Abstract
Aim
The aim of this systematic review was to analyse recurrence rates after different surgical techniques for perineal hernia repair.
Method
All original studies (n ≥ 2 patients) reporting recurrence rates after perineal hernia repair after abdominoperineal resection (APR) were included. The electronic database PubMed was last searched in December 2021. The primary outcome was recurrent perineal hernia. A weighted average of the logit proportions was determined by the use of the generic inverse variance method and random effects model.
Results
A total of 19 studies involving 172 patients were included. The mean age of patients was 64 ± 5.6 years and the indication for APR was predominantly cancer (99%, 170/172). The pooled percentage of recurrent perineal hernia was 39% (95% CI: 27%–52%) after biological mesh closure, 29% (95% CI: 21%–39%) after synthetic mesh closure, 37% (95% CI: 14%–67%) after tissue flap reconstruction only and 9% (95% CI: 1%–45%) after tissue flap reconstruction combined with mesh.
Conclusion
Recurrence rates after mesh repair of perineal hernia are high, without a clear difference between biological and synthetic meshes. The addition of a tissue flap to mesh repair seemed to have a favourable outcome, which warrants further investigation.
Keywords: abdominoperineal resection, flap, mesh, perineal hernia repair
INTRODUCTION
Perineal hernia after abdominoperineal resection (APR) remains a vexing problem for both patients and clinicians. In the current literature the incidence of symptomatic perineal hernia ranges from 7% to 30% [1, 2, 3]. A perineal hernia may cause discomfort, pain, wound healing problems, urogenital dysfunction and small bowel obstruction [4, 5, 6]. Depending on the severity of symptoms, preference and experience of the surgeon, an elective repair is sometimes considered. In contrast to abdominal wall hernias, literature on perineal hernia repair is very limited.
Recurrence rates after surgical repair of a perineal hernia are high, and no consensus has been reached regarding the preferred method. Many options have been described, including primary closure, biological and synthetic mesh closure and tissue flap reconstruction. Moreover, there are no recommendations on whether an abdominal, perineal or combined approach is best. To date, two systematic reviews have been conducted on this topic; these were published in 2012 and 2017 [7, 8]. Both studies were limited by small numbers and heterogeneity making any meaningful comparison between the outcomes of different techniques difficult. Surgical repair of symptomatic perineal hernia has increasingly gained attention, and several additional reports have been published since then.
Therefore, the aim of this systematic review was to compare outcomes between the different surgical techniques for perineal hernia repair after APR based on the most recent literature.
METHOD
Study design and participants
The inclusion criterion was all original studies describing success rates of surgical perineal hernia repair after either laparoscopic or open APR. Exclusion criteria were articles written in any language other than English, non‐human population, age below 18 years, total population less than two, congenital perineal hernia and perineal hernia after sacrectomy or total pelvic exenteration. Papers published before the year 2000 were excluded to minimize the impact of technical developments over time. Also, patients who had had primary closure of a perineal hernia were excluded since this is no longer considered a valid surgical option [8]. The quality of studies was assessed using the Newcastle–Ottawa Scale (NOS). The protocol was prospectively registered in the Prospero database (registration number CRD42021274677). The systematic review was performed according to the AMSTAR2 checklist [9].
Systematic literature search
The electronic database of PubMed (1939–2021) was systematically searched with the help of a librarian. The following medical subject heading (MESH) terms were used: (“perineal” OR “perineum”) AND (“hernia”). All papers were screened for title and abstract to determine if they met the inclusion criterion. Eligible papers were retrieved and the full text was read to determine inclusion. All full‐text papers were screened by two independent authors (SSH, TPAB). Any discrepancies between the two authors were resolved by a third author (GDM or PJT).
Primary and secondary outcomes
The primary outcome was recurrent perineal hernia. The different types of reconstruction were biological mesh closure, synthetic mesh closure, tissue flap reconstruction only and tissue flap reconstruction combined with mesh closure. Secondary outcomes were the time interval between hernia repair and recurrence, and second recurrence.
