Thank you Bojan for you question. We never close the peritoneum after entering the pelvis for an APR procedure. Mesothelial cells will cover the extra- peritoneal pelvis soon after surgery. The perineal wound should however be closed with multi-layer interrupted sutures. Doing so, we never saw patients with entrapped bowel loop in the pelvis requiring a second surgery.

Hi Bojan

I had exactly a similar situation, where I closed the peritoneum and postoperatively small bowel herniated into the pelvis. I had to do laparoscopic exploration and managed to free the small bowel loops from the pelvis. I opened all the sutures on the peritoneum and did not close it again. The patient did well.Since then, I never close peritoneum even if it can be easily closed. I bring down the omentum and pack it in pelvis. No trouble after that.

Thanks for your answers so far . Now we have three different approaches. Closing, leaving open and leaving open but packing with omentum. I would vey like to leave open but I'm not sure about ileum. It will surely fall into pelvis, which is at the begginig exposed, there is surelly some blood at first days and I'm afraid of adhesions and ileus. Massimo, You have no such compications?

Bojan

never closed the peritoneum for an ap resection.

Every time I try to close pelvis with the residual peritoneum but not always is simply or possible, so, I'm used to put on, the great omentum and occasionally I place a piece of Vicryl mesh sutured to the peritoneum around the defect. Two vacuum drains are left inside for 3-4 days.

Whenever possible close the pelvis peritoneum. The appraoch, wether  open or laparoscoopic  is equal. Considerations are, 1.)  the  necissaty  of postoperative  radiation therapy, 2.) the prevention of  awfull intestinal adhesions i.E. long term follow up small bowel  ileus within the lower pelvis. 3.) to enable treatment and to optimize treatment possibilities in the case of recurrent extraluminal cancer , which in most cases manifestates within the small pelvis. I think the use of interrupted or continous sutures is similar. Main fact - the plevic peritoneum is closed. The implantation of meshes is contriversial, because the potential of infection. 

We rarely close the peritoneum after APR in our service. My personal approach is to close the perineum and leave the ileum to freely fall into the pelvis, together with the omentum but not wrapped.. I try to avoid any tension in the omentum or any forced position for the ileum. I always pay attention to hemostasis and leave a drain into pelvis(for 24 to 48 h). In 3 patients we had distant interventions(cholecistitis, ventral hernia and parastomal hernia ) and for our surprise we found few adhesions in the pelvis that was mostly covered by peritoneum. 

I do not agree with the closure of the peritoneum because in some cases you will have some tension over there that can lead to partial suture openings even if you put continuous sutures. Beside that, if you close both the perineum and the peritoneum, between them will develop a non-drained space, a place for a seroma, hematoma or abscess to form, anyway causing inflammation, ileus and secondary adhesions. So, if you close the peritoneum I think it's advisable to leave the perineum open. My professor always does this in open surgery and he did't encounter problems like occlusion, but the perineal wound closes very slowly, especially after radiation therapy. 

I try to close the pelvic peritoneum after APR .I use contınue sutures to avoid any herniation.Meanwhile, we did not found any early and late ileus after extralevator excision for local advenced rectum tumors.

We always try to close the peritoneum with or without using the omentum to fill the gap. If radiotherapy is necessary it leaves the small bowell untouched. If your not able to close it completly then we woud prefer to leave it open completly to avoid incarceration.

Never, because the peritoneum generally doesn't meet easily and small gaps will be left (which are much more dangerous than big gaps for causing internal small bowel obstruction). Its the same reason I never close mesenteric defects after segmental resection.

Presumably the reason for closure is to prevent perineal hernia.  In actual fact, the small bowel in most people rarely migrates far below the sacral promontory.  Anyone with experience of ileo-anal pouch surgery will know how much mobilisation is needed in most patients in order to get the small bowel to reach the anus, so in most patients closure with prevention of perineal hernia in mind is unnecessary.  Same principle applies to mesh closure of the pelvic floor after wide AP excision; mostly unnecessary and costly.

We never close the peritoneum. It does not help at all. 

We prefer closing peritoneum if it is possible to.

The rate of post operative occlusion after pelvic surgeries is higher than the others, especially those involving proctectomies or APR. The experiences mentioned before covered the most questions. Nevertheless I suggest in cases of necessity of closing the pélvis there is a absorbable mesh called BIO A, flexible enough to suit into the pélvis, with no need of sutures at all, I've used sometimes with excelent results.

I usually do not close the pelvis after rectal surgery. In case of wide raw surfaces exposed (i.e. after exenterative procedures), deep infectious conditions or palliative surgery por pelvic cancer with residual tumor remaining, I exclude the pelvis by means of an omental flap or -if this is not possible- a reversed TRAM flap pedicled on inferior epigastric vessels

We never close the peritoneum after this type of surgery.Not only because it does not help but because we remove it unblocked with the rectum.

