COMPLEX REPAIRS DEMAND CROSSLINKED DURABILITY Permacol™ Surgical Implant Advanced Solutions for Abdominoperineal Excision Steps in a Prone Abdominoperineal Excision with Permacol™ Surgical Implant Reconstruction Ian Daniels FRCS, Exeter Colorectal Unit, Royal Devon & Exeter Foundation Trust Hospital

INTRODUCTION The traditional technique for performing The demonstration by the Swedish an abdominoperineal excision (APE) surgeon Torbjorn Holm of the prone involved two surgeons operating perineal approach, and the recognition synchronously from the abdomen and by the histopathologist Phil Quirke that with the patient in the Lloyd- the key to improving outcome lay in the Davies position. However, results for excision of a cylindrical specimen, has APEs were poor when compared to total focused attention on the operative mesorectal excision (TME) surgery for technique. Recent studies have tumours proximal in the . The demonstrated lower involved CRM principle outcome measures used rates and increased volume of tissue involved circumferential resection excised using the perineal approach. margin (CRM) and local recurrence However, this ‘more radical’ approach rates. These poor results were felt leads to a large perineal defect and a to be due to anatomical and surgical deficient pelvic floor. We have been difficulties. With the advent of MRI using Permacol™ surgical implant to staging and the introduction of close this defect and we demonstrate preoperative MDT assessment, our early experience in this booklet. attention has focused upon the surgical technique and avoidance of ‘wasting’ of the specimen. 1 2

STEP 1: Division of the vessels and abdominal dissection. A standard TME approach is made as disease. Subsequent MRI demonstrated described by Professor Heald, in this case tumour regression from the potentially an open approach with mobilisation of involved circumferential resection margin, the omentum on a pedicle from the left and with no evidence of distant metastases, gastroepiploic vessels, using the omentum surgery was planned. At operation the to fill the after resection. procedure follows a TME dissecting Pre-operative MRI staging has been posteriorly to the level of the distal sacrum 3a 3b used and treatment planned through the and anteriorly the peritoneal multidisciplinary team. The patient had an reflection was divided high to allow end-stoma formed prior to combination dissection in front of Denonvilliers’ fascia. chemoradiotherapy for locally advanced

STEP 2: Posterior swab and abdominal closure. A swab is placed posterior to the rectum below. A 30Ch tube drain is placed above and remains in the patient. This acts as a this, together with the omentum and the guide when performing the dissection from abdomen is then closed.

STEP 3: Prone positioning and patient safety. The patient is then transferred to an is closed and the buttocks and upper operating trolley and repositioned on posterior leg separated using tape. These the operating table in the prone jack- tapes are secured to the operating table. knife position. Careful attention is paid to The patient is then re-draped and prepared supporting the patient with pillows and for the perineal excision. anaesthetic adjustments made. The anus 4 5a

STEP 4: Anatomical landmarks for perineal excision. Using the as the upper landmark, and inferiorly below. Taking the extended skin seems to the ischial tuberosities laterally, a teardrop-shaped improve cosmesis. The skin is then retracted using incision is made, extending upward to a hooked retractor. encompass the natal cleft skin and flattened

5b 6 STEP 5: Vertical dissection to the apex of the ischioanal fossa. The extent of the tumour influences the extent the pelvic floor muscles and overlying fascia are of excision of the ischioanal fat. The staging MRI identified. Posteriorly, the coccyx becomes the can be used in sagittal view to assess the need critical landmark as this is the key to successful for coccygeal excision and coronal view to assess pelvic floor excision. Laterally the vessels are taken the extent of excision of the ischioanal fat. For from the 3 and 9 o’clock positions, the dissection a radical excision, the first landmark identified is always from the 12 o’clock round to 3 and 9 o’clock. the gluteus maximus and following this down,

STEP 6: Dissection of the pelvic floor muscles. In this lateral view the pelvic floor has been The endopelvic fascia is then incised from the incised from left to right (coccyx left) along its anterior surface of the coccyx to reveal the swab origin revealing the endopelvic fascia beneath. left from the abdominal approach. This fascial The dissection continues from left to right layer is then incised again from 12 o’clock having either released the pelvic floor off the through to 3 and 9 o’clock. coccyx or divided the coccyx/distal sacrum. STEP 7: Delivery of the rectum. The rectum is then delivered through the defect created, the TME plane having The anterior dissection (6 o’clock) is the last to be performed to release the been clearly followed, with inversion of the specimen and the anterior peritoneum specimen. In this specimen the coccyx has not been excised and the notch already divided, the plane of surgery remains outside Denonvilliers’ fascia. can be seen where it was attached. This specimen can be described as a ‘cyclindrical excision.’ By continuing the dissection from above, along Denonvilliers’ fascia, the sphincter urethrae muscles and origin of the cavernosa can be identified in the male. In the female patient a concomitant hysterectomy and partial vaginectomy can be performed, or for extended resections in the male, a partial prostatectomy can be performed, or even a total prostatectomy if necessary.

