Perineal Hernias: Diagnosis and Surgical Management

Perineal hernia occurs frequently in aged collies as a result of weakening of the pelvic diaphragmatic muscle or its total failure, thereby allowing displacement of abdominal contents into the perineum. Surgical management include subtotal colectomy, colotomy, internal obturator muscle transposition and perineal herniorrhaphy. This report highlights a case of perineal hernia associated with megacolon as well as its successful management in a dog. A seven years old, male Rough Collie was presented with a complaint of right perineal swelling that has lasted for a week as well as inappetance and absence of defecation. Physical examination was unremarkable except for 3% dehydration and a firm, large perineal non-reducible swelling. Plain abdominal radiography revealed perineal hernia with megacolon. Serum chemistry showed azotaemia. Emergency surgical intervention involving colotomy, perineal herniorrhaphy with incisional colopexy were conducted. Post-operative care included ceftriaxone injection at 50mg/kg intramuscularly, intravenous fluid infusion, one week fasting, daily wound dressing, Nutriplus® gel supplementation and administration of recovery diet post-fasting. Thus, surgical management using traditional perineal herniorrhaphy, colotomy with colopexy was effective in correcting the perineal hernia with megacolon.

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

Perineal hernias are uncommon complications following laparoscopic abdominoperineal operations. There is still very little known about perineal hernia. There are only few case reports to describe the repair of postoperative hernias after laparoscopic abdominoperineal resection (APR) in the literature. Here we present one patient with a perineal hernia after laparoscopic abdominoperineal resection for rectal cancer. The surgical management with manual purse-string suture is described and discussed in this case report.

An 8-year-old 6.8-kg neutered male Dachshund was presented for evaluation of vomiting, diarrhea, anorexia, and swelling over the right perineal region. The dog had a history of a bilateral perineal herniorrhaphy and castration 14 months prior to presentation. Bilateral perineal hernias were confirmed by digital rectal examination. Abdominal ultrasonography confirmed the presence of intestine within the right hernia. Three days after admission to the hospital, the region of the right perineal hernia became painful, erythematous, and edematous. Computed tomography revealed jejunal incarceration within the right hernia with dilation of 1 jejunal segment that indicated intestinal obstruction. Abdominal exploratory surgery was performed, during which irreducible small intestinal incarceration was confirmed. Intra-abdominal jejunal resection and anastomosis was performed, and an approximately 13-cm-long section of the jejunum was resected. Bilateral perineal herniorrhaphies with internal obturator and superficial gluteal muscle transposition were performed. Six months after surgery, digital rectal examination of the dog revealed that the repair was intact. The dog had no perineal hernia-related clinical signs at the time of the recheck examination. For the dog of the present report, surgical management of small intestinal strangulation associated with a perineal hernia was successful. Although a portion of the small intestines can frequently be found within perineal hernias in dogs, perineal hernia-related small intestinal strangulation has not been previously described, to the authors' knowledge. Veterinarians and clients should be aware of this potential complication secondary to perineal hernia and be prepared to perform an abdominal surgical procedure to address small intestinal incarceration in affected dogs.

Perineal hernia (PH) is a well-known complication after abdominopelvic resection, but no consensus exists about the best technique for perineal hernia repair (Reference 1-3). We present the case of a man with a posterior perineal hernia after low anterior resection with subtotal inter-sphincter resection and colo-anal anastomosis. The patient is a 72-year-old man known to have an adenocarcinoma of the rectum treated with neoadjuvant radiochemotherapy (50 Gy and Xeloda) and low anterior resection with subtotal inter-sphincteric resection, colo-anal anastomosis and protective ileostomy in December 2015. In 2016, the patient presented with 3 episodes of recurrent prolapse of the colo-anal anastomosis requiring resection of the prolapse and a new colo-anal anastomosis with anterior and posterior levatroplasty during the last intervention. The protective ileostomy was finally closed in December 2016. In December 2019, the patient complained about a new perineal swelling without pain. A surgical management for perineal hernia was proposed, but refused by the patient. In January 2022, because of the inconvenience caused by the perineal hernia, the patient accepted a surgical intervention. A pelvic MRI was performed in January 2022 with evidence of a large perineal hernia with mesocolic content, no cancer recurrence. The repair was made through a perineal approach with a bioasbrobable monofilament polyester mesh with little tissue attachment (Symbotex, Covidien Product, Medtronic Parkway, Minneapolis, USA). The operation lasted 104 min, with minor bleeding (<20ml). The patient was discharged on postoperative day 10. At 7-month follow-up, he has no recurrence of the perineal hernia. Perineal hernia is vey a rare complication following restorative rectal cancer surgery. As a result, management is poorly described in the literature. As the patient presented with 3 prolapses of the colo-anal anastomosis requiring surgical repair with absolutely no adhesions before the perineal hernia repair, we choose a mesh repair to strengthen the pelvic floor and a direct perineal approach to perform levatorplasty.

