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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1143_Библиотеки_им_академика_М_И_Перельмана
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79 Case on Rectovesical Fistula After LAR
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Fig. 79.4 CT scan, rectal
contrast showing the fi stula
into the bladder
Fig. 79.5 Cystoscopy,
showing the fi stula, 2 cm
from the left ureter with
staples
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Treatment of Complication: Operation
During the laparotomy, the place of the anastomosis was found because of the
stenosis present and the staples. The urologist dissected the bladder from Retzius
area and opened the bladder in longitudinal direction. From the inside two ureter
catheters could be introduced into the ureters and the fi stula localized (Fig. 79.6 ).
The bladder was incised longitudinally up to the fi stula and in this way the fi stula
could be closed in two layers. From there the rest of the rectum was dissected until
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Fig. 79.6 Bladder is open,
fi stula is visible
M.A. Cuesta and R.J. van Moorselaar
Illustration 79.1 Infrequent complication. Should be solved by means of cystostomy, coloanal
anastomosis, and tissue interposition. Once fi stula is considered closed, by cystoscopy, ileostomy
can be closed
the anal channel and then resected. After mobilization of the splenic fl exure, an
end-to- side coloanal anastomosis was manually performed transanally and the
protective ileostomy was left for deviation of the new anastomosis (Illustration
79.1 ). The rest of epiplon was interposed between the bladder and the
neorectum.
Patient did well and 8 weeks later, after control of the anastomosis, the deviation
ileostomy was taken down. Patient is doing very well.
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437
Discussion
This is a very rare complication after TME resection because of rectal cancer. That
means that the surgeon has made a lesion of the bladder during anterior dissection
at an unusual place [ 1 ].
Once diagnosed the complication, it is important to know exactly the location of
the fi stula. Distance of fi stula to the ureter is important for the procedure to follow.
If the fi stula involves the left ureter, this can be anastomosed in the bladder. For the
rectum, a coloanal anastomosis is the only possibility.
Reference
1. Kim CW, Kim JH, Shin VS et al. Complications after sphincter saving resection in rectal
cancer patients according to whether chemoradiotherapy is performed before or after surgery.
Int J Radiat Oncol Biol Phys. 2010;78:156–63.
Chapter 80
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Case on Perineal Problems After APR
Miguel A. Cuesta , Alexander A.F.A. Veenhof, and Juan de Dios Franco
Keywords Abdomino perineal resection • APR • Perineal abscess • Perineal hernia
• Rectal cancer
First Patient
Perineal Infection: Diagnosis and Indication for Surgery
A 54-year-old contractor was diagnosed with having a very distal rectal adenocarcinoma, stage T3N1M0. He suffered tenesmus and blood in feces for 4 months before
consulting the General Practitioner. The MRI and endosonography showed the
external sphincters as not free from the tumor, and we decided to perform a cylindrical laparoscopic APR. Neoadjuvant therapy by 5×5 Gy was given and patient was
operated on 6 weeks later. A new MRI before the operation showed an important
regression of the tumor.
Operation
The colostomy place was marked and he underwent mechanical colon preparation.
The operation occurred without technical problems and perineal defect was closed
M. A. Cuesta , M.D. (*) • A.A.F.A. Veenhof , M.D.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl; a.veenhof@vumc.nl
J. de Dios Franco
Department of Surgery , Hospital de Jerez , Cadiz , Spain
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_80,
© Springer International Publishing Switzerland 2014
439
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Fig. 80.1 CT scan showing a
perineal abscess
Fig. 80.2 CT scan, recurrent
perineal abscess
M.A. Cuesta et al.
by using an omental fl ap, introduced to the pelvis lateral of the colostomy. Pathology
of the specimen was pT2N0M0 radical resected with circumferential margins of
1 cm.
Postoperative Course: Identifi cation and Treatment
of Complication
Postoperative course was complicated by fever and a perineal wound infection.
