Secondary perineal hernia following open abdominoperineal excision of the rectum: report of a case and review of the literature

Abstract

This is a case report of a 46-year-old man who presented with a painful perineal lump four months after abdominoperineal excision of the rectum (APER) with pre-operative radiotherapy and adjuvant chemotherapy. Perineal hernia (suspected clinically) was confirmed by magnetic resonance imaging, and the patient underwent open Permacol mesh repair via a perineal approach. Symptomatic perineal herniation after surgical resection is a rare phenomenon, and the approach to management remains challenging. Several different surgical approaches and techniques of repair have been described. In this report, we review the literature surrounding the presentation, aetiology and repair of this unusual post-operative complication. Furthermore, our case confirms that closure of the hernial orifice with mesh via a perineal approach is a satisfactory technique.

Prevention of perineal hernia after laparoscopic and robotic abdominoperineal resection: review with illustrative case series of internal hernia through pelvic mesh

“…12,13 In most cases, the perineal hernias are asymptomatic, but often enough, a dragging feeling and discomfort in the perineum, urinary symptoms and bowel compromise can occur. [2][3][4][5][6] Despite the lack of evidence in the literature, some surgeons feel compelled to reinforce the surgically weakened pelvic floor after APR to prevent these complications. Multiple tissue as well as mesh techniques have been described to reinforce a weakened floor postpelvic surgery.…”

“…The duration between surgery and hernia formation usually reported is 4-14 months. [3][4][5][6] The most common presenting symptoms are perineal pain, dragging sensation and discomfort on standing or sitting. However, to our knowledge, there are no reported early postoperative internal hernias through a mesh defect after laparoscopic or robotic APR related to attempts at perineal hernia prevention.…”

Perineal herniation of an ileal neobladder following radical cystectomy and consecutive rectal resection for recurrent bladder carcinoma

“…4 It often occurs within the first year after surgery, especially for low rectal neoplasia or following extended surgery. 1 When performing APRR, a fragile zone is created in the lesser pelvis, being exposed to gravity, pressure and tension, which can lead to perineal herniation of intraperitoneal contents. In order to prevent herniation after APRR, omentoplasty can be performed during the resection, with good clinical results.…”

“…1 For large defects, a combined procedure can be performed. Nowadays, most secondary perineal hernias are treated by applying synthetic absorbable or non-absorbable meshes.…”

“…1,2 Risk factors include insufficient closure of the peritoneum or pelvic floor, extended resections, (neo)adjuvant radio/chemotherapy, smoking, wound infections, obesity, wound dehiscence and female sex. 1 Symptoms may vary from an uncomfortable perineal feeling, to a newly appearing perineal protrusion or pain and they can also include changes in urinary or bowel function. Treatment depends on the symptoms and can range from conservative treatment to perineal, abdominal or abdominoperineal reoperation.…”