Background: Recognized as a relatively common surgical condition in geriatric male dogs, particularly intact individuals, perineal hernia occurs due to the weakening or rupture of the pelvic diaphragm muscles. Anatomical failure allows for the protrusion of pelvic or abdominal organs such as the rectum, prostate, or urinary bladder into the perineal region. Improvement of treatment outcomes and recovery, a thorough understanding of the physiological responses and tissue adaptations occurring during and after surgical correction is essential. Purpose: Explored in this case report are the physiological responses and tissue adaptations in a dog diagnosed with a perineal hernia involving the urinary bladder (vesica urinaria), encompassing both pre- and post-surgical periods, while evaluating the effectiveness of the surgical and postoperative management approach. Case(s): A 12 year old intact male dog was presented with progressive perineal swelling and dysuria. Physical examination and rectal palpation identified a unilateral perineal hernia, with the urinary bladder herniated into the perineal region. Case Management: Surgical correction was performed using the internal obturator muscle flap technique. Preoperative stabilization included fluid therapy and analgesia, while postoperative care consisted of antibiotics, pain management, and daily wound care. Monitoring was conducted over four weeks to evaluate tissue adaptation and urinary function recovery. Conclusion: Mild to moderate inflammation was observed during the first postoperative week, followed by granulation tissue formation and progressive strengthening by the third week. Successful recovery indicates that the internal obturator flap technique is effective for repairing perineal hernia involving the urinary bladder.

Perineal hernias are uncommon complications after open abdominoperineal resection. We present two patients with a perineal hernia after laparoscopic abdominoperineal resection. Surgical correction of symptomatic hernias is a challenging problem caused by the effects of preceding surgery. The surgical management with a mesh is described and discussed in this case report.

Perineal hernias, categorised as primary or secondary, pose a clinical challenge necessitating surgical intervention. Herein we present the surgical management of a postoperative perineal hernia of the retrorectal space. A 42-year-old female patient presented to the clinic with symptoms such as perineal discomfort, bulging, and constipation after previous surgical tailgut cyst excision. Diagnosis involved MRI, confirming rectal herniation into the retrorectal space. The surgical approach featured a perineal intervention using a unilateral inferior gluteal flap to reinforce the posterior rectal space, avoiding mesh complications. The patient experienced a successful recovery, highlighting the importance of tailored interventions based on symptoms and complications. Secondary perineal hernias, often postoperative, present diverse challenges influenced by multiple factors such as pelvic surgeries. Surgical repair options include perineal and abdominal approaches, mesh usage, and flap methods, each with variable outcomes. This case study contributes to the evolving understanding of perineal hernias, emphasising the need for multidisciplinary approaches and ongoing research to enhance management strategies in this complex clinical scenario.

IntroductionPerineal hernias, protrusions through the pelvic diaphragm, are a rare complication post-abdominoperineal resection. The shift to extralevator APR techniques could be linked to a potential increase in these hernias. This case series evaluates the surgical management of perineal hernias, focusing on the evolving role of robotic surgery. Given the limited existing research on robotic repairs in this context, it highlights its potential as an innovative approach.Presentation of CaseIn a case series, we report three patients who underwent robotic abdominoperineal resection (APR) for rectal and anal canal carcinoma after neoadjuvant chemoradiation. The 65-year-old female developed a perineal hernia 7 months post-operatively, the 67-year-old male after 4 years, and the 63-year-old female presented with a recurrent perineal hernia post-APR with gracilis flap reconstruction. All patients underwent successful robotic hernia repairs with mesh placement and demonstrated symptomatic improvement post-operatively.DiscussionPerineal hernia management lacks a standardized protocol, with methods ranging from open to laparoscopic techniques. A review of recent literature suggests increasing favorability towards laparoscopic and robotic approaches due to their less invasive nature. Our cases demonstrate the advantages of robotic surgery’s precision and improved visualization, supporting its use in perineal hernia repair, although more research is needed to confirm.ConclusionRobotic-assisted surgery for perineal hernia repair post-APR shows promise, enhancing the benefits of laparoscopic methods. This series underlines the potential of this approach, though further investigation in larger studies is essential to establish its advantages.

