Techniques of perineal hernia repair: A systematic review and meta-analysis

Background: Perineal hernias are rare, underreported and poorly studied complications of extensive pelvic surgeries. Their management is challenging, with currently no treatment algorithm available. Method: MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were searched. Studies comprising at least 3 patients who underwent surgical perineal hernia repair were included. The primary outcome was perineal hernia recurrence. The secondary outcomes were overall complications and surgical site occurrences. Results: Twenty-nine studies were included, comprising 325 patients undergoing 347 repairs. Overall complications were 33% (95% confidence interval 24%–43%) in the entire cohort, 31% (19%–44%) after perineal repair, 39% (14%–67%) after abdominal repair, and 36% (19%–53%) after mesh repair (20% with biological, 46% with synthetic mesh). The surgical site occurrence rate was 18% (8%–29%). The overall recurrence rate was 22% (15%–29%). Recurrence after perineal repair was 19% (10%–29%): 20% with mesh (25% with biological, 19% with synthetic), 24% with primary repair, and 39% with flap repair. Recurrence after an abdominal repair was 18% (11%–26%): 16% with laparoscopic, 12% with open, 16% with mesh (24% with biological, 16% with synthetic), 30% with primary, and 25% with flap repair. No significant differences could be found in the meta-analysis regarding overall complications and recurrence. Conclusion: Synthetic mesh repair seems to be associated with a lower recurrence rate than other techniques, especially after an abdominal approach. The perineal and abdominal approaches appear to be safe, with similar recurrence rates. The combined approach seems promising, but more evidence is needed.