Addressing the empty pelvic syndrome following total pelvic exenteration: does mesh reconstruction help?

Abstract

Aim Perineal wound complications and pelvic abscesses remain a major source of morbidity after total pelvic exenteration. The void created in the pelvis after these multi‐visceral resections leads to fluid accumulation and translocation of bowel within the pelvic cavity, which may increase the risk of pelvic abscess, perineal fluid discharge with perineal wound dehiscence and prolonged ileus. This study describes a novel technique using degradable synthetic mesh with overlying omentum to preclude small bowel and fill the empty space after total pelvic exenteration, and aimed to investigate the rate of pelvic abscess and perineal wound‐related complications in this group. Method Ten patients who underwent total pelvic exenteration followed by implantation of degradable synthetic mesh at a quaternary referral centre were identified and included. The mesh was moulded to the contours of the bony pelvis at the level of the pubic symphysis anteriorly and inferior to the sacral promontory posteriorly. The data on the number of postoperative perineal wound‐related complications including pelvic abscesses were collected. Results There was no perioperative mortality. Five patients (50%) developed postoperative complications. One patient developed an abscess inferior to the mesh that required surgical drainage and another had a pre‐sacral collection that was successfully managed conservatively. Two patients developed intra‐abdominal collections requiring percutaneous drainage. Median length of stay was 20 days (range 16–35). No perineal hernia or entero‐perineal fistula was detected in any patient either clinically or radiologically at a median follow‐up of 7 months. Conclusion Degradable synthetic mesh reconstruction following exenterative surgery may reduce postoperative complications related to the perineal wound.

Long-term outcomes of biological mesh repair following extra levator abdominoperineal excision of the rectum: an observational study of 100 patients

“…A wide variation in wound healing and perineal hernia rates is also reported after primary closure of the perineum [17]. Primary closure is associated with high tension and a large volume area of dead space, which predisposes to postoperative perineal complications [39]. The only RCT comparing primary closure with biological mesh reconstruction, showed no significant difference in wound healing, but a large difference in perineal hernia rates.…”

Response to Carboni et al.

“…The healing of the pelvic floor and skin can also be affected, especially with an empty pelvis after total exenteration. This is due to the accumulation of pelvic fluid which, according to our data, has a risk of infection of approximately 20% . This can lead to wound dehiscence and then delayed healing of the perineal wound.…”

“…Thank you for your thoughtful comments and enquires about our article . Thank you for the opportunity to respond to the questions.…”

Novel use of the Bakri balloon to minimize empty pelvis syndrome following laparoscopic total pelvic exenteration

“…The procedure leaves a large empty space in the pelvis, often leading to postoperative collections, abscess formation, prolonged ileus, intestinal obstruction and small bowel fistulas, collectively termed empty pelvis syndrome (EPS) [2][3][4]. A number of surgical options [5][6][7][8][9][10][11][12][13] have been suggested to overcome this problem. However, to date, the search for the ideal solution continues.…”