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Healing of the Perineal Wound after Intersphincteric Dissection of the Rectum for Inflammatory Bowel Disease
Abstract
During the past 20 years a marked change in attitude to the surgical technique of removal of the rectum for inflammatory bowel disease has taken place among surgeons interested in colo-rectal surgery. This development has occurred in two main aspects of surgical technique. Firstly, the extent of removal of tissue from the pelvis has changed from standard abdomino-perineal excision techniques to a very conservative excision. In the second place, management of the perineal wound now consists of primary closure of the wound with closed drainage wherever possible, in contrast to previous methods of packing the perineum. Although close dissection of the rectum from the abdominal aspect has been advocated for many years, it is only relatively recently that Lyttle and Parks (1977) advocated very close dissection of the rectal wall from the perineal aspect. They suggested that an easy plane could be found in most patients between the internal sphincter (smooth muscle) and external sphincter (striated muscle) thus preserving intact the somatic sphincter apparatus and the muscles of the pelvic floor. It has been suggested that not only is nerve damage in the pelvis unlikely to occur during such a dissection but also the size of the cavity produced in the pelvis is small, with consequent reduction in dead space.
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Four hundred and fifty-three patients who underwent ileostomy and excisional large bowel surgery for chronic inflammatory disease at two teaching hospitals and 35 non-teaching hospitals within the North East Metropolitan Hospital Region during the years 1955-66 were surveyed through a study of hospital case records. The surgical results and complications are presented in part I; a study of the health of these patients after their discharge from hospital is made in part II in an attempt to answer the question posed by many ileostomists, `Are we as healthy as other people?'
Delay in healing of the perineal wound is a major cause of disability in patients after excision of the rectum.
The outcome of primary suture in 76 patients treated at St Mark's Hospital between 1967 and 1976 was correlated with a number of factors describing the patients, their preparation for surgery and details of surgical technique and management.
The perineal wound healed by first intention in 33 patients. The remaining 43 patients regarded as failures included 7 with delayed breakdown after initial healing.
The results showed that women fared better than men. Excision of the rectum following colectomy and ileostomy was associated with failure of the perineal wound to heal in 9 out of 10 patients. Treatments with peroperative ampicillin and topical antibacterial agents were both correlated significantly with success. Preoperative sepsis and operative contamination were followed by perineal sepsis and wound breakdown on 16 out of 21 occasions.
Discriminant analysis showed that topical and peroperative antibacterial treatments, sex, preoperative sepsis and finally ACTH were the most important variables in descending order of importance. The prediction of success and failure by this procedure was 72.4 per cent correct.
Wide excision of the rectum in inflammatory bowel disease is both unnecessary and undesirable as the healthy pelvic floor is damaged and the pelvic nerves put at risk. An operative technique is described which includes dissection of the anal canal and rectum in the intersphincteric plane, i.e. the plane of fusion between the visceral rectum and anal canal and the somatic pelvic musculature, which minimizes these undesirable elements.
Fifty–three cases are presented. Perineal wound healing rates are comparable with those of other methods of resection and only 1 of 14 men reported partial sexual dysfunction following this operation.
Three methods of perineal wound closure were studied in a randomized prospective clinical trial in 106 patients undergoing excision of the rectum for inflammatory or malignant disease. In method 1 the perineal wound was managed by open drainage. In both methods 2 and 3 the perineal wound was closed by primary suture, suprapubic suction drains being left down to the presacral space, but in method 2 the pelvic peritoneal floor was reconstituted, whilst in method 3 it was left unsutured. Topical and systemic antibiotics were administered to all patients submitted to primary closure of the perineal wound but not routinely to those whose perineal wound was left open.
The overall operative mortality was 8·5 per cent but no deaths could be definitely attributed to perineal wound complications. The incidence of primary wound healing after methods 2 and 3 was 45·2 and 4·9 per cent respectively. Operative contamination of the perineal wound had an adverse effect on perineal wound healing. The incidence of persistent wound sinuses and unhealed wounds at 3 and 6 months after primary wound closure was rather less than that encountered after open drainage.
It was concluded that primary closure of the perineal wound is the treatment of choice following excision of the rectum, except in cases in which contamination of the perineal wound has occurred during operation or the final state of haemostasis in the pelvis with diathermy and suture at the conclusion of the dissection was deemed to be unsatisfactory.
Closed-suction drainage with peritoneal and perineal suture has been used in 106 patients undergoing proctectomy for carcinoma or ulcerative or Crohn's colitis. This technique resulted in primary wound healing in 63 per cent of all the patients. Wound breakdown and delayed primary healing were particularly likely to occur in the young, in patients with Crohn's disease, in those who had contaminated wounds and in those on prolonged systemic steroid therapy. Even in the high-risk patients primary wound healing could still be achieved in 33 per cent. If haematoma or infection of the wound occurs the wound can be opened and the patient is no worse than if the wound had been packed initially.
The results of excisional surgery with the eastablishment of a permanent ileostomy in 246 patients with ulcerative colitis operated on in the years 1955-69 at St. Mark's Hospital, London, are presented. The overall mortality of the primary surgery was 8.1 per cent, being 9.3 per cent in the years 1955-9, 10.6 per cent in the years 1960–4, and 5.3 per cent the years 1965–9. This mortality was 1.6 per cent in 128 patients treated electively, 10.7 per cent in 75 cases coming to urgent surgery, and 23.3 per cent in 75 cases coming to urgent surgery, and 23.3 per cent in 43 patients undergoing emergency operations. The mortality in this third group fell from 36.4 per cent in the years 1955-;9 to 25 per cent in the years 1960–9. The indcidence of major postoperative complications for patients treated by total proctolectomy or colectomy and ileostomy was also clearly related to the preoperative servertity of the disease, being 18.8 per cent in the elective cases, 31.3 per cent in the urgent cases, and 40 per cent in the emergency cases.
Late complications of surgery were, with the exception of intestinal obstruction requiring surgery, infrequent in this series and showed a marked fall in the last 5 years of the study. With the possible exception of urolithiasis, the investigation revealed no increased susceptibility to diseases or conditions of a general nature in the long-term study of these patients (average length of follow-up 7 years) and emphasized the excellent life expectancy in patients in whom radical surgery had been carried out in the absence of malignant change.
Four hundred and fifty-three patients who underwent ileostomy and excisional large bowel surgery for chronic inflammatory disease at two teaching hospitals and 35 non-teaching hospitals within the North East Metropolitan Hospital Region during the years 1955-66 were surveyed through a study of hospital case records. The surgical results and complications are presented in part I; a study of the health of these patients after their discharge from hospital is made in part II in an attempt to answer the question posed by many ileostomists, ;Are we as healthy as other people?'
The rate of wound healing after proctectomy was assessed in a series of 105 patients. Early healing was dependent principally on the primary diagnosis, to a lesser extent on faecal contamination and was not related to steroid administration. Early healing (with 3 months) occurred in 72 per cent of patients undergoing operation for cancer and 45 per cent of these operated on for ulcerative or Crohn's colitis.
Management of the pelvic space after proctectomy
- J H Broader
- B A Masselink
- G D Oates
- JH Broader