Minimally invasive versus open abdominoperineal resection and the risk of postoperative perineal hernia: a systematic review and meta-analysis

Background The impact of minimally invasive surgery on the risk of postoperative perineal hernia after abdominoperineal resection (APR) or extralevator abdominoperineal excision (ELAPE) remains uncertain. This study compares perineal hernia rates and perioperative outcomes between minimally invasive and open approaches. Methods PubMed, Scopus, Web of Science, and Cochrane Library were searched through June 2026. Pooled odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated using random-effects models. A Bayesian meta-analysis was additionally performed for the primary outcome. Results Four comparative observational studies involving 763 patients were included; 249 underwent minimally invasive APR/ELAPE, and 514 underwent open APR/ELAPE. Postoperative perineal hernia was significantly more frequent following minimally invasive surgery (OR 4.13; 95% CI 2.24–7.61; p < 0.001). Intraoperative blood loss was significantly lower in the minimally invasive group (MD − 156.5 mL; 95% CI − 298.4 to − 14.5; p = 0.03), as was operative time (MD − 41.7 min; 95% CI − 60.8 to − 22.5; p < 0.01). No significant differences were observed in hospital stay (MD − 2.5 days; 95% CI − 5.4 to 0.4; p = 0.09) or 30-day readmission rates (OR 1.41; 95% CI 0.82–2.42; p = 0.209). Bayesian analysis yielded a posterior mean OR of 4.04 (95% CrI 1.96–8.36), corresponding to a 99.9% posterior probability that minimally invasive surgery increases the risk of postoperative perineal hernia. Conclusion Minimally invasive APR/ELAPE was associated with an increased risk of postoperative perineal hernia compared with the open approach. Strategies to reduce this complication while preserving the benefits of minimally invasive surgery warrant further investigation.