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.
- Wiatrek RL, Thomas JS, Papaconstantinou HT. Perineal wound complications after abdominoperineal resection. Clin Colon Rectal Surg 2008; 21:76.
- Christian CK, Kwaan MR, Betensky RA, et al. Risk factors for perineal wound complications following abdominoperineal resection. Dis Colon Rectum 2005; 48:43.
- MacKeigan JM, Cataldo PA.. Chapter 21: Abdominoperineal Resection. In: Complications of Colon and Rectal Surgery, Hicks TC, Beck DE, Opelka FG, Timmcke AE.. (Eds), Williams & Wilkins, Media 1996. p.312.
- Robles Campos R, Garcia Ayllon J, Parrila Paricio P, et al. Management of the perineal wound following abdominoperineal resection: prospective study of three methods. Br J Surg 1992; 79:29.
- Irvin TT, Goligher JC. A controlled clinical trial of three different methods of perineal wound management following excision of the rectum. Br J Surg 1975; 62:287.
- Terranova O, Sandei F, Rebuffat C, et al. Management of the perineal wound after rectal excision for neoplastic disease: a controlled clinical trial. Dis Colon Rectum 1979; 22:228.
- Chapter 63: True pelvis, pelvic floor and perineum. In: Gray's Anatomy, 40th, Standring S. (Ed), Churchill, Livingstone, Elsevier, 2008. p.1083.
- Baqué P, Karimdjee B, Iannelli A, et al. Anatomy of the presacral venous plexus: implications for rectal surgery. Surg Radiol Anat 2004; 26:355.
- Altemeier WA, Culbertson WR, Alexander JW, et al. Primary closure and healing of the perineal wound in abdominoperineal resection of the rectum for carcinoma. Am J Surg 1974; 127:215.
- Delalande JP, Hay JM, Fingerhut A, et al. Perineal wound management after abdominoperineal rectal excision for carcinoma with unsatisfactory hemostasis or gross septic contamination: primary closure vs. packing. A multicenter, controlled trial. French Association for Surgical Research. Dis Colon Rectum 1994; 37:890.
- Dietz DW, Bailey HR. Postoperative complications. In: The ASCRS Textbook of Colon and Rectal Surgery, Wolff BG, Fleshman JW, Beck DE, Pemberton JH, Wexner SD (Eds), Springer, New York 2006. p.152.
- Pollard CW, Nivatvongs S, Rojanasakul A, Ilstrup DM. Carcinoma of the rectum. Profiles of intraoperative and early postoperative complications. Dis Colon Rectum 1994; 37:866.
- Rothenberger DA, Wong WD. Abdominoperineal resection for adenocarcinoma of the low rectum. World J Surg 1992; 16:478.
- Nilsson PJ, Svensson C, Goldman S, Glimelius B. Salvage abdominoperineal resection in anal epidermoid cancer. Br J Surg 2002; 89:1425.
- Papaconstantinou HT, Bullard KM, Rothenberger DA, Madoff RD. Salvage abdominoperineal resection after failed Nigro protocol: modest success, major morbidity. Colorectal Dis 2006; 8:124.
- Corman ML, Veidenheimer MC, Coller JA, Ross VH. Perineal wound healing after proctectomy for inflammatory bowel disease. Dis Colon Rectum 1978; 21:155.
- Murrell ZA, Dixon MR, Vargas H, et al. Contemporary indications for and early outcomes of abdominoperineal resection. Am Surg 2005; 71:837.
- Artioukh DY, Smith RA, Gokul K. Risk factors for impaired healing of the perineal wound after abdominoperineal resection of rectum for carcinoma. Colorectal Dis 2007; 9:362.
- Randomized study on preoperative radiotherapy in rectal carcinoma. Stockholm Colorectal Cancer Study Group. Ann Surg Oncol 1996; 3:423.
- Initial report from a Swedish multicentre study examining the role of preoperative irradiation in the treatment of patients with resectable rectal carcinoma. Swedish Rectal Cancer Trial. Br J Surg 1993; 80:1333.
- Marijnen CA, Kapiteijn E, van de Velde CJ, et al. Acute side effects and complications after short-term preoperative radiotherapy combined with total mesorectal excision in primary rectal cancer: report of a multicenter randomized trial. J Clin Oncol 2002; 20:817.
- Horn A, Halvorsen JF, Dahl O. Preoperative radiotherapy in operable rectal cancer. Dis Colon Rectum 1990; 33:823.
- Randomised trial of surgery alone versus radiotherapy followed by surgery for potentially operable locally advanced rectal cancer. Medical Research Council Rectal Cancer Working Party. Lancet 1996; 348:1605.
- Bujko K, Nowacki MP, Kepka L, et al. Postoperative complications in patients irradiated pre-operatively for rectal cancer: report of a randomised trial comparing short-term radiotherapy vs chemoradiation. Colorectal Dis 2005; 7:410.
