A novel repair of a perineal hernia with long-term follow-up

Abstract

Dear Editor: Pelvic floor hernias are rare events. At this time, there have only been case reports and small case series from each reporting institutions. Pelvic floor hernias can be divided into either anterior or posterior perineal hernias. Anterior perineal hernias present as masses in the labium majus via defects in the pelvic floor anterior to the transverse perineal muscle. Posterior perineal hernias defects are either in the levator ani muscles or between the levator ani and coccygeus muscles, and emerge as swellings between the anus and the ischial tuberosity. The etiology of perineal hernias can range from primary (congenital and acquired) to secondary. Congenital perineal hernias are extremely rare in humans and there is no prevalence reported. Spontaneous primary perineal hernias are also rarely reported in the literature, with little more than 100 cases reported. Suspected risk factors for acquiring a primary perineal hernia are female (5:1 ratio), pregnancy, obesity, ascites, and recurrent pelvic floor infections. These risk factors also associate with increasing intra-abdominal and pelvic pressures or an acquired weakened pelvic floor. The most commonly reported cause of perineal hernias is secondary to previous operations. Any surgical intervention to the pelvic floor region may potentially compromise the pelvic floor strength. The incidence of large perineal hernias requiring repair is less than 1% after abdominoperneal resection and 3–6% after pelvic exenteration. Transabdominal, transperineal, and combined approaches are described in repairing perineal hernias. In this letter, we describe a novel simplified approach using a trans-obturator dual mesh reconstruction of the pelvic floor and demonstrate the potential advantages in a patient with long-term follow-up. Our patient is a 65-year old man with a past medical history of chronic obstructive pulmonary disease (COPD) with chronic cough, diabetes mellitus (DM), HIVon Highly Active Anti-Retroviral Therapy (HAART), who underwent a total mesorectal nerve sparing abdominal perineal resection in January 2006 for a bulky stage 3(pT3pN2pM0) adenocarcinoma of the rectum. Prior to resection, he received neoadjuvant chemoradiation and also underwent a reduction and repair of a large inguinal scrotal hernia. Six months following surgery, he complained of a large mass on his buttock and also perineal pain. He was unable to sit and reported extremely limited standing or walking due to perineal pain. On physical examination, he had a large midline mass of the buttock at the perineal scar with brawny edema of the overlying skin. Computed tomography (CT) and positron emission tomography (PET) scans revealed no recurrence and a large perineal hernia. CT scan showed marked pelvic floor defect with prolapsing but unobstructed bowel. The patient was evaluated by plastic surgery for repair with native tissues but was deemed a prohibitive risk for gracilis or other soft tissue flap secondary to a heavy smoking habit and radiation history. R. K. Chander Montifiore North (affiliate of New York Medical College), Bronx, NY, USA