Perineal hernia repair after abdominoperineal excision or extralevator abdominoperineal excision: a systematic review of the literature

The incidence of perineal hernia after abdominoperineal excision and extralevator abdominoperineal excision ranges from 1 to 26%. In this systematic review, we compared surgical options and postoperative outcomes of perineal hernia repair in this setting from 2012 to 2016 with findings in a review of publications 1944-2011. We searched the PubMed database using the keywords "hernia" AND "perineum" identified 392 papers published from 1946 to 2016. Two hundred and ninety-six papers published before 2012 were excluded and 96 were found to be potentially relevant. Twenty-one studies with a total of 108 patients were included in the final analysis. Perineal hernia repair was performed using the perineal approach in 75 patients (69.44%), the laparoscopic approach in 25 patients (23.14%), the open abdominal approach in three patients (2.77%) and the laparoscopic perineal approach in three patients (2.77%) and the open abdominoperineal approach in two patients (1.8%). Non-absorbable mesh was used in 41 (37.96%) of cases, composite mesh in 20 (18.51%) and biological mesh in 19 (17.59%). Flap reconstruction was used in 25 patients (23.14%). First and second recurrences were observed in 26 (24.07%) and 7 (26.92%) cases, respectively. Comparison of perineal hernia repair from 1944 to 2011 and from 2012 to 2016 showed that perineal and laparoscopic approaches are currently the most commonly used techniques. Primary defect closure was abandoned in favor of synthetic or composite mesh placement. Use of flap reconstruction spread rapidly and the recurrence rate was low. Randomized control trials and a larger sample size are needed to confirm these data and to develop a gold standard treatment for secondary hernia repair after abdominoperineal excision or extralevator abdominoperineal excision.