7a 7b 7c STEP 8: Reconstruction of the pelvic floor using Permacol™ surgical implant. Following haemostasis, the omental paddle Initial suture placement is along the coccyx is delivered into the wound, together with with further sutures placed along the the 30Ch drain. fascial line of attachment of the pelvic floor ™ The Permacol™ surgical implant is cut to muscle. Anteriorly I reflect the Permacol fit the defect, with the anterior (6 o’clock) surgical implant behind the in part left long. Using a piece of 1mm thick the male, as suturing the cavernosus or 10x10cm Permacol™ surgical implant fills sphincter urethrae is unwise. the pelvic space easily. In the female, the posterior vagina can be The Permacol™ surgical implant is sutured reinforced or if partial vaginectomy has ™ using a 2/0 nonabsorbable monofilament been performed the Permacol surgical suture. implant can be used to support the repair.

STEP 9: Closure of the perineal wound. Once the tapes have been released, the The fat is then closed with a 2/0 absorbable wound will oppose. However, to reduce braided suture, the skin being closed with 8a 8b tension, the fat can be mobilised from the a 4/0 dissolvable monofilament and a gluteus maximus and the lower fibres of skin glue. Four to six interrupted mattress the muscles released from the proximal sutures are placed along the wound for coccyx and distal sacrum. I place a 10Ch security. It is important that the patient is vacuum drain in the space remaining, the nursed on their side in the first 24 hours Permacol™ surgical implant having been and when sitting, an appropriate cushion is left slightly loose to allow it to sag into the used. space with gravity.

9a 9b CLINICAL BIBLIOGRAPHY Permacol™ Surgical Implant for Complex , Pelvic Floor Reconstruction and Prone Abdominoperineal Excision.

1. Catena F, Ansaloni L, Gazzotti F, et al. Use of porcine 11. Shaikh FM, Giri SK, Durrani S, Waldron D, Grace PA. 18. Nelson RA, Butler CE. Surgical outcomes of VRAM versus dermal collagen graft (Permacol) for hernia repair in Experience with porcine acellular dermal collagen thigh flaps for immediate reconstruction of pelvic and contaminated fields. Hernia. 2007;11(1):57-60. implant in one-stage tension-free reconstruction of perineal cancer resection defects. Plast Reconstr Surg. 2. Gallagher H. Acellular porcine dermal graft in 16 complex acute and chronic abdominal wall defects. World J Surg. 2009;123(1):175-183. incisional hernia repairs. Abstract at ECCP/EACP 2nd 2007;31(10):1966-1972. 19. Nisar PJ, Scott HJ. Myocutaneous flap reconstruction of Joint Meeting, Bologna, Italy, 2005 12. Skipworth RJ, Smith GH, Anderson DN. Secondary the pelvis after abdominoperineal excision. Colorectal 3. Parker DM, Armstrong PJ, Frizzi JD, North JH Jr. perineal hernia following open abdominoperineal Dis. 2009;11(8):806-816. Porcine dermal collagen (Permacol) for abdominal wall excision of the rectum: report of a case and review of the 20. Wille-Jørgensen P, Pilsgaard B, Møller P. Reconstruction reconstruction. Curr Surg. 2006;63(4):255-258. literature. Hernia. 2007;11(6):541-545. of the pelvic floor with a biological mesh after 4. Hooks VH. Preliminary experience with porcine dermis in 13. Barrington JW, Abdel-Fattah M, Arunkalaivanan AS, abdominoperineal excision for rectal cancer. Int J abdominal wall repair. Abstract at ECCP/EACP 2nd Joint Austin S, Isaacs J. Longitudinal study of pelvicol Colorectal Dis. 2009;24(3):323-325. Meeting, Bologna, Italy, 2005. pubovaginal slings using magnetic resonance imaging. 21. Shihab OC, Moran BJ, Heald RJ, Quirke P, Brown G. MRI J Obstet Gynaecol. 2004;24(5):542-546. 5. Munikrishnan V. The management of complex abdominal staging of low rectal cancer. Eur Radiol. 2009;19(3): wall defects and hernia using Permacol™ biological 14. Abhinav K, Shaaban M, Raymond T, Oke T, Gullan R, 643-650. implant. ACPGBI, Gateshead, UK, 2006. Montgomery AC. Primary reconstruction of pelvic floor 22. Salerno G, Chandler I, Wotherspoon A, Thomas K, defects following sacrectomy using Permacol™ biological ™ Moran B, Brown G. Sites of surgical wasting in the 6. Brown J. Case series of Permacol biological implant implant graft. Eur J Surg Oncol. 2009;35(4):439-443. porcine dermal collagen used in complex abdominal wall abdominoperineal specimen. Br J Surg. 2008;95(9): repairs. Presented at the ESCP, Lisbon, Portugal, 2006. 15. Kim JS, Hur H, Kim NK, et al. Oncologic outcomes 1147-1154. after radical surgery following pre-operative 7. Murphy E. A novel pelvic floor closure technique using 23. West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke chemoradiotherapy for locally advanced lower rectal P. Evidence of the oncologic superiority of cylindrical porcine dermal collagen after abdominoperineal excision cancer: abdominoperineal resection versus sphincter of the rectum. Presented at the ECCP/EACP 2nd Joint abdominoperineal excision for low rectal cancer. J Clin preserving procedure. Ann Surg Oncol. 2009;16(5): Oncol. 2008;26(21):3517-3522. Meeting, Bologna, 2005. 1266-1273. 8. Phull P. A study of Permacol™ biological implant in the 24. Morris E, Quirke P, Thomas JD, Fairley L, Cottier B, 16. den Dulk M, Putter H, Collette L et al. The Forman D. Unacceptable variation in abdominoperineal repair of complex surgical wounds and flap donor sites. abdominoperineal resection itself is associated with an Presented at the European Hernia Society/GREPA, Turin, excision rates for rectal cancer: time to intervene? Gut. adverse outcome: the European experience based on a 2008;57(12):1690-1697. Italy, 2005. pooled analysis of five European randomized clinical trials 9. Hammond TM, Chin-Aleong J, Navsaria H, Williams NS. on rectal cancer. Eur J Cancer. 2009;45(7):1175-1183. 25. Holm T, Ljung A, Häggmark T, Jurell G, Lagergren J. Extended abdominoperineal resection with gluteus Human in vivo cellular response to a cross-linked acellular 17. Cresti S, Ouaïssi M, Sielezneff I, et al. Advantage of collagen implant. Br J Surg. 2008;95(4):438-446. maximus flap reconstruction of the pelvic floor for rectal vacuum assisted closure on healing of wound associated cancer. Br J Surg. 2007;94(2):232-238. 10. Brown J. Permacol™ biological implant used to repair with omentoplasty after abdominoperineal excision: a massive complex abdominal wall hernia. Abstract at case report. World J Surg Oncol. 2008;6:136. ECCP/EACP 2nd Joint Meeting, Bologna, Italy. Permacol™ surgical implant product details Advancing the concept of soft tissue repair