- Musters GD, Buskens CJ, Bemelman WA, Tanis PJ. Perineal wound healing after abdominoperineal resection for rectal cancer: a systematic review and meta-analysis. Dis Colon Rectum 2014; 57:1129.
- Silen W, Glotzer DJ. The prevention and treatment of the persistent perineal sinus. Surgery 1974; 75:535.
- Prytz M, Angenete E, Ekelund J, Haglind E. Extralevator abdominoperineal excision (ELAPE) for rectal cancer--short-term results from the Swedish Colorectal Cancer Registry. Selective use of ELAPE warranted. Int J Colorectal Dis 2014; 29:981.
- Leicester RJ, Ritchie JK, Wadsworth J, et al. Sexual function and perineal wound healing after intersphincteric excision of the rectum for inflammatory bowel disease. Dis Colon Rectum 1984; 27:244.
- McLeod R, Cohen Z, Langer B, Taylor B. Primary perineal wound closure following excision of the rectum. Can J Surg 1983; 26:122.
- Hartz RS, Poticha SM, Shields TW. Healing of the perineal wound. Arch Surg 1980; 115:471.
- Fingerhut A, Hay JM, Delalande JP, Paquet JC. Passive vs. closed suction drainage after perineal wound closure following abdominoperineal rectal excision for carcinoma. A multicenter, controlled trial. The French Association for Surgical Research. Dis Colon Rectum 1995; 38:926.
- Tompkins RG, Warshaw AL. Improved management of the perineal wound after proctectomy. Ann Surg 1985; 202:760.
- Khoo AK, Skibber JM, Nabawi AS, et al. Indications for immediate tissue transfer for soft tissue reconstruction in visceral pelvic surgery. Surgery 2001; 130:463.
- Kapoor V, Cole J, Isik FF, et al. Does the use of a flap during abdominoperineal resection decrease pelvic wound morbidity? Am Surg 2005; 71:117.
- Nilsson PJ. Omentoplasty in abdominoperineal resection: a review of the literature using a systematic approach. Dis Colon Rectum 2006; 49:1354.
- Shibata D, Hyland W, Busse P, et al. Immediate reconstruction of the perineal wound with gracilis muscle flaps following abdominoperineal resection and intraoperative radiation therapy for recurrent carcinoma of the rectum. Ann Surg Oncol 1999; 6:33.
- Radice E, Nelson H, Mercill S, et al. Primary myocutaneous flap closure following resection of locally advanced pelvic malignancies. Br J Surg 1999; 86:349.
- De Broux E, Parc Y, Rondelli F, et al. Sutured perineal omentoplasty after abdominoperineal resection for adenocarcinoma of the lower rectum. Dis Colon Rectum 2005; 48:476.
- Howell AM, Jarral OA, Faiz O, et al. How should perineal wounds be closed following abdominoperineal resection in patients post radiotherapy--primary closure or flap repair? Best evidence topic (BET). Int J Surg 2013; 11:514.
- Bratzler DW, Houck PM, Surgical Infection Prevention Guidelines Writers Workgroup, et al. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis 2004; 38:1706.
- Meyer L, Bereuter M, Marusch F, et al. Perineal wound closure after abdomino-perineal excision of the rectum. Tech Coloproctol 2004; 8 Suppl 1:s230.
- de Bruin AF, Gosselink MP, Wijffels NA, et al. Local gentamicin reduces perineal wound infection after radiotherapy and abdominoperineal resection. Tech Coloproctol 2008; 12:303.
- Gruessner U, Clemens M, Pahlplatz PV, et al. Improvement of perineal wound healing by local administration of gentamicin-impregnated collagen fleeces after abdominoperineal excision of rectal cancer. Am J Surg 2001; 182:502.
- Musters GD, Burger JW, Buskens CJ, et al. Local Application of Gentamicin in the Prophylaxis of Perineal Wound Infection After Abdominoperineal Resection: A Systematic Review. World J Surg 2015; 39:2786.
- Alam NN, Narang SK, Köckerling F, et al. Biologic Mesh Reconstruction of the Pelvic Floor after Extralevator Abdominoperineal Excision: A Systematic Review. Front Surg 2016; 3:9.
- Musters GD, Klaver CE, Bosker RJ, et al. Biological Mesh Closure of the Pelvic Floor After Extralevator Abdominoperineal Resection for Rectal Cancer: A Multicenter Randomized Controlled Trial (the BIOPEX-study). Ann Surg 2016.
- Chadi SA, Kidane B, Britto K, et al. Incisional negative pressure wound therapy decreases the frequency of postoperative perineal surgical site infections: a cohort study. Dis Colon Rectum 2014; 57:999.
