Extra-Levator AbdominoPerineal excision (eLAPE): a complicated postoperative perineal hernia

Abstract

A 75-year-old woman presented with perineal wound dehiscence and small bowel prolapse of a perineal hernia, 6 years after extra-Levator AbdominoPerineal Excision (eLAPE) procedure for rectal cancer. She underwent emergency wound refashioning and perineal hernia repair with Parmacol mesh. Her postoperative recovery was complicated by long-standing ileus, wound infection, and she was discharged to community palliative care services. In this case report, we raise awareness of postoperative eLAPE complications and describe an unfortunate case where a postoperative perineal hernia was not repaired in a patient with multiple comorbidities.

Background

Extra-Levator AbdominoPerineal Excision (eLAPE) has been associated with improved oncological outcomes and as such has replaced conventional AbdominoPerineal Resection for the treatment of low rectal tumours.^{1 2} Nonetheless, postoperative complications remain common. Up to 44% of patients will experience postoperative hernia, wound break down or infection.³ This is an unusual case of wound dehiscence and small bowel prolapse in a patient with a postoperative perineal hernia. We highlight this case as the complication occurred after a significantly long postoperative period, where the decision was made not to repair the postoperative perineal hernia. In addition, the dramatic complication of small bowel protruding from the perineum is something that to our knowledge has not been reported before. We discuss the case and the surgical management of this unfortunate emergency.

Case presentation

A 75-year-old woman presented with rectal bleeding, perianal discomfort and lower abdominal pain. On examination, she had a painful rectal mass. Following a biopsy of the rectal mass, MRI pelvis and staging CT scan, she was diagnosed with rectal adenocarcinoma in 2013 (TNM staging-T3N0M0 at diagnosis). Her medical history included diabetes, hypertension and chronic obstructive pulmonary disease (COPD). Her type 2 diabetes was controlled with metformin, with glycated haemoglobin of 43 mmol/mol (20–42) in 2013. She had long-term oxygen therapy at home for chronic obstructive pulmonary disease (COPD) and although she denied continuing to smoke; on examination it appeared that she continued to be a heavy smoker.

Once diagnosed with rectal adenocarcinoma, the patient underwent neoadjuvant chemoradiotherapy: six cycles of oxaliplatin and capecitabine and external beam radiotherapy. After 6 months of treatment, in 2014, she was diagnosed with multiple lung metastases on a positron emission tomography scan and given a further course of palliative chemotherapy: irinotecan, capecitabine and bevacizumab. She continued to have symptoms or rectal pain and tenesmus. Following this course of chemotherapy, she underwent an eLAPE procedure with primary mesh closure. Her anaesthetic preoperative assessment reported a peak flow volume of 170 L/min (normal range 360–390 L/min) and mild anaemia (haemoglobin 110 g/L, mean cell haemoglobin 26.4 pg). Due to the high risk of postoperative chest complications, she had a planned discharge to the high-dependency unit (HDU) postoperatively. She spent five nights in HDU and was then transferred back to the ward. She had a difficult postoperative recovery. She was treated for a chest infection on HDU, a prolonged ileus and required total parenteral nutrition (TPN). On day 18 postoperatively, she suffered a perineal wound infection and wound dehiscence. This required simple refashioning of the wound with sutures and a course of intravenous antibiotics. Her perineal wound healed and she was discharged 30 days postoperatively back to her normal residence.

From 2014, she was under surveillance with the oncology team and her serum carcinoembryonic antigen remained stable (<3.5 from 2014 to 2017). In 2015, she presented to her general practitioner (GP) with perineal pain and swelling post eLAPE. An MRI identified a large perineal hernia containing fluid and small bowel loops. She was comfortable and declined any surgical intervention. During this time, she was given frequent courses of steroids for exacerbations of her COPD. In 2017, she was deemed too frail in the event that she required further chemotherapy and was discharged back to the GP with palliative care support.

In 2019, she was referred from the out-of-hours GP whom she had presented with a 24-hour history of abdominal pain and discomfort in the perineum. On examination, she had free loops of small bowel protruding from the previous perineal incision (figure 1). She was referred to the general surgical team and underwent emergency repair. Her P-POSSUM (Portsmouth Physiological and Operative Severity Score) was calculated, with 37.8% risk of mortality.

Figure 1.

Initial presentation with small bowel herniation.

The hernia repair was completed using a combined abdominal and perineal approach. The oedematous bowel was pushed back from the perineum and pulled up through the abdominal incision. All bowel was deemed viable and washed with an extensive saline wash. Once reduced, the perineal wound was refashioned (figure 2). The defect was repaired with a Parmacol (porcine) mesh secured with prolene beneath the muscle layer (figure 3). A perineal drain was inserted into the pelvis (figure 4).

Figure 2.

Reduction of bowel and refashioned wound edges.

Figure 3.

Insertion and fixation of porcine mesh.

Figure 4.

Closure of defect and insertion of a drain.

Outcome and follow-up

Postoperatively, the patient was transferred to the HDU for one night and then transferred back to the colorectal ward. She was managed by the colorectal ward team with input from the dietition and palliative care specialist nurses. She suffered postoperative ileus and her stoma took 11 days to start functioning. During this time she was commenced on TPN. Albumin level dropped to 17 g/L (baseline 46) and creatinine to 21 μmol/L (baseline 50). She suffered a superficial perineal wound infection that responded to a 7-day course of intravenous antibiotics (Co-Amoxiclav, according to local antibiotic guidelines). The wound culture was sterile. The histology of the wound showed extensive ulceration, granulation tissue but no malignant features. She was discharged 20 days postoperatively with community palliative care support and daily district nurse review of the wound in the community.

Discussion

eLAPE involves en bloc excision of the levator ani complex of muscle surrounding the distal mesorectum. This extensive excision has led to improved oncological outcomes and is replacing conventional abdominoperineal resection.^{1 2} However, the extent of the excision involved in the eLAPE procedure poses an increased challenge in perineal reconstruction. With only the ischioanal fat and skin left, closure may be under increased tension. The resection leaves significant pelvic dead space where fluid can accumulate and infection can develop. In addition, neoadjuvant chemoradiation has also been associated with increased perineal morbidity.^3–7 Given the complexity of closure, there are various reconstructive techniques: primary closure, myocutaneous flaps and mesh but no overriding consensus of the best surgical technique in the current literature.^6–9

In this case, our patient presented with bowel herniation, a year after eLAPE with mesh. Current literature suggests a median interval for the diagnosis of perineal hernia from surgery as 10.5 months so this is not an atypical postoperative complication.³ She had many risk factors for hernia formation including COPD, diabetes and recurrent courses of steroids. This is the first reported case of dehiscence and bowel herniation, and therefore, we highlight it as a consideration when managing postoperative perineal hernia in the community, especially in patients with risk factors for poor wound healing.³

Learning points.

• Post extra-LevatorAbdominoPerineal Excision (eLAPE), perineal hernia is common and patients who have undergone neoadjuvant chemoradiotherapy are more at risk.

• Extra care needs to be taken with patients at risk due to patient-specific risk factors.

• Wound dehiscence following eLAPE can occur more than 6 years postoperatively in the presence of a perineal hernia and with significant comorbidities.