Perineal Repair of a Postoperative Perineal Hernia – Case Report  

Seke Manase Ephraim Kazuma1, Kazi Mufaddal1, Vivek Sukumar 1, Avanish Saklani 1 

1Department of Colorectal Surgical Oncology, Tata Memorial Hospital, Mumbai, Parel, India 

 

Correspondence to: Prof. Avanish Saklani. Email: asaklani@hotmail.com 

Received: 21 May 2021; Revised: 06 Dec 2021; Accepted: 14 Dec 2021; Available online: 5th Feb 2022

 

Summary 

Postoperative perineal hernia (PerH) following abdominoperineal resection is a rare complication of radical pelvic oncologic surgery performed with curative intent for rectal cancer, with a reported prevalence of 0.6–7%. PerH is clinically diagnosed as an occurrence of a swelling in the perineum caused by the herniation of abdominal or pelvic viscera through a defect in the pelvic floor. The definitive repair method of pelvic floor defect of PerH is not established but includes exclusion of tumor recurrence and repair of pelvic floor defect. We herein report the treatment of a PerH using a combination of biological mesh and a V-Y gluteal fascio-cutaneous advancement flap, performed at Tata Memorial Hospital, in Parel, Mumbai, India. 

Keywords: Perineal hernia, V-Y flap, Biological mesh, Extra levator abdominoperineal excision, ELAPE 

 

Ann Afr Surg. 2022; 19(2): 116-120 

DOI: http://dx.doi.org/10.4314/aas.v19i2.9 

 

Funding: None 

© 2022 Author. This work is licensed under the Creative Commons Attribution 4.0 International License. 

Introduction 

 Postoperative perineal hernia (PerH) following abdominoperineal resection (APR) was first reported by Yeomans in 1939 (1); it is a rare complication of radical pelvic oncologic surgery for rectal cancer, with a reported prevalence of 0.6–7% (2, 3). PerH is clinically diagnosed as an occurrence of a swelling in the perineum caused by the herniation of abdominal or pelvic viscera through a defect in the pelvic floor (2, 4, 5). The hernial sac may contain bowel (commonly small bowel), urinary bladder, uterus, or omentum. APR is performed for low rectal cancer involving the levator ani muscles and external anal sphincter (2). Low rectal cancer is locally advanced at presentation and is treated with neoadjuvant radiotherapy and radical surgery to achieve oncologically negative margins; hence, rectal cancer survivors have a chance at cure or a long disease-free survival or overall survival (3, 6). 

Although the cause of PerH is unknown, it has been observed to occur after neoadjuvant radiotherapy, perineal wound complications, and damage and/or loss of the pelvic floor (2). Symptomatic, reducible, and non-complicated perineal hernia requires surgical treatment, which can be performed with a perineal approach in which the hernia is repaired by placement of a composite mesh (2, 5, 7). 

We report a case of uncomplicated PerH that was managed in the Department of Colorectal Surgical Oncology at Tata Memorial Hospital, in Parel, Mumbai, India. 

Case Presentation

 A 57-year-old woman with no comorbidities presented with non-metastatic rectal cancer on August 1, 2018. Biopsy revealed moderately differentiated adenocarcinoma of the rectum, and magnetic resonance imaging (MRI) showed that the tumor was in the lower rectum, involving the levator ani and external anal sphincter with suspicious right pelvic nodes. The patient received neoadjuvant chemoradiotherapy, and after completion, she was evaluated by a multidisciplinary committee comprising surgical, medical, radiation  

oncologists, a radiologist, and an intervention radiologist. 

An open extralevator abdominoperineal excision (ELAPE) with a right pelvic nodal excision was performed. Histopathology showed that the resection had negative margins and that all nodes were negative for metastasis. 

The patient received five cycles of adjuvant chemotherapy (capecitabine and oxaliplatin). 

The follow-up findings in 2019 (colonoscopy, carcinoembryonic antigen, and contrast-enhanced computerized tomography scan) were normal. However, the patient presented with a perineal hernia and parastomal hernia during a follow-up visit with non-specific symptoms, and she wanted it operated on. Figure 1 shows the perineal hernia and MRI results. MRI confirmed perineal hernia without evidence of tumor recurrence. 

The patient’s perineal hernia was repaired on November  26, 2020, as shown in Figures 2 and 3. Postoperative recovery was uneventful. 

Click to view Figure 1: A) large perineal hernia, shown by arrow. B) MRI image showing herniation between gluteal maximus muscles, shown by arrow. C) Hernia sac at the level of upper femur, shown by arrow. 

 

Click to view Figure 2: A) Mobilization of hernia sac after incising and excising excess skin B) Reduction of hernia content, inspection for recurrence and closure of hernia sac. 

The following operative steps summarize the procedure. 

1. The patient was placed on prone position, under general anesthesia, with endotracheal intubation as shown in Figure 4. 

2. A perineal elliptical incision was made to include the previous perineal incision and redundant skin (Figure 5). 

3. The perineal skin was dissected off the hernial sac. 

4. The hernial sac was opened; it was non-adherent, and the herniated small bowel was carefully reduced. 

5. The hernial sac was re-adjusted and closed. 

6. Composite mesh was laid on and fixed around the pelvic bones and soft tissues. 

7. A bilateral V-Y gluteal fascio-cutaneous advancement flap was sutured on to cover the defect and reinforce the mesh (Figure 3). 

8. The skin was closed in layers.