Perineal Hernia Research Articles

Perineal hernia repair after abdominoperineal resection: a pooled analysis

The purpose of this study was to determine treatment characteristics and clinical outcome for patients with perineal hernia after abdominoperineal excision (APE). A systematic search of the literature revealed 40 individually documented patients, published between 1944 and 2010. Three additional patients treated at our centre were added. Patient characteristics, type of repair and outcome were entered into a database and a pooled analysis of these 43 patients was performed. The pooled analysis revealed a median time interval of 8 months between APE and surgical repair of perineal hernia. The surgical approaches were perineal in 22 patients, open abdominal in 11, open abdominoperineal in three, laparoscopic in five and laparoscopic-perineal in two patients. A primary recurrence was documented in 13 patients and a second recurrence in three. The recurrence rate was 5/25 for synthetic or biological mesh, 6/12 for primary closure and 2/6 for the remaining techniques. Recurrent perineal hernia was repaired using a synthetic or biological mesh (n = 6), primary closure (n = 5) or a muscle flap (gluteus or gracilis; n = 4). From these limited and biased data based on published case descriptions, it appears that the recurrence rate of primary perineal hernia repair after APE is lower with the use of a mesh or other assisted closure than with primary suture repair.

Recurrent Perineal Hernia After Benign Pelvic Reconstructive Surgery

Abstract Background: Secondary acquired perineal hernias are rare events usually associated with extensive pelvic surgery. Although most are asymptomatic, when symptoms are present surgical intervention is warranted. There is currently no consensus regarding the management of these hernias. An unusual case of a recurrent perineal hernia following sacrospinous fixation resulting in large bowel incarceration is reported. Case: A 64-year-old woman presented with an anterior vaginal wall prolapse and multiple pelvic-floor defects. She subsequently underwent a sacrospinous fixation and enterocele repair. The enterocele recurred and she underwent a second enterocele repair. Approximately 6 months later, she presented with a perineal hernia that involved an incarceration of the large bowel. Results: The hernia was reduced, the pelvic-floor defect was repaired, and a biologic, absorbable mesh was applied. Approximately 5 months later, the patient presented with a recurrence of the perineal hernia. The hernia was ...

Laparoscopic repair of primary perineal hernias: the approach of choice in the 21st century

Perineal hernias are rare and result from the herniation of a viscus through the pelvic floor. Symptomatic perineal hernias are repaired surgically, historically via an open perineal, abdominal or abdominoperineal approach. We describe laparoscopic repair of a primary perineal hernia with mesh using the transabdominal approach. We believe that for uncomplicated primary perineal hernias laparoscopic repair is technically feasible, and associated with rapid recovery and minimal complications.

Perineal reconstruction after abdominoperineal excision using inferior gluteal artery perforator flaps2

Perineal wound complications following abdominoperineal excision (APE) for low rectal tumours remain an important cause of morbidity and prolonged hospital stay, particularly after chemoradiotherapy. The aim was to assess outcomes after using inferior gluteal artery perforator (IGAP) flaps for immediate perineal reconstruction, and to compare these with the authors' previous experience and published literature on myocutaneous flaps. A series of patients who underwent immediate IGAP flap reconstruction after APE between April 2008 and December 2010 were examined retrospectively to determine patient demographics, length of operation, complications (perineal wound and general) and length of hospital stay. Forty patients with rectal adenocarcinoma (33 primary and 7 recurrent disease) underwent immediate IGAP flap reconstruction following APE. Median follow-up was 9 months. Neoadjuvant chemoradiotherapy was received by 98 per cent of the patients. Thirty-two patients underwent APE plus IGAP flaps (25 open, 7 laparoscopic), with a median operating time of 402 min, and eight patients had multivisceral resection (MVR) plus IGAP flaps (7 total pelvic exenteration (TPE), 1 abdominosacral resection), with a median duration of surgery of 561 min. There was one death (fatal stroke) and four major flap complications (10 per cent) (1 enteroperineal fistula, and 3 deep wound infections). Median length of hospital stay was 13 days after APE plus IGAP flaps and 27 days following MVR plus IGAP flaps. Late complications occurred in two patients who had vaginal reconstruction and developed perineal hernias requiring revisional surgery. Although operating times are long, the IGAP flap is robust, with no flap necrosis observed in this series.

Perineal hernias in children: Case report and review of the literature

Perineal hernias (pelvic floor hernias) are extremely rare occurring through defects in musculature of the pelvic floor. This report presents a successfully treated case of primary perineal hernia and takes a review of the existing literature. The case of a 14-month-old girl with a great perineal hernia is presented. Diagnosis was secured by barium enema. The pelvic defect was successfully treated by primary suture with prolene. The literature shows many different approaches for treatment of perineal hernia, such as open or laparoscopic mesh repair, and perineal, abdominal or combined access in the adult, but our case like others confirms that primary closure of the hernial orifice through a perineal approach is also feasible in children.