"Always" and "Never" delimits intellectual flexibility during  the  art of performing a surgical.exercise. I suggest individualization  I have performed open and closed.  Either way works uneventfully depending upon your anatomy and healing response. I have always been afraid to use foreign bodies, e.g. mesh, because I've seen erosions, adhesions, etc.. 

Good discussion,After APR i was taught to close the peritoneum during my training  in UK.After I started Lap APR ,i have not closed the pelvic peritoneum so for due to technical reasons .More over when we close, the sutures may not stay(cut through).I have not found any complication except in one pt ,where small bowel strictured following radiation.This was probably due to the loop got adherent to the raw area at the time or during immidiate post op .

Hallo Bojan!I usualy  prefer to close peritoneum using continued suture with monofilament 3/0 material and I don`t have any complication yet.

I was taught to clos the peritoneum, but after real radical resection it is impossible to clos and so I leave it open.

Yes, we closed the peritoneal after APR.

I never close  the pelvic peritoneum when I did laparoscopic resections.

It is too hard to close the peritoneum after radical resections and also no need to close.

The peritoneum is actually removed enbloc with APR surgery, in most cases it is impossible to approximate the peritoneal edges.

In few cases, the peritoneum is lax enough to be approximated by sutures without being teared. 

It's not necessary to close the peritoneum. An ometum flap in the perineum is more useful

I RARELY USED TO CLOSE PELVIC PERITONEUM BUT IF ANY DOUBT I ADOPT THE OMENTAL PEDUNCULATED FLAP, AS IN DUMONT REMARK

No

I close the peritoneum after APR. I think ,this repair decrease the risk of bowel obstruction due to pelvic adhesion.On the othere hand if the wound infection and dehiscence occurs after the operation in the perineal wound ,it can prevent the evisceration .

I did not. if anysurgeon do perform APR with posterior approach laparoscopically it is quite a bit imposible to close the peritoneum. nor did I. however I can use a such mesh like vicryl or dual one to close over the prostate galnd and the perineal place.

in such patient who are a few fortunately, a type of repair with vascularized flaps can employed. it is not necessary in that circumstance too.  

We do not close the peritoneum after APR routinely.Nowadays,neoadjuvant chemoradiotherapy for low rectal cancer has become the standard procedure.Few patients need to receive postoperative radiotherapy,so we do not need to consider the radiation damage to small bowel which adhere to the pelvic wall. If we close the peritoneum,we should suture it firmly enough.A gap is dangerous.we encounter a case similar to your's.

In cancer surgery, no attempt should be made to reperitonise the pelvis. Simply because, the sutures will not hold,  it is not desirable in addiotion can be harmful. The reporter's experience proves the point. Nothing untoward happens if this is not done.

i agree with most of the answer  and for those reasons don't close

I do not close peritoneum for two reasons; first if you perform lymphadenectomy and go wide there is no enough peritoneum, secondly with a stiches on peritoneum you potentially create a small holes and possibility for incarceration is in my experience greater. We didn't encountered problems in women’s because of their wide pelvis but in a narrow men's pelvis in a few cases we had a prolonged postoperative recovery due to paralytic ileus and in one case we need a reoperation. I never used mash.

Good question In open surgery we routinely close pelvic peritoneum after APR.But after Lap APR it is very difficult to bring the edges together,,more over it does not make any difference in not closing.`.In female patients anyway we do not need to close as the uterus falls back and fills the space.

I DON'T DO VIDEOLAP, AND IN OPEN SURGERY FOR APR I ALWAYS CLOSE DE PELVIC PERITONIUM WHEN IT' S POSSIBLE GET THE BORDERS LOOSELY, IT PERMITS A STRONG SUTURE AND WE HAVE NO DEHISCENCE IN THIS SITUATION, EVEN TOUGH I HAVE HAD ADHERENCE WITH SMALL BOWELL IN THE LINE SUTURE WITH OBSTRUCTION AND REOPERATION. BUT WHEN THE PERITONEUM DOES NOT CLOSE TOGETHER I USE THE MESH CALLED BIO A MADE OF ABSORBABLE MATERIAL AND FITS GOOD IN PELVIS WITH GOOD RESULTS. 

My limited experience with closing the pelvic peritoneum resulted in a small hole and small bowel slipping through causing post -operative small bowel obstruction.

I leave it open and leave tube drain We never face early postoperative complications in terms of small bowel obstruction but Faced bowel adhesions "as late complication" in form of pain

I usually perform APR laparoscopically and I never close the peritoneum over the pelvis . So far I have experienced no small bowel complication in the course by doing that.