1. 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

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

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

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

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

7. 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

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

9. 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

10. Wound infection

11. 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

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

13. 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.

14. 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

15. Thank you

16. 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

17. 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/ 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

18. 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/ with no flaps.
2/6 pt with dehiscence vs. 4/ with no dehiscence

19. 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