Langenbeck's Archives of Surgery

, Volume 390, Issue 3, pp 255–258

Use of bone anchors in perineal hernia repair: a practical note

Authors

    • Department for General, Hepatobiliary Surgery and TransplantationUniversity Hospital of Ghent
  • Piet Pattyn
    • Department for General, Hepatobiliary Surgery and TransplantationUniversity Hospital of Ghent
Original Article

DOI: 10.1007/s00423-004-0523-6

Cite this article as:
Berrevoet, F. & Pattyn, P. Langenbecks Arch Surg (2005) 390: 255. doi:10.1007/s00423-004-0523-6

Abstract

Background

Bone anchoring systems are used extensively in orthopaedic surgery but have scarcely been reported as useful in abdominal wall or perineal hernia repair. After coccygectomy or sacrectomy the development of bowel herniation is not uncommon. Considering repair of such a perineal hernia, adequate fixation of the prosthetic mesh is difficult and, therefore, recurrence is rather frequent, mostly due to insufficient anchoring of the mesh to the bony structures.

Methods

We discuss a patient in which the Mitek GII anchoring system was used to overcome the problem of soft-tissue-to-bone attachment in such cases.

Conclusion

Bone anchoring systems seem to be an efficient method to overcome the problems of soft-tissue-to bone attachment in both abdominal and perineal hernia repair.

Keywords

Perineal herniaBone anchorSoft tissueMesh repair

Introduction

After coccygectomy or sacrectomy, with or without reconstruction of the sacral bed by muscle flaps, and also after abdomino-perineal rectum extirpation, the development of bowel herniation has been reported several times [13]. Prosthetic mesh repair is a possible therapeutic option in these cases. However, mesh repair of these sacral or perineal herniations may be extremely difficult, mostly due to problems concerning secure bone anchoring.

The same is true in the treatment of extensive abdominal hernias, incisional or primary. When the hernia sac reaches towards the pelvic ring, fixation of the mesh to the bony edges is the critical point during this type of reconstruction.

Mitek GII anchors have been reported to be useful in different kinds of orthopaedic procedures, as well as in urological and gynaecological surgery. More recently, their use has been described in recurrent abdominal wall hernias, but, to our knowledge, there has been no report of the use of Mitek anchoring in perineal hernia repair. In this short practical note we would like to report our excellent results with the use of Mitek anchors in such a case, which offer perfect fixation of the mesh to the bony structures with very easy handling and no recurrence after a follow-up of more than 4 years.

Case report

Our patient was a 66-year-old woman who was seen at our department for an extensive sacral hernia (Fig. 1). Twenty years before, she had undergone radiation therapy in the perineal area, complicated with sacral fistulisation, partial sacral resection and severe decubitus.
Fig. 1

Extensive sacral hernia with the patient on knees and elbows. Caudal view.

Reconstruction of the perineal floor had been carried out afterwards with an intercostal artery perforator flap. Currently, she complained about discomfort when sitting down, as she was “sitting on her bowel”. At clinical examination an obvious sacral hernia was present, with apparent bulging of the rectum dorsally. No strangulation or obstructive signs were present. The hernia was reducible but reappeared spontaneously. The patient’s continence was intact.

During the surgical procedure the patient was positioned on her knees and elbows, and the former transverse incision of the flap reconstruction was used. Mobilisation of both rectum and hernia sac was performed (Fig. 2), with appropriate reduction of the hernia.
Fig. 2

Mobilisation of rectum and hernia sac.

A Bard Composix mesh was used to strengthen the pelvic floor. It is a non-absorbable, sterile prosthesis specially designed for the reconstruction of soft tissue deficiencies. It is constructed of two layers of polypropylene mesh to encourage tissue ingrowth, placed towards the subcutis and sacrum, and one layer of expanded polytetrafluoroethylene to minimise tissue ingrowth, placed towards the bowel.