Data extraction
Data extracted included gender, age, primary disease and neoadjuvant radiotherapy. Specifically, for perineal hernia repair we extracted approach and surgical technique, content of perineal hernia (e.g. small bowel, omentum), complications, follow‐up duration, definition of recurrence and the recurrence rate. Time intervals between APR and repair of perineal hernia and between repair and recurrence were extracted, as well as the surgical technique for a redo for second recurrence.
Data from the included studies were extracted independently by three authors (SSH, TPAB, SIK). Any discrepancies were discussed amongst the three reviewers. If no consensus could be reached, a third author was consulted (GDM or PJT).
Data synthesis
Categorical data are presented using proportions and percentages. Numerical data were transformed from medians to means in order to calculate weighted means. For each method of perineal hernia reconstruction and approach to repair, a weighted average of the logit proportions was determined by the use of the generic inverse variance method and random effects model. Heterogeneity was assed using I 2 and was considered significant if I 2 > 75%. A p‐value <0.05 was considered statistically significant. Publication bias was assessed using a funnel plot. Analyses were performed with the use of RStudio Team (Integrated Development for R, RStudio Inc., 2019).
RESULTS
The search resulted in 872 papers, which were all screened by title and abstract. The Preferred Reporting Items for Systematic Review and Meta‐Analysis (PRISMA) flow diagram is shown in Figure 1 [3, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27]. A total of 19 studies, describing 172 patients, were included in this review (Table 1). Quality assessment was performed using the NOS (Table S1).
FIGURE 1.
Flow diagram demonstrating the course of inclusion and exclusion of papers
TABLE 1.
Included studies
| Study | Year | No. of patients | Study design | Type of repair | n | Recurrence | Definition of recurrence | Complications | Type complication and treatment |
|---|---|---|---|---|---|---|---|---|---|
| Morales‐Cruz et al. | 2021 | 10 | Cohort | Synthetic mesh | 10 | 3 | Clinical examination and radiological assessment | 2 | One seroma (conservative), one small bowel obstruction (conservative) |
| Yamamoto et al. | 2021 | 2 | Cohort | Tissue flap + mesh a | 2 | 0 | Not defined | 1 | One seroma (percutaneous drainage) |
| Bertrand et al. | 2020 | 21 | Cohort | Biological mesh | 15 | 7 | Clinical examination | 4 | Missing |
| Synthetic mesh | 5 | 2 | 1 | Missing | |||||
| Tissue flap only a | 1 | 0 | 0 | n.a. | |||||
| Blok et al. | 2020 | 34 | Cohort | Biological mesh | 13 | 7 | Clinical examination | 4 | Two wound infections (one percutaneous drainage, one conservative), one wound dehiscence (conservative), one small bowel perforation (operative) |
| Synthetic mesh | 13 | 5 | 6 | Four wound infections (three percutaneous drainage, one conservative), two fistulas (conservative) | |||||
| Tissue flap + mesh* | 8 | 0 | 0 | n.a. | |||||
| Jafari et al. | 2020 | 6 | Case serie | Biological mesh | 6 | 3 | Clinical examination and radiological assessment | 1 | One urinary retention (conservative) |
| Coelho et al. | 2019 | 4 | Case serie | Tissue flap only a | 4 | 2 | Clinical examination and radiological assessment | 0 | n.a. |
| Hassan et al. | 2019 | 3 | Case serie | Synthetic mesh | 3 | 0 | Not defined | 1 | One small bowel obstruction (conservative) |
| Yasukawa et al | 2018 | 2 | Case serie | Synthetic mesh | 2 | 0 | Not defined | 0 | n.a. |
| Levic et al. | 2017 | 17 | Cohort | Biological mesh | 16 | 4 | Clinical examination | 1 | One wound infection (conservative) |
| Tissue flap only a | 1 | 1 | 0 | n.a. | |||||