After drainage of it on the ward, he again developed fever and a CT scan showed
abscesses deep in the perineal wound (Fig. 80.1 ). Under anesthesia, the abscesses
were drained and the wound was left open for rinsing. During operation we could
see that the omentum left in the pelvis was vital. Two more times during the next 6
months, patient had to be admitted because of recurrent abscesses, these then being
drained under anesthesia (Fig.
80.2 ). At cancer control after 1 year, the CT scan
80 Case on Perineal Problems After APR
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showed two hepatic metastases, being resected. He still feels pain and discomfort at
the perineal wound.
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Second Patient
Perineal hernia: Diagnosis and Indication for Surgery
A 59-year-old woman with rectal cancer, T3N1M0, underwent in September 2003
a laparoscopic APR with curative intent following neoadjuvant chemoradiotherapy.
Preoperative MRI examination already had shown tumor invasion of the surrounding tissue, thus necessitating excision of the posterior vaginal wall along with the
tumor. The operation defect was fi lled with an omentoplasty, and the perineum was
closed in layers. No postoperative complications occurred.
Pathology study showed a radically removed pT2N1 adenocarcinoma.
Postoperative Course: Identifi cation and Treatment
of Complication
During follow-up, no metastases or local recurrence were found. However,
11 months following surgery the patient complained of a perineal swelling inducing
pain and discomfort while sitting. In addition, she developed pollakiuria shortly
after. An abdominal CT scan (Fig. 80.3 ) showed uterus and small intestine protru-
sion into the small pelvic cavity, thus objectifying a postoperative perineal hernia
(Fig. 80.4 ).
A perineal approach was used to correct the hernia, during which the tissues
around the edges and the uterus in retrofl exion were approximated and covered by
a Vicryl ® mesh (Fig. 80.5a ). Surgery occurred without complications, as did the
patient’s recovery. However, the perineal hernia persisted and became progressively
symptomatic. A second CT scan showed a recurrent hernia.
Through an abdominal–perineal approach the recurrent perineal hernia was corrected. A Pfannenstiel incision was used to locate the defect in the pelvic fl oor. It
appeared that the small bowel had herniated through a small defect situated behind
the uterus and right tuba. After reposition of the small bowel, the defect was closed
again by means of a mesh (Fig. 80.5b ). No postoperative complications were seen.
Since the last intervention, no recurrent hernia has been observed, and the patient
remains recurrence free.
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Fig. 80.3 Ct scan, perineal
hernia with intestinal contents
M.A. Cuesta et al.
Fig. 80.4 A perineal hernia
80 Case on Perineal Problems After APR
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Fig. 80.5 ( a ) fi rst operation,
defect in the perineum. ( b )
second operation, defect
covered perineal by a mesh
a
b
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Discussion
The Best Method to Close the Perineal Defect After APR?
After classical APR, the pelvic fl oor muscles and the skin are approximated and the
space drained. But following the more extended cylindrical resection, the question
arises how to deal with the defect. Holm et al. advises to close the defect by means
of gluteal fl ap plasty [
defect. In our case, the omentum fl ap as used may be the origin for the problem, due
to partial necrosis. We note that contamination of the perineal wound is frequent and
in radiated patients may lead to deep wound infections. Zorcolo et al. studied the
risk factors for perineal wound complications after abdominoperineal resection
(APR), with particular reference to preoperative radiotherapy [ 2 ]. Perineal compli-
cations were identifi ed in patients who had preoperative long-course radiotherapy
1 ]. Another possibility is the use of a mesh to approximate the
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(Group 1) and those who had surgery alone (Group 2). One hundred and fi fty-seven
patients met the inclusion criteria. Preoperative radiotherapy was performed in 68
(44.7 %) patients (Group 1), and 89 (55.3 %) patients (Group 2) underwent surgery
alone. The overall rate of perineal wound complications was 14.8 %. The wound
infection rate was similar in each group (Group 1, 10/68, 14.7 %; Group 2, 13/89,
14.9 %;). An elevated BMI (>30) was the only factor correlated with perineal morbidity on univariate analysis ( P = 0.01). They concluded that preoperative radio-
therapy does not infl uence perineal healing other than in patients with obesity [ 2 ].
