Uterus and extralevator abdominoperineal excision: a technique.

BACKGROUND: Perineal hernia is well described after standard abdominoperineal excision of rectum. There appears to be an increasing incidence of perineal hernia following extralevator abdominoperineal excision of the rectum. Currently, there is no standard for the prevention of perineal wound herniation and its potential sequelae. Techniques have been described to prevent perineal hernia, including the use of mesh, muscle flaps, or simple layered closure. OBJECTIVE: This technique describes the use of the uterus in postmenopausal women as a "natural packing material" to prevent the small bowel from entering the lower pelvis, and subsequent perineal herniation. PROCEDURE: The procedure involves retroverting the uterus and securing it to the bony pelvis with the use of nonabsorbable suture material. This can be achieved via the abdominal route as well as the perineal wound. LIMITATIONS: This procedure is only applicable in women with uterus in situ. Dyspareunia may be a side effect. Caution is advised in premenopausal women, because positional menstruation may be an issue. Subsequent hysteroscopy and hysterectomy may be difficult. Care should be taken to avoid damage to the presacral venous plexus and sacral nerves. CONCLUSION: Uterine interposition is a practical, low-risk, inexpensive solution to this problem in a selected group of patients. It avoids the cost and complications of prosthetic mesh and myoplastic reconstruction procedures.