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Background: Current evidence suggests that pelvic floor reconstruction following extralevator abdominoperineal excision of rectum (ELAPER) may reduce the risk of perineal herniation of intra-abdominal contents. Options for reconstruction include mesh and myocutaneous flaps, for which long-term follow-up data is lacking. The aim of this study was to evaluate the long-term outcomes of biological mesh (Surgisis ® , Biodesign™) reconstruction following ELAPER., Methods: A retrospective review of all patients having ELAPER in a single institution between 2008 and 2018 was perfomed. Clinic letters were scrutinised for wound complications and all available cross sectional imaging was reviewed to identify evidence of perineal herniation (defined as presence of intra-abdominal content below a line between the coccyx and the lower margin of the pubic symphysis on sagittal view)., Results: One hundred patients were identified (median age 66, IQR 59-72 years, 70% male). Median length of follow-up was 4.9 years (IQR 2.3-6.7 years). One, 2- and 5-year mortality rates were 3, 8 and 12%, respectively. Thirty three perineal wounds had not healed by 1 month, but no mesh was infected and no mesh needed to be removed. Only one patient developed a symptomatic perineal hernia requiring repair. On review of imaging a further 7 asymptomatic perineal hernias were detected. At 4 years the cumulative radiologically detected perineal hernia rate was 8%., Conclusions: This study demonstrates that pelvic floor reconstruction using biological mesh following ELAPER is both safe and effective as a long-term solution, with low major complication rates. Symptomatic perineal herniation is rare following mesh reconstruction, but may develop sub clinically and be detectable on cross-sectional imaging.

Introduction: An abdominoperineal excision of rectum (APER) may be required for rectal tumours less than 6 cm from the anal verge. Recently, the cylindrical APER has been used to prevent the "surgical waist" and so decrease margin involvement. However, removal of the levators leaves a large defect. Myocutaneous flaps [e.g. vertical rectus abdominis (VRAM)] are often used to fill the cylindrical resection defect, but have disadvantages associated with operative time, expertise and morbidity. We report our early experience of pelvic floor reconstruction with a biological mesh following cylindrical APER., Methods: Data on consecutive patients having cylindrical APER between January 2008 and November 2010 were collected. Outcomes were compared between a VRAM reconstruction group and a mesh group., Results: In 15 consecutive patients with low rectal cancer, five patients had VRAM pelvic floor reconstruction prior to ten patients having biosynthetic mesh repairs. The median operative time for the VRAM cohort was 405 min, compared with 259 min for the mesh (p = 0.0013). The median length of postoperative stay was 20 days for VRAM and 10 days for the mesh group (p = 0.067). There were four early complications for the VRAM group compared with seven for the mesh cohort (p = 0.37). The median cost per patient for the VRAM cohort was £11,075 compared to a median cost of £6,513 for the Mesh (p = 0.0097)., Conclusion: The use of a biological mesh for pelvic floor reconstruction following cylindrical APER is feasible with morbidity comparable to VRAM reconstruction. There is significant cost-saving using a biosynthetic mesh, mainly due to reduced length of stay.