| Li et al. | 2017 | 2 | Case serie | Synthetic mesh | 2 | 0 | Clinical examination and radiological assessment | 0 | n.a. |
| Goedhart et al. | 2016 | 12 | Cohort | Synthetic mesh | 12 | 3 | Not defined | 0 | n.a. |
| Allen et al. | 2015 | 6 | Case serie | Synthetic mesh | 6 | 0 | Not defined | 2 | One seroma (percutaneous drainage), one small bowel obstruction (operative) |
| Sayers et al. | 2015 | 8 | Case serie | Biological mesh | 5 | 1 | Not defined | missing | n.a. |
| Tissue flap only a | 3 | 1 | Missing | n.a. | |||||
| Suzuki et al. | 2015 | 2 | Case serie | Synthetic mesh | 2 | 1 | Not defined | 0 | n.a. |
| Abbas et al. | 2014 | 6 | Case serie | Biological mesh | 2 | 0 | Not defined | Missing | n.a. |
| Synthetic mesh | 4 | 0 | Missing | n.a. | |||||
| Martijnse et al. | 2012 | 29 | Cohort | Synthetic mesh | 29 | 9 | Clinical examination | 5 | Two urinary retention, one wound infection, one seroma, one fistula (all conservative) |
| Veenhof et al. | 2007 | 2 | Case serie | Synthetic mesh | 2 | 1 | Clinical examination and radiological assessment | 1 | One small bowel obstruction (conservative) |
| Dulucq et al | 2006 | 3 | Case serie | Synthetic mesh | 3 | 0 | Not defined | 0 | n.a. |
| De Campos et al | 2005 | 3 | Case serie | Biological mesh | 3 | 0 | Not defined | 0 | n.a. |
Abbreviation: n.a., not applicable.
Includes sub‐, fascio‐ and musculocutaneous flaps.
Patient characteristics and perineal hernia management
The mean age of the total cohort was 64 ± 5.6 years, and 48% (69/143) of patients were male. The indication for APR was predominantly cancer (99%, 170/172), and 94% (133/141) received neoadjuvant radiotherapy if preoperative therapy was reported. The time interval between APR and surgical repair was 42 ± 16.7 months. The surgical approach was an open perineal repair in 72% (106/147), which was combined with an abdominal approach in 8% (8/106). In the remaining patients in whom the surgical approach was reported, a transabdominal laparoscopic [18% (27/147)] or transabdominal open repair [10% (14/147)] was performed. Synthetic mesh closure was applied in more than half of the included patients (54%, 93/172), followed by biological mesh closure (35%, 60/172). Tissue flap reconstruction, with and without mesh, was performed in 6% (10/172) and 5% (9/172), respectively. The meshes used in combination with tissue flap reconstruction were evenly distributed [synthetic mesh 50% (5/10), biological mesh 50% (5/10)]. Patient characteristics are presented in Table 2.
TABLE 2.
Patient characteristics
| Variable | Missing data (%) | n (%) or mean ± SD |
|---|---|---|
| Sex (male) | 29/172 (17) | 69/143 (48) |
| Age (years) | 32/172 (19) | 64 ± 5.6 |
| Primary disease | 0/172 (0) | |
| Cancer | 170/172 (99) | |
| Inflammatory | 1/172 (1) | |
| Functional | 1/172 (1) | |
| Neoadjuvant therapy | 31/172 (18) | |
| Radiotherapy | 133/141 (94) | |
| Short‐course radiotherapy | 18/133 (14) | |
| Long‐course radiotherapy | 94/133 (71) | |
| Type not specified | 21/133 (16) | |
| Interval between APR and perineal hernia repair (months) | 72/172 (42) | 42 ± 16.7 |
| Content hernia a | 101/172 (59) | |
| Small bowel | 38/71 (54) | |
| Colon | 2/71 (3) | |
| Bladder | 9/71 (13) | |
| Uterus | 9/71 (13) | |
| Omentum | 33/71 (47) | |
| Approach to hernia repair | 25/172 (15) | |
| Perineal open | 98/147 (67) | |
| Abdominal laparoscopic | 27/147 (18) | |
| Abdominal open | 14/147 (10) | |
| Combined (abdominoperineal) | 8/147 (5) | |
| Type of perineal hernia repair | 0/172 (0) | |
| Biological mesh | 60/172 (35) | |
| Synthetic mesh | 93/172 (54) | |
| Tissue flap only b | 9/172 (5) | |
| Tissue flap + mesh b | 10/172 (6) |
Abbreviation: APR, abdominoperineal resection.
