Perineal Repair After Extralevator Abdominoperineal Excision for Low Rectal Cancer

BACKGROUND: Extralevator abdominoperineal excision for low rectal cancer includes resection of the pelvic floor as a part of the operative technique to reduce the risk of tumor-involved section margins. OBJECTIVE: This study aimed to compare perineal defect reconstruction with a fasciocutaneous gluteal flap vs biological mesh regarding healing and occurrence of perineal hernia. DESIGN: Retrospective review of medical records comparing surgical methods during 2 consecutive periods. SETTINGS: Tertiary care university medical center (Colorectal Section, Surgical Department P, Aarhus University Hospital, Denmark). PATIENTS: Patients with low rectal cancer who underwent extralevator abdominoperineal excision from December 2005 through October 2008 were included. INTERVENTION: The perineum was reconstructed with a fasciocutaneous gluteal flap in the first period and with a biological mesh in the second period. MAIN OUTCOME MEASURES: We assessed rates of perineal wound infection requiring surgical intervention and perineal hernia diagnosed by clinical examination. RESULTS: The study comprised 57 patients: 33 patients with gluteal flap and 24 with biological mesh reconstruction. Perineal hernia developed in 7 (21%) patients in the gluteal flap group and in none (0%) of the patients in the mesh group (P < .01). Median follow-up was 3.2 (1.7-4.3) years for gluteal flap and 1.7 (0.4-2.2) years for biologic mesh. All hernias occurred within the first postoperative year (median, 6 months; range, 1-12 months). Infectious complications were seen in 2 patients (6%) with a gluteal flap and in 4 patients (17%) with mesh repair (P = .26). After 3 months, all patients were completely healed except for 1 patient in each group with a persistent perineal sinus. The median (range) hospital stay was 14 (8-23) days in the flap group and 9 days (6-35) in the mesh group (P < .05). LIMITATIONS: This was a nonrandomized retrospective observational study comparing 2 methods used in different time periods. CONCLUSION: We recommend biological mesh reconstruction of the pelvic floor after extralevator abdominoperineal resection because this method can achieve a high healing rate with an acceptable risk of infection, a low hernia rate, and a shorter hospital stay without donor-site morbidity.