Levator Avulsion: A Review of Surgical Anatomy and Repair Technique for Primary Posterior Perineal Hernias

Abstract

Video Objective Perineal hernias are exceptionally uncommon gynecologic pathologies that may have a drastic impact on women's health. Hernias that contain pelvic visceral structures present an especially unique challenge that requires immediate attention. Evidence is lacking as to the optimal surgical approach. Our objective is to describe our minimally-invasive technique for the repair of primary posterior perineal hernias with symptomatic bladder prolapse. Setting This patient is a sixty-two year-old female who presented with a large bulge in her left buttock and a chief complaint of difficulty urinating that required reduction in order to void. Her medical history is significant for a prior vaginal delivery without complications, and a prior rectocele repair. Outpatient workup that included cystogram, CT and MRI imaging revealed a left perineal hernia that involved the entire bladder. She was diagnosed with a posterior perineal hernia. Interventions This patient's condition was treated via surgical management. Due to the large defect size and absent levator ani musculature, re-approximation for pelvic support was not feasible and thus a 5 × 4 cm segment of propylene mesh was placed and sutured between the left vaginal sidewall and left pelvic sidewall periosteum. Following, a sacrocolpopexy was performed to repair her perineal descent, and the prolapsed bladder was replaced with a psoas hitch procedure to the contralateral side. Conclusion Primary posterior perineal hernias with concomitant symptomatic bladder prolapse may be repaired with a sacrocolpopexy, paravaginal mesh placement, and a psoas hitch procedure. Using a robotic-assisted, minimally-invasive repair technique has been proven to have favorable short-term outcomes regarding symptomatology as well as anatomic replacement of pelvic viscera. Patients should be counseled about the option for surgical management of perineal hernias, as well as the need for future research to evaluate the long-term outcomes and quality of life markers following transabdominal laparoscopic perineal hernia repairs with use of mesh placement.