Management of perineal complications following an abdominal perineal resection
- Robin Boushey, MD
Robin Boushey, MD
- Assistant Professor of Surgery
- University of Ottawa
- Lara J Williams, MD, MSc, FRCSC
Lara J Williams, MD, MSc, FRCSC
- Assistant Professor of Surgery
- University of Ottawa
An abdominal perineal resection (APR) is a surgical procedure that removes the rectum and anus (perineal component) and creates an end colostomy (abdominal component). An APR is primarily used to resect a very low rectal cancer or anal cancer. It also is a salvage treatment for recurrent rectal or anal cancer and is a surgical treatment for severe inflammatory bowel disease.
The most frequent complications of a perineal resection include hemorrhage, perineal wound complications, persistent perineal sinus, and perineal hernia. Factors associated with an increased risk of perineal complications include intraoperative hemorrhage, intraoperative gross contamination, operative perineal wound management, preoperative radiation therapy, and indications for surgery (malignant versus benign) [1,2]. Management of the perineal wound ranges from packing to partial closure, primary closure, and closure with continuous irrigation . Primary closure of the perineum following an APR is widely accepted when intraoperative hemostasis is intact and no gross contamination has occurred [4-6].
The perineal complications following an APR are reviewed here. Anastomotic and intra-abdominal, pelvic, and genitourinary complications are discussed elsewhere. (See "Management of anastomotic complications of colorectal surgery" and "Management of intraabdominal, pelvic, and genitourinary complications of colorectal surgery".)
ANATOMY OF THE PERINEUM AND PELVIS
The perineum lies below the pelvic floor and anterior to the sacrum and coccyx. The perineum is bounded anteriorly by the pubic symphysis and the arcuate ligament, posteriorly by the coccyx, anterolaterally by the ischiopubic rami and the ischial tuberosities, and posterolaterally by the sacrotuberous ligaments (figure 1 and figure 2 and figure 3 and figure 4 and figure 5 and figure 6) [7,8].
HEMORRHAGE AND HEMATOMAS
Meticulous hemostasis during the perineal portion of the dissection is essential for reducing the risk of postoperative hemorrhage. The incidence of early and delayed postoperative perineal hemorrhage ranges from 0 to 4 percent . Perineal bleeding can develop from several sources, including the presacral venous plexus, the prostate in men or vagina in women, the pelvic floor musculature, or distal branches of the internal iliac vessels. Life-threatening postoperative hemorrhage is related to lack of intraoperative control of hemostasis. Hematomas occur as fluid accumulates in an undrained or inadequately drained space.
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- ANATOMY OF THE PERINEUM AND PELVIS
- HEMORRHAGE AND HEMATOMAS
- Risk factors
- PERINEAL WOUND COMPLICATIONS
- Risk factors
- PERSISTENT PERINEAL SINUS
- Risk factors
- PERINEAL HERNIA
- Risk factors
- SUMMARY AND RECOMMENDATIONS