™ Permacol™ Surgical Implant Since 1998 Permacol surgical implant ∙∙Does not promote infection Size (cm) Thickness (mm) Product Code Minimum Quantity Supplied per Order technology has delivered innovative Does not act as a focus for infection 2 x 20 1.00 5220-100 1 solutions for complex soft tissue repairs ∙∙ Allows antibiotics to be used to bring the 3 x 3 0.50 5033-50 1 and has gained the approval of surgeons ∙∙ 1.00 5033-100 1 around the world. infection under control 1.50 5033-150 1 3 x 6 1.50 5063-150 1 Over 450,000 implants based on Permacol™ Similarly, postoperative infections will not 4 x 18 1.00 5418-100 1 surgical implant porcine dermal collagen require removal of Permacol™ surgical 5 x 5 0.50 5000-50 1 technology have been distributed globally implant, provided the infection can be 1.00 5000-100 1 for implantation. 1.50 5000-150 1 brought under control with the use of 5 x 10 0.50 5001-50 1 Clinical evidence shows excellent antibiotics. For many surgeons Permacol™ 1.00 5001-100 1 integration and neovascularisation post surgical implant has become the implant of 1.50 5001-150 1 implantation with ordered and high-quality choice for the repair of complex soft tissue 10 x 10 1.00 5110-100 1 1.50 5110-150 1 collagen deposition leading to highly problems. 10 x 15 1.00 5115-100 1 effective and durable repairs. This coupled Note: If Permacol™ surgical implant is 1.50 5115-150 1 with its ability to support the growth of used in contaminated or infected wounds ™ 15 x 20 1.00 5152-100 1 mesothelial cells means Permacol frequent monitoring of the surgery site is 1.50 5152-150 1 surgical implant has an extremely low advised. 18 x 28 1.00 5120-100 1 adhesion profile. 1.50 5120-150 1 20 x 30 1.00 5230-100 1 Surgeons are able to place Permacol™ PRODUCT BENEFITS: 1.50 5230-150 1 surgical implant directly in contact with Natural strength 20 x 40 1.50 5240-150 1 ∙∙ the bowel with excellent results and as Biocompatibility 20 x 50 1.50 5250-150 1 ∙∙ Permacol™ surgical implant does not 9 x 28 1.50 5928-150 1 ∙∙Crosslinked for durability 5 x 15 1.50 5645-150 1 contract, the problems associated with Integration and neovascularisation 28 x 40 1.50 55284-150 1 synthetic meshes and erosion of the bowel ∙∙ Low adhesion profile Permacol™ Surgical Implant Injection are remote. ∙∙ Size (ml) - Product Code Supplied per Order Minimum Quantity 2.5 - 6000-200 1

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