision; SD: standard deviation.
that radiation therapy delays the colonization process of the
mesh by host tissues [20,21]. All our patients received
composite mesh, biological mesh, and a flap reconstruction radiation therapy, which may explain the high rate of recur-
had been used for 38%, 19%, 18%, and 23% of patients, rence in our series [22].
respectively [9]. The use of biological mesh can also result in postoperative
Martijnse et al. reported a 5% recurrence rate with a high- complications. In a Food and Drug Administration database
tension repair using a non-absorbable mesh in 21 patients, review, 150 major complications were reported concerning
with a median follow-up of 24 months [8]. reconstructions undertaken using xenograft biological mesh

Figure 3 Recurrence in a male patient after perineal hernia repair with a biological mesh. a: one month after surgery; b: no clinical
recurrence at 6 months; c: sagittal section of CT scan at 6 month after surgery. The small intestine is at the level of the pelvic floor; d:
clinical recurrence at 18 months after surgery; e: sagittal section of CT scan at 18 month. The small intestine is extending underneath
of the pelvic floor.
Biological mesh used to repair perineal hernias
Table 2 Patient characteristics at the time of perineal hernia repair and at follow-up.
Number Sex Age Smoking Primary tumor
1 F 65 Ex-smoker Rectum
2 F 49 No Rectum
3 M 67 Ex-smoker Rectum
4 F 66 No Anus
5 F 69 No Rectum
6 M 61 No Anus
APE: abdominoperineal excision; ELAPE: extralevator abdominoperineal excision; *: patients who had a pernieal hernia recurrenace after
surgical repair.
implantations into the abdominal wall from 1997 to 2008.
The most frequent complications were identified as acute
mechanical failure (42%), mesh disintegration (32%), and
poor integration (13%). The use of cross-linked meshes were
found to have the most adverse events [23].
In one literature review, complications of acellular der-
mal matrices in abdominal wall reconstructions were
reported to have predominantly involved hernia recurrence,
infection, skin necrosis, and seroma [24]. In another litera-
ture review concerning the use of biological matrices in
contaminated fields, one-stage repair of ventral incisional
hernias involved infrequent subsequent mesh removal but
with a high recurrence rate [25].
We opted to use a non-cross-linked mesh. Surgisis (Cook
Biodesign1) is a three-dimensional extracellular matrix of
the porcine submucosal small intestine. This matrix has been
reported to facilitate host cell and blood vessel infiltration
[26]. Our high recurrence rate might be explained due to the
use of a non-cross-linked mesh. Degradation of non-cross-
linked mesh has been shown to occur faster than cross-linked
mesh [27,28]. Cross-linked mesh has been reported to induce
an inflammatory response, and involve less tissue remodeling
[29]. Encapsulation and fistulae formation post-PerH repair
have been reported with the use of cross-linked mesh [7,30].
Different matrices do not have the same efficiency or
complication rates. In a recent prospective study involving a
database of 229 patients who had undergone abdominal wall
reconstruction using 3 acellular dermal matrices, namely,
fortiva, strattice, and alloderm, it was reported that there
was an increased recurrence rate using alloderm (22%) com-
pared to strattice (11.2%) and fortiva (6.9%); and a seroma
rate significantly lower using fortiva (1.4%) compared to
strattice (13.3%) and alloderm (11.9%). However, complica-
tion rates in relation to delayed healing, skin necrosis, fistula
formation, and hematoma formation were not significantly
different [31].
There is currently no consensus concerning the optimal
operative approach in managing perineal hernias. Similar to
other reports, we selected the perineal approach due to its
simplicity [6]. A prone position offers better exposure, and
the visceral mass does not interfere with the operation field
[32]. Using this approach, anterior fixation of the mesh is the
most technically demanding aspect. Caution is required to
avoid injury to the male urethra or to the vagina. Anterior
fixation of the mesh is undertaken on less solid tissues than
lateral or posterior mesh fixations. The challenges involved
with anterior fixation may explain failures that occur follow-
ing the use of this approach.
e19
Surgery Follow-up Recurrence*
(month) (month)
APE 14 No
ELAPE 35 No
ELAPE 25 Yes (6)
ELAPE 27 Yes (8)
ELAPE 40 No
ELAPE 14 Yes (6)
The abdominal technique allows better visualization of
the defect and identification of tumor recurrence, while the
perineal approach minimizes the potential risks associated
with entering the peritoneal cavity. However, the abdominal
technique is a more intricately demanding approach that
may require extensive enterolysis. A combined approach is
also possible. According to several case reports, laparotomy,
laparoscopy, or a robotic approach would provide better
coverage of this area using a larger mesh [33—35].
There is currently no consensus as to the optimal opera-
tive technique in terms of prevention and management of
PerH. Pelvic floor reconstruction using biological mesh or a
myocutaneous flap at the time of ELAPE has been reported to
improve perineal wound healing and to prevent PerH forma-
tion [12,36].
The gluteal flap, and the rectus abdominis and gracilis
muscle flaps are most commonly used to repair the pelvic
floor after ELAPE to reduce the risk of wound healing com-
plications and PerH formation. However, complications may
be associated with donor-site morbidity and flap necrosis.
ELAPE also requires the expertise of an attending plastic
surgeon [37,38].
Foster et al. [39] demonstrated that primary reconstruc-
tion at the time of ELAPE may be preferable in potentially
preventing PerH. In that systematic review comparing 225
perineal closures after ELAPE using flaps and 85 closures
using biological mesh, no significant difference in the rate of
perineal wound complications or PerH formation was found.
However, the rate of PerH formation was low in both pro-
cedures: 3.9% after flap reconstruction and 3.5% after bio-
logical mesh closure. Myocutaneous or fasciocutaneous
gluteal and vertical rectus abdominis muscle flaps were used
most frequently.
Lefevre et al. [40] showed that patients who had under-
gone a vertical rectus abdominis myocutaneous flap proce-
dure after APE for anal cancer developed fewer PerHs than
did patients who had omentoplasty, with no difference
observed in the incidence of abdominal incisional hernia
formation.
In a randomized trial, Muster and al. [13] compared
primary perineal closure and biological mesh closure after
ELAPE. The rate of PerH formation was significantly lower in
the biological mesh group, while wound-healing times did
not differ. These findings showed that synchronous recon-
struction using a biological mesh or a flap at the time of
ELAPE decreased the rate of PerH formation, which suggests
that to prevent PerH formation the use of biological mesh
should be more frequently considered.
e20
This study had some limitations, namely, the retrospec-
tive design of this study and the small sample size. However,
given the limited data available on this topic, we considered
it useful to report our patient outcomes and experiences.
Despite the limitations of our study, perineal hernia repair
with a non-cross-linked biological mesh via a perineal
approach resulted in a high recurrence rate in patients
who had undergone radiotherapy and APE for anorectal
cancer.
Preventing PerH recurrence should be considered and, in
cases of recurrence, the use of biological mesh could be used
in conjunction with a flap. Surgery undertaken in collabora-
tion with a plastic surgeon may result in improved outcomes.
Disclosure of interest
The authors declare that they have no competing interest.
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