The mesh was fixed dorsally to the sacral bone with Mitek anchors (DePuy Mitek, Norwood, Mass., USA) (Fig. 3). These were made of nickel–titanium alloy and were delivered with a preloaded disposable anchor/inserter assembly designed to facilitate the delivery and installation of the anchor in bone. As a suture a braided long-term absorbable or non-absorbable material can be used. The bone hole site was prepared with the appropriately sized Mitek drill bit and drill guide delivered with the anchors. Proper drill hole size is 2.4 mm×14.2 mm, according to the manufacturer’s guidelines. Minimum bone hole spacing is 5 mm. Axial alignment of the Mitek anchor is very important and was established adequately in order for the anchor to be pushed in. One must not twist or apply bending force to the inserter as this may damage the anchor, suture or inserter tip. Incomplete insertion or severe bone porosity may lead to anchor pullout. The anchors were then inserted without excessive tension by retraction of the slide cover and release of the anchor (Fig. 4), the suture and the needle (Fig. 5). The inserter was then removed from the drill hole, and the tissue attachment completed. The right part of the mesh was secured to the levator muscles with Mersilene 0 sutures. Subsequently, all fat tissue and skin were closed over the mesh. Recent follow-up after 4.5 years did not show recurrence of disease.
Fig. 3

Mitek anchoring system as used for prosthesis fixation.

Fig. 4

Inserter system for Mitek anchor system.

Fig. 5

Mesh placement with adequate bone-to-soft-tissue fixation.

Discussion

Attachment of soft tissue to bone is a common problem encountered in orthopaedic, urological and gynaecological surgery. In abdominal surgery it may cause problems in certain types of hernia repair.

While both sacrum and coccyx prevent caudal herniation of the abdominal organs in normal physiology, herniation of the small bowel and/or colon may occur after coccygectomy or sacrectomy. Not only the bony protection disappears in those cases, but also the muscular structures of the pelvic floor are weakened, even after reconstruction of the sacral bed, promoting sacral or perineal hernia. The same is true after abdomino-perineal rectum excision or proctectomy [4], making perineal herniation much more frequent.

Prosthetic mesh repair is the first choice in this type of hernia surgery, as well as in cases of large abdominal wall herniation or in cases of incisional hernias [5]. Fixation of the prosthesis to the os pubis or one of the other pelvic bones may, here, often be necessary. However, mesh repair of these perineal herniations is difficult, mostly due to insufficient bone anchoring, and gives rise to a significant recurrence rate.

Especially in orthopaedic surgery bone anchoring is an almost every day routine. Various types of anchors have been used extensively in tendon repair [6]. In the treatment of urinary stress incontinence bone anchors are used in the pubovaginal sling procedures and in bladder neck suspension, fixing the mesh to the pubic tubercle [7].

To overcome the problem of soft-tissue-to-bone attachment in sacral hernia repair we used the Mitek GII bone anchoring system to fix the prosthetic mesh. In the literature we have found no other reports describing this technique for perineal hernias, although recently Fergestad et al. reported the use of bone anchors in complex abdominal wall hernias [8]. In the patient mentioned in this short note, this anchoring system was easy to handle and offered an excellent attachment of the mesh to the bony structures.

One could argue that in patients with moderate-to-severe osteoporosis this technique has its limitations [9]. However, osteoporosis seems not to be a significant problem in these cases; our patient was a woman of over 65 years of age, no problem during bone drilling or anchor fixing occurred. This may partially be due to the fact that in the pelvic area one can choose the anchoring places very carefully, in less osteoporotic places, compared to the use of those anchors in hallux valgus reconstruction, e.g. where the bony surface is much smaller and bone porosity is of greater importance.

Reports have been published that mention the possibility that patients might develop osteomyelitis or infectious complications after bone anchors have been used [10], but, in our opinion, any foreign body might give rise to this type of problem, as might metal anchoring systems.

In conclusion, we think that the Mitek anchoring system is an efficient method to overcome the problems of soft-tissue-to-bone attachment in both abdominal and perineal hernia repair, using a prosthetic mesh with easy handling and excellent fixation of the mesh. The complication rate caused by the use of these foreign bodies remains to be evaluated.

Copyright information

© Springer-Verlag 2004