Use of bone anchors in perineal hernia repair: a practical note
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- Berrevoet, F. & Pattyn, P. Langenbecks Arch Surg (2005) 390: 255. doi:10.1007/s00423-004-0523-6
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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.
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.
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.
KeywordsPerineal herniaBone anchorSoft tissueMesh repair
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 [1–3]. 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.
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.
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.
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 , 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 . 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 . 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 .
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 . 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 . 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 , 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.