Is there need for Pelvic Floor Reconstruction after Abdominoperineal Resection/ Pelvic Exenteration (APER/PE)? A Saklani, N Marsden, M Davies, C Sekaran, U Khot, N D Carr, J Beynon Colorectal Department, Singleton Hospital, Swansea Much discussion about skin closure after APER, very little discussion about pelvic floor reconstruction

Aim Incidence of Perineal hernia following APER. Assess: Incidence of Perineal hernia following APER. Need for Pelvic Floor Reconstruction after (APER/PE)?

Methods Retrospective 2004-2009 APER and Pelvic exenteration OPSC code Details of pelvic floor closure Early and delayed perineal wound problems

Results Total 76 APER 60 APER + Contiguous organ excision 16 Laparoscopic 14

Results Median age 70 years (36-87) Male/female 1.2 Rectal cancers 63 Anal cancers 7 Gynaecological Ca. 5 Miscellaneous 1

Method of pelvic floor repair (n = 76) Omentopexy alone 34 Omentopexy + Other reconstruction 12 Permacol alone 4 Synthetic mesh 5 Gracilis transposition 1 VRAM flap 1 None 19

Results RT n=35 (46%) Exenteration n=13 Reconstruction n=23 (Mesh/gracilis)

Results (n=76) Median Follow up 17 months(1-55) No of patients analysed 70 Delayed Wound healing 22 ( 30%) Wound dehiscence 6 (8.3%) Managed conservatively 3

Wound infection

Perineal wound dehiscence (p=NS) Total Yes No Details not available Pelvic floor reconstruction 4 18 1 23 No Pelvic floor reconstruction 2 47 53 6 65 5 76

Perineal Hernias Total 5/70 Omentopexy alone 2/34 No reconstruction 3/19 Reconstructed pelvic floor 0/23

Perineal hernia 53 patients underwent a omentoplasty alone. 4 patients were not available for analysis in this group. However, 5 patients developed a perineal hernia. On the left side, patients who underwent some form of pelvic floor reconstruction is shown and you will notice that none of these developed a perineal hernia.

Conclusion Perineal hernia after APER is not uncommon. Omentopexy and soft tissue closure may not prevent perineal hernia. Recommend pelvic floor repair in all patients undergoing pelvic ablative surgery

Thank you

Perineal hernias Pelvic floor Reconst. Age Sex RTx Surgery Omentum Skin flaps Wound dehiscence Fu months outcome 80 F No APER 30 m Lung mets No sx 40 Yes PE 32 m Enterocele Repaired PH no sx 70 M Lap 9 M Repaired perineal approach 85 13 m Not fit SX 61 9 m Vaginal prolapse awaiting SX

Factors for Perineal hernias Type of procedure Omentoplasty Radiotherapy Female sex Hysterectomy 4/60 APER vs 1/12 PE 2/41 with omentum vs 3/29 no omentum 2/31 with RT vs 3/38 with no RT. 4/32 females vs. 1/39 males 2/16 hysterectomy vs 1/13 intact uterus

Factors for Perineal hernia Pelvic floor repair Skin flaps Wound dehiscence 0/22 PFR vs. 5/49 without PFR 0/5 patients with flaps vs. 5/66 with no flaps. 2/6 pt with dehiscence vs. 4/65 with no dehiscence

Pelvic floor reconstruction No Pelvic floor reconstruction Total Male/female 11/12 30/23 P=NS Radiotherapy/ no RT 14/ 8 21/32 P=0.05 Omentoplasty Yes/no 12/11 34/19 APER/ Pelvic Exenteration 15/8 48/5 P<0.05 Skin flaps/no skin flaps 5/18 1/53