Extralevator abdominoperineal resection for rectal cancer has predominated over the common technique during recent years providing better oncologic results. However, extralevator abdominoperineal resection has been associated to a higher incidence of wound complications and perineal hernia. Several risk factors including preoperative pelvic radiotherapy, laparoscopic abdominoperineal resection, women, previous hysterectomy, obesity, coccygectomy, long small bowel mesentery, postoperative wound infection, and open pelvic peritoneum have been correlated to increased perineal hernia rate. Despite the minor clinical manifestation of a perineal hernia, its effect on the quality of life remains remarkable. Therefore, the surgical management of a perineal hernia after abdominoperineal resection is still a challenge for colorectal surgeons. Several techniques have been used including biologic meshes and myocutaneous flaps. Nevertheless, the ideal technique has not yet been proved. During last years, colorectal surgeons have utilized minimally invasive techniques such as robotic repair of perineal hernias. We presented the first case in the literature of a combined approach of robotic-assisted repair using a bio-absorbable mesh and a gluteal fasciocutaneous flap reconstruction.

Perineal hernia in an intact male dog and its surgical management through hernioplasty

SummaryThis case report records a unilateral perineal hernia in a 7‐year‐old female donkey. The donkey had a history of unilateral swelling lateral to the left vulvar lip and difficulty in defaecation. Upon palpation, the swelling was painless, soft and reducible. Ultrasonography revealed a hyperechoic hernia sac containing dilated nonmotile bowel with homogenous hypoechoic contents. Primary herniorrhaphy was performed after repositioning of the herniated bowel. The donkey made an uneventful recovery with no recurrence or complications for 6 months of available follow‐up. In conclusion, perineal hernia should be considered in the differential diagnosis of perineal swellings in donkeys. Clinical examination, ultrasonography and surgical exploration are valuable for definite diagnosis of perineal hernia in donkeys. Surgical herniorrhaphy was successful in correcting the problem in this case.

SummaryA rare case of bilateral perineal hernia was reported in a 24‐year‐old Italian Trotter mare. The mare presented a history of chronic weight loss and bilateral perineal swelling. The right‐sided swelling displayed signs of being chronic, while the left side experienced a singular episode of acute perineal swelling, coinciding with signs of colic. Due to concerns regarding potential recurrent colic episodes and the risk of bowel entrapment, the mare was hospitalised to perform a complete clinical and diagnostic assessments, and to establish an appropriate treatment. Based on history, clinical manifestations, results of palpation and ultrasonography, it was determined that the swelling was indicative of bilateral perineal hernia. An initial attempt at surgical correction through appositional herniorrhaphy proved unsuccessful. Subsequently, a novel technique involving the transposition of the semimembranosus muscle was employed as a secondary intervention. This alternative surgical method effectively addressed the issue without any short‐ or long‐term recurrence or complications. In conclusion, perineal hernias should be included in differential diagnoses for perineal swelling in equids. Furthermore, when appositional herniorrhaphy proves ineffective, transposition of the semimembranosus muscle may be considered as a surgical option.

Primary perineal hernias are rare and can be a diagnostic challenge. We report the case of a 45-year-old female patient who presented with painless perineal swelling suggestive of perineal hernia. Computed tomography (CT) scanning revealed a pelvic mass herniating through the pelvic floor into the perineum. The lesion was completely excised by an abdominoperineal approach. Histopathological examination of the lesion revealed a leiomyoma. This case report suggests that the possibility of perineal herniation of a pelvic leiomyoma should be considered in a female patient with suspected primary perineal hernia. We recommend an abdominoperineal approach for the surgical management of such a lesion.

BackgroundSwelling of the perineal region in male dogs is most commonly caused by a perineal hernia. Clinical signs associated with perineal hernia are constipation, tenesmus or stranguria. This case report documents a rare cause of perineal swelling created by the growth of a malignant tumour leading to urethral obstruction and subsequent stranguria.Case presentationAn 11-year-old neutered male German Shepherd was presented for swelling in the perineal region and stranguria for three days. Complete blood count and serum biochemistry were unremarkable. Ultrasound revealed a heterogeneous mass in the perineal region. Retrograde urethrography showed a severe narrowing of the urethra caudal to the pelvis. A fine-needle aspirate of the mass was highly suspicious for liposarcoma. Staging was performed by computed tomography (CT) of the thorax and abdomen. Total penile amputation in combination with pubic-ischial pelvic osteotomy, transposition of the remaining urethra through the inguinal canal, V-Y-plasty cranial to the prepuce and preputial urethrostomy were performed to remove the tumour. Histopathology confirmed a well-differentiated liposarcoma with complete histological margins. Six months after the surgery the dog was doing well and there were no signs indicating local tumour recurrence.ConclusionsWide surgical excision is generally recommended for soft tissue sarcomas, however this is sometimes not feasible for large tumours. In the case reported here, tumour resection was achieved by a combination of several surgical techniques with a good clinical outcome.