Perineal Hernia Repair After Abdominoperineal Rectal Excision

A perineal hernia can severely disable everyday activities. Its repair is a surgical challenge, and guidance by the literature is limited. The series described so far are small or encompass a long period in which even nonmesh techniques were used. The aim of this study was to review recent results of a perineal mesh-based repair. Medical charts of patients with a symptomatic perineal hernia after abdominoperineal resection due to rectal cancer were reviewed. Data included patients' characteristics, operative details, recurrence, and complications. In total, 29 patients underwent repair of a symptomatic perineal hernia after an abdominoperineal resection due to rectal cancer. The majority was male (66%), and the median age was 59 years (range, 41-83). All patients received neoadjuvant treatment.From 2003 until 2006, polytetrafluoroethylene or Vypro mesh and Prolene 2.0 sutures were used for perineal hernia repair. All 8 repairs failed; repeated repair using various methods was successful in 63%. After 2006, the surgical technique was changed into a high-tension repair with the use of a nonabsorbable mesh. This technique was successful for 20 of 21 patients (95%). Complications encountered in the entire group of 29 patients were urinary retention (n = 2), wound infection, seroma, and fistula (n = 1 each). Even though this is the largest group described in the literature, the results are limited because of the small number of patients. Repair of perineal hernia remains challenging and only a few reports offer advice on how to manage this unusual problem. However, superior results have been shown with the new mesh-based technique through perineal approach with only 5% recurrence.

Use of canine small intestinal submucosa allograft for treating perineal hernias in two dogs

Here, we describe two dogs in which canine small intestinal submucosa (SIS) was implanted as a biomaterial scaffold during perineal herniorrhaphy. Both dogs had developed severe muscle weakness, unilaterally herniated rectal protrusions, and heart problems with potential anesthetic risks. Areas affected by the perineal hernia (PH) located between the internal obturator and external anal sphincter muscles were reconstructed with naïve canine SIS sheets. In 12 months, post-operative complications such as wound infections, sciatic paralysis, rectal prolapse, or recurrence of the hernia were not observed. Symptoms of defecatory tenesmus also improved. Neither case showed any signs of rejection or specific immune responses as determined by complete and differential cell counts. Our findings demonstrate that canine SIS can be used as a biomaterial scaffold for PH repair in dogs.

Dynamic Magnetic Resonance Imaging Demonstrates the Integrity of Perineal Reconstruction following Cylindrical Abdominoperineal Excision with Reconstruction of the Pelvic Floor Using Porcine Collagen

A 72-year-old female presented with a six-month history of increased frequency of defecation, rectal bleeding, and severe rectal pain. Digital rectal examination and endoscopy revealed a low rectal lesion lying anteriorly. This was confirmed histologically as adenocarcinoma. Radiological staging was consistent with a T3N2 rectal tumour. Following long-course chemoradiotherapy repeat staging did not identify any metastatic disease. She underwent a laparoscopic cylindrical abdominoperineal excision with en bloc resection of the coccyx and posterior wall of the vagina with a negative circumferential resection margin. The perineal defect was reconstructed with Permacol (biological implant, Covidien) mesh. She had no clinical evidence of a perineal hernia at serial followup. Dynamic MRI images of the pelvic floor obtained during valsalva at 10 months revealed an intact pelvic floor. A control case that had undergone a conventional abdominoperineal excision with primary perineal closure without clinical evidence of herniation was also imaged. This confirmed subclinical perineal herniation with significant downward migration of the bowel and bladder below the pubococcygeal line. We eagerly await further evidence supporting a role for dynamic MR imaging in assessing the integrity of a reconstructed pelvic floor following cylindrical abdominoperineal excision.

A transperineal approach to perineal hernia repair using suture anchors and acellular porcine dermal mesh

Perineal hernia following major pelvic surgery is a rare but recognised complication. Various surgical approaches to the repair of a symptomatic perineal hernia have been described. We describe the first reported use of the Mitek suture anchors to secure an acellular porcine dermal graft to the ischia during the transperineal repair of a large perineal hernia.

Retained surgical swabs in 13 dogs

To report the signalment, history, clinical signs, diagnostic and surgical findings and outcome in dogs and cats with retained swabs, medical records of dogs and cats that were referred to...

Rectus abdominis myocutaneous flaps for perineal reconstruction: modifications to the technique based on a large single-centre experience.

Perineal wound breakdown with delayed wound healing represents a significant cause of morbidity following surgery and radiotherapy to the perineum. The rectus abdominis myocutaneous (RAM) flap has been used increasingly to reconstruct the perineum with good effect. We describe our six-year experience of reconstruction of the perineum with the RAM flap and share some surgical adjuncts we believe are useful. We conducted a retrospective case note review of all patients who underwent a reconstruction of the perineum using the RAM flap between August 2003 and October 2009. Indications for the flap, complication rates and outcomes were all observed. We conducted 16 RAM flap procedures, 15 of which (94%) were primary repairs and 1 (6%) a secondary repair. Three (19%) developed donor site hernias, two (12.5%) developed minor perineal wound infections, eight (50%) developed minor perineal wound breakdown and in one (6%) