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Background: Abdominoperineal resection (APR)—the standard surgical procedure for low-lying rectal cancer (LRC)—leads to significant perineal defects, posing considerable reconstruction challenges that, in selected cases, necessitate the use of plastic surgery techniques (flaps). Purpose: To develop valuable decision algorithms for choosing the appropriate surgical plan for the reconstruction of perineal defects. Methods: Our study included 245 LRC cases treated using APR. Guided by the few available publications in the field, we have designed several personalized decisional algorithms for managing perineal defects considering the following factors: preoperative radiotherapy, intraoperative position, surgical technique, perineal defect volume, and quality of tissues and perforators. The algorithms have been improved continuously during the entire period of our study based on the immediate and remote outcomes. Results: In 239 patients following APR, the direct closing procedure was performed versus 6 cases in which we used various types of flaps for perineal reconstruction. Perineal incisional hernia occurred in 12 patients (5.02%) with direct perineal wound closure versus in none of those reconstructed using flaps. Conclusion: The reduced rate of postoperative complications suggests the efficiency of the proposed decisional algorithms; however, more extended studies are required to categorize them as evidence-based management guide tools.

Objective: To compare drainage and healing by secondary intention with drainage, delayed excision and direct closure (DE/DC). Methods: Between January 2003 and January 2010, 130 patients admitted with an acute pilonidal abscess were randomized to undergo either elliptical incision and drainage (I and D) and healing by secondary intention (Group 1, n=66) or I and D and DE/DC (Group 2, n=64). Data regarding patient and sinus characteristics, hospital stay, healing time, postoperative complications, and recurrence were prospectively collected. Patients were followed-up for a mean of 62.4 months. Results: Ninety percent of patients were men and 10% were women, with a mean age of 26.4 years and a mean body mass index of 31.5. There was no difference in hospital stay between both groups. Mean healing time was significantly (p=0.035) longer for patients in group 1 (32.2 days), compared to those in group 2 (10.7 days). Group 1 patients had significantly fewer postoperative complications (4.5% versus 17.2%, respectively) (p=0.020). The 2 groups had a similar recurrence rate of a pilonidal abscess (6.1% versus 6.3%, p=0.984), and a rate of development of a chronic pilonidal sinus (PNS) (25.8% versus 23.4%, p=0.840). Conclusions: Although there is more rapid healing and fewer visits for dressing with I and D and DE/DC of an acute pilonidal abscess, this is accompanied by a significantly higher overall complication rate than with I and D and secondary healing. Recurrence of an acute abscess or development of a chronic pilonidal sinus is similar with both procedures. [Arch Clin Exp Surg 2012; 1(1.000): 8-13]