- Sumrien H, Newman P, Burt C, et al. The use of a negative pressure wound management system in perineal wound closure after extralevator abdominoperineal excision (ELAPE) for low rectal cancer. Tech Coloproctol 2016; 20:627.
- Kressner U, Graf W, Mahteme H, et al. Septic complications and prognosis after surgery for rectal cancer. Dis Colon Rectum 2002; 45:316.
- Miccini M, Borghese O, Scarpini M, et al. Anastomotic leakage and septic complications: impact on local recurrence in surgery of low rectal cancer. Ann Ital Chir 2011; 82:117.
- Hawkins AT, Berger DL, Shellito PC, et al. Wound dehiscence after abdominoperineal resection for low rectal cancer is associated with decreased survival. Dis Colon Rectum 2014; 57:143.
- Lohsiriwat V. Persistent perineal sinus: incidence, pathogenesis, risk factors, and management. Surg Today 2009; 39:189.
- Karoui M, Cohen R, Nicholls J. Results of surgical removal of the pouch after failed restorative proctocolectomy. Dis Colon Rectum 2004; 47:869.
- Rosen L, Veidenheimer MC, Coller JA, Corman ML. Mortality, morbidity, and patterns of recurrence after abdominoperineal resection for cancer of the rectum. Dis Colon Rectum 1982; 25:202.
- Bauer JJ, Gelernt IM, Salk BA, Kreel I. Proctectomy for inflammatory bowel disease. Am J Surg 1986; 151:157.
- Keighley MR, Allan RN. Current status and influence of operation on perianal Crohn's disease. Int J Colorectal Dis 1986; 1:104.
- Lohsiriwat V, Clark SK. Persistent perineal sinus after ileoanal pouch excision in inflammatory bowel diseases: incidence, risk factors, and clinical course. Dis Colon Rectum 2008; 51:1795.
- Chadwick MA, Vieten D, Pettitt E, et al. Short course preoperative radiotherapy is the single most important risk factor for perineal wound complications after abdominoperineal excision of the rectum. Colorectal Dis 2006; 8:756.
- Wiseman JS, Senagore AJ, Chaudry IH. Relationship of pelvic radiation to intestinal blood flow. J Surg Res 1996; 60:239.
- Bascom T, Bascom JU. Persistent perineal sinus after proctectomy for Crohn's disease; simplified repair using skin flap. Am J Surg 2002; 184:85; author reply 85.
- Yamamoto T, Mylonakis E, Keighley MR. Omentoplasty for persistent perineal sinus after proctectomy for Crohn's disease. Am J Surg 2001; 181:265.
- Ryan JA Jr. Gracilis muscle flap for the persistent perineal sinus of inflammatory bowel disease. Am J Surg 1984; 148:64.
- Hurst RD, Gottlieb LJ, Crucitti P, et al. Primary closure of complicated perineal wounds with myocutaneous and fasciocutaneous flaps after proctectomy for Crohn's disease. Surgery 2001; 130:767.
- Yousaf M, Witherow A, Gardiner KR, Gilliland R. Use of vacuum-assisted closure for healing of a persistent perineal sinus following panproctocolectomy: report of a case. Dis Colon Rectum 2004; 47:1403.
- Schaffzin DM, Douglas JM, Stahl TJ, Smith LE. Vacuum-assisted closure of complex perineal wounds. Dis Colon Rectum 2004; 47:1745.
- Loessin SJ, Meland NB, Devine RM, et al. Management of sacral and perineal defects following abdominoperineal resection and radiation with transpelvic muscle flaps. Dis Colon Rectum 1995; 38:940.
- Aboian E, Winter DC, Metcalf DR, Wolff BG. Perineal hernia after proctectomy: prevalence, risks, and management. Dis Colon Rectum 2006; 49:1564.
- Beck DE, Fazio VW, Jagelman DG, et al. Postoperative perineal hernia. Dis Colon Rectum 1987; 30:21.
- Sarr MG, Stewart JR, Cameron JC. Combined abdominoperineal approach to repair of postoperative perineal hernia. Dis Colon Rectum 1982; 25:597.
- Skipworth RJ, Smith GH, Anderson DN. Secondary perineal hernia following open abdominoperineal excision of the rectum: report of a case and review of the literature. Hernia 2007; 11:541.
- So JB, Palmer MT, Shellito PC. Postoperative perineal hernia. Dis Colon Rectum 1997; 40:954.
- HULLSIEK HE. Perineal hernia following abdominoperineal resection. Am J Surg 1956; 92:735.
- Ryan S, Kavanagh DO, Neary PC. Laparoscopic repair of postoperative perineal hernia. Case Rep Med 2010; 2010.
- Ogilvie JW, Ricciardi R. Complications of perineal surgery. Clin Colon Rectal Surg 2009; 22:51.
- 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