El Gazzaz et al. evaluated the factors involved with perineal wound infection,
fi stulas, reoperation, and perineal hernias after primary closure after APR for distal
rectal cancer [ 3 ]. Patients who developed perineal wound complications (Group A)
were compared with the group of patients without complications (Group B). The
overall rate of wound complications was 16.2 %, and reoperation was required in
5.2 % of patients. A greater proportion of Group A patients had associated comorbidity ( P = 0.001), obesity (0.04), neoadjuvant chemoradiation (0.02), and intraop-
erative bleeding (0.04). In multivariate analysis, comorbidity was the only
independent factor associated with the development of perineal complications [ 3 ].
M.A. Cuesta et al.
Incidence, Causes, and Treatment of Perineal Hernias
Symptomatic perineal hernias following APR remain rare. Neoadjuvant chemoradiotherapy may be responsible for delayed and diffi cult healings in the perineal
area following this type of surgery. However, no literature is available to support
this hypothesis of higher incidences of perineal hernias with the onset of neoadjuvant therapy. Moreover, laparoscopic approach with the creation of less intraabdominal adhesions may play a role in a higher incidence of perineal hernias. The
increase use of cylindrical APR operations for distal rectal cancer will need a better
closure of the perineal wound by means of muscular plasty or a mesh. Perineal hernias remain a challenging problem, and surgical correction should only be attempted
when the hernia becomes symptomatic. So et al. reported no recurrences following
the abdominal approach for correction and 5.3 % recurrence following the perineal
approach [ 4 ]. Although the abdominal approach has a better success rate, better
exposure, and conformation on the absence of recurrent disease, this approach is
much more invasive. The choice between an abdominal correction or a perineal correction therefore remains a custom-made decision for each individual patient.
Perineal hernias have been described following abdominoperineal resection,
sacrectomy, protectomy, and coccygectomy [ 5 ]. The latter can be described as some
form of intra-abdominal content protruding through the pelvic fl oor into the perineal area [ 6 ]. The true incidence of postoperative perineal hernias is diffi cult to
estimate as the majority remain asymptomatic. However, reported frequencies following APR vary from 0.13 to 0.93 % [ 4 – 6 ]. When perineal hernias become symp-
tomatic, they can cause pain in the perineum due to erosion of skin, bowel
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obstruction, and urinary problems. Several approaches for symptomatic perineal
hernias have been described: abdominal, perineal, or a combination of both.
References
1. Anderin C, Martling A, Lagergren J, et al. Short term outcome after gluteus maximus myocu-
taneous fl ap reconstruction of the pelvic fl oor following extra-levator abdominoperineal exci-
sion of the rectum. Colorectal Dis. 2011;13:1463–318.
2. Zorcolo L, Restivo A, Capra F, et al. Does long-course radiotherapy infl uence postoperative
perineal morbidity after abdominoperineal resection of the rectum for cancer? Colorectal Dis.
2011;13:1407–12.
3. El-Gazzaz G, Kiran RP, Lavery I. Wound complications in rectal cancer patients undergoing
primary closure of the perineal wound after abdominoperineal resection. Dis Colon Rectum.
2009;52:1962–6.
4. So JB, Palmer MT, Shellito PC. Postoperative perineal hernia. Dis Colon Rectum.
1997;40:954–7.
5. Franklin Jr ME, Abrego D, Parra E. Laparoscopic repair of postoperative perineal hernia.
Hernia. 2002;6:42–4.
6. Veenhof AA, vd Peet DL, Cuesta MA. Perineal hernia after laparoscopic abdominoperineal
resection for rectal cancer: report of two cases. Dis Colon Rectum. 2007;50:1271–4.
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