A combination could be possible in one patient.
Includes sub‐, fascio‐ and musculocutaneous flaps.
Perineal hernia repair – pooled outcomes
Recurrent perineal hernia was assessed using physical examination only in four studies, a combination of physical and radiological examination in five studies and was not defined in the remaining studies (Table 1). The pooled percentage of recurrent perineal hernia was 32% (95% CI: 26%–40%) after a total follow‐up of 25 ± 10.6 months. The pooled recurrence rate was 39% (95% CI: 27%–52%) after biological mesh closure, 29% (95% CI: 21%–39%) after synthetic mesh closure, 37% (95% CI: 14%–67%) after only a tissue flap reconstruction and 9% (95% CI: 1%–45%) after tissue flap reconstruction combined with mesh. The pooled recurrence rates and follow‐up data are presented in Table 3. The corresponding forest plot is shown in Figure 2.
TABLE 3.
Perineal hernia repair – pooled outcomes
| Type of repair | n (%) | Pooled recurrence (%) (95% CI) | Mean time to recurrence (months) ± SD | Missing data, n (%) | Mean total follow‐up (months) ± SD | Missing data, n (%) | Type of redo repair | n (%) | Pooled second recurrence (%) (95% CI) |
|---|---|---|---|---|---|---|---|---|---|
| Total | 172/172 (100) | 32 (26–40) | 17 ± 5.5 | 16/49 (33) | 25 ± 10.6 | 44/172 (26) | Total | 25/25 (100) | 41 (21–65) |
| Biological mesh | 60/172 (35) | 39 (27–52) | 14 ± 5.1 | 12/22 (55) | 33 ± 18.4 | 36/60 (60) | Primary closure | 2/25 (8) | Missing |
| Synthetic mesh | 93/172 (54) | 29 (21–39) | 18 ± 5.6 | 3/24 (13) | 21 ± 7.2 | 7/93 (8) | Biological mesh | 2/25 (8) | 50 (6–94) |
| Tissue flap only a | 9/172 (5) | 37 (14–67) | 12 ± 0.0 | 1/3 (33) | n.a. | 9/9 (100) | Synthetic mesh | 19/25 (76) | 44 (20–71) |
| Tissue flap + mesh a | 10/172 (6) | 9 (1–45) | n.a. | n.a. | 27 ± 20.4 | 0/10 (0) | Tissue flap only a | 2/25 (8) | 17 (1–81) |
Abbreviation: n.a., not applicable.
Includes sub‐, fascio‐ and musculocutaneous flaps.
FIGURE 2.
Forest plot showing the effect of type of perineal hernia repair (biological mesh, synthetic mesh, tissue flap only and tissue flap + mesh) on the risk of recurrence of perineal hernia
When the perineal hernia was repaired through an abdominal approach, the pooled recurrence rate was 25% (95% CI: 14%–40%), which was 37% (95% CI 28%–47%) after a perineal approach and 19% (95% CI: 6%–49%) after a combined approach (Table S2).
Redo surgery was performed in 50% (25/50) of the patients who developed a recurrent perineal hernia. Second repair was predominantly performed using synthetic mesh closure (76%, 19/25), followed by primary closure (8%, 2/25), biological mesh closure (8%, 2/25) and solely tissue flap reconstruction (8%, 2/25; Table 3). The pooled percentage of a second recurrence after redo surgery was 44% (95% CI: 20%–71%) after synthetic mesh closure. In the two patients with biological mesh closure one developed a second recurrence compared with none of the two patients with solely tissue flap reconstruction. The second recurrence rate in the two patients with primary closure was not reported.
DISCUSSION
This systematic review with pooled analyses showed that literature on perineal hernia repair after APR is still limited, with several small case series. Synthetic mesh closure was most frequently used. The pooled outcomes revealed that biological and synthetic mesh closure resulted in comparable high recurrence rates. Although only small numbers were available, tissue flap reconstruction seemed only to be valuable when combined with mesh closure. So far no recurrences have been reported after perineal hernia repair using the combination of a tissue flap and mesh in nine patients.
The perineal hernia recurrence rate was the highest after biological mesh repair, which might be explained by the inherent features of biological mesh. However, if it was only the loss of strength of a biological mesh that causes recurrent hernias, one would expect much better results after synthetic mesh. In addition, the difference in follow‐up duration between the biological (33 ± 18.4 months) and synthetic mesh (21 ± 7.2 months) group must be taken into consideration, since perineal hernias develop gradually over time. Therefore, the high recurrence rates are more likely related to the bridging type of repair, without the possibility of reinforcing a layer of fascia or any other type of tissue. This makes a perineal hernia essentially different from a ventral abdominal wall hernia.
Our previous systematic review published by Mjoli et al. included 36 studies between 1944 and 2010 with 40 individually documented patients who underwent surgical repair, and we added three patients from our institution [8]. At that time, we just summarized the scarcely available literature based on a remarkably low number of patients from papers published over a 66‐year period. Balla et al. [7] included 21 studies with 108 patients in the period 2012–2016 and made an historical comparison with our pooled analysis of literature between 1944 and 2011. This revealed that the perineal approach was still most commonly used, that laparoscopy was replacing the open abdominal approach, that primary closure had been abandoned and that the use of flap reconstruction significantly increased. But recurrence rates in the more recent literature were no lower.
The total pooled recurrence rate in our study was found to be higher than in the previously performed reviews [7, 8]. An explanation for this might be the mainly incidental reports of single cases before 2010 that are at high risk of publication bias, while the more recently published small case series and cohort studies are probably more representative of true technical success. In addition, we excluded all case reports in the present review. Another explanation is related to follow‐up duration. Mjoli et al. [8] already argued that the focus of the included historical papers was on the technical aspects of repair, with limited follow‐up duration and lack of data on long‐term outcomes. Blok et al. [12] found that the recurrence rate doubled after 12 months of follow‐up, emphasizing the importance of sufficient follow‐up duration to reliably assess the success of perineal hernia correction.
Four studies described a total of nine patients with tissue flap reconstruction of the pelvic floor, of whom four (44%) developed a recurrence [3, 13, 14, 18]. Tissue flaps alone might not provide enough strength, with a relatively high risk of a recurrent hernia. This is in line with a comparative cohort study from Denmark including 57 patients who underwent extralevator APR with immediate perineal reconstruction using a gluteal flap in 33 and a biological mesh in 24 patients [28]. A perineal hernia developed in seven patients with a flap (21%) after median 3.2 years of follow‐up, while no perineal hernias were observed after median of 1.7 years in the biological mesh group. Therefore, mesh‐only and flap‐only reconstructions, regardless of the technique, seem to be insufficient to repair perineal hernias.
In the studies of Yamamoto et al. and Blok et al., tissue flap reconstruction was combined with mesh closure [10, 12]. None of the total of 10 patients had a recurrence after a mean follow‐up duration of 27 months. This suggests that combining the two methods of reconstruction might improve outcomes compared with the results of each of the techniques alone. This also makes sense from a theoretical perspective, because a mesh provides strength and a flap fills a soft tissue defect. After mesh‐only reconstruction of the pelvic floor at the level of the transected levator muscles, a dead space remains at the level of the prior anal canal. Subsequently closing the subcutaneous fat and skin in the midline might not properly fill this dead space, or results in too much tension. This can lead to an accumulation of fluid, and subsequently the risk of pelvic and perineal infections. Wound complications in general are associated with a higher risk of developing a hernia [29]. A tissue flap reconstruction of the perineal defect following mesh repair provides a tension‐free closure with optimal support of the mesh by well‐vascularized tissue that potentially improves ingrowth. However, patient numbers are small, and the hypothetical advantages of a combined technique have to be confirmed in larger series.
This systematic review has several limitations. A major weakness is the large number of small case series, with almost half of the included studies (9 of 19) describing four or fewer patients. However, in recent years a few larger studies have been published which were not included in the previously performed systematic review of Balla et al. [7]. Furthermore, this is the first review in which recurrence rates have been pooled for type of perineal hernia repair (i.e. biological mesh, synthetic mesh, tissue flap only, combined tissue flap and mesh) [7, 8]. The quality assessment of the studies had some limitations, in particular due to the lack of a control group. Furthermore, in 10 studies there was no clear definition of a recurrent perineal hernia. In addition, studies did not examine the downsides of different perineal hernia repair techniques, for example mesh infection, small bowel fistula and donor site morbidity or flap necrosis in the case of tissue flap reconstruction. Besides, we were not able to correct for predisposing factors for perineal hernia between the different surgical closure techniques (e.g. smoking, hysterectomy, wound complications after APR, omentoplasty).
Regarding the implications for clinical practice, a synthetic mesh might be considered to be the first choice in noncontaminated perineal hernia repair, given similar pooled recurrence rates, lower costs compared with a biological mesh and no concerning data on mesh infections. Following mesh reconstruction of the pelvic floor, one might consider closure of the perineal subcutaneous fat and skin by using a fasciocutaneous transposition or rotation flap on hypothetical grounds and supported by currently available evidence, although of low quality.
CONCLUSION
This study has shown that synthetic and biological mesh closure are the most frequently used techniques for perineal hernia repair, preferably using a perineal approach. However, recurrence rates are high after both types of mesh. Tissue flap reconstruction only also appeared to be insufficient, while tissue flap reconstruction combined with a mesh seemed to be promising in preventing recurrences after perineal hernia repair. However, numbers were low, indicating the need for large prospective studies or randomized controlled trials.
AUTHOR CONTRIBUTION
All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Sarah Sharabiany, Thomas P.A. Brouwer and Saskia I. Kreisel. The first draft of the manuscript was written by Sarah Sharabiany, Thomas P.A. Brouwer, Saskia I. Kreisel, Gijsbert D. Musters and Pieter J. Tanis and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
CONFLICT OF INTEREST
The authors declare that they have no conflicts of interest.
ETHICS STATEMENT
This study has been approved by the medical ethical committee of the UMC – location AMC – and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
PERMISSION TO REPRODUCE MATERIAL FROM OTHER SOURCES
There was no reproduced material used from other sources in this article.
CLINICAL TRIAL REGISTRATION
Prospero database, registration number CRD42021274677.
Supporting information
Table S1
Table S2
ACKNOWLEDGEMENTS
We would like to thank Susan van Dieren for her help with the statistical analyses.
Sharabiany S, Brouwer TPA, Kreisel SI, Musters GD, Blok RD, Hompes R, et al. Mesh, flap or combined repair of perineal hernia after abdominoperineal resection – A systematic review and meta‐analysis. Colorectal Dis. 2022;24:1285–1294. 10.1111/codi.16224
Sarah Sharabiany and Thomas P. A. Brouwer contributed equally.
Funding information
No funding has been received by any author in relation to this article.
DATA AVAILABILITY STATEMENT
Data are available from the authors upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1
Table S2
Data Availability Statement
Data are available from the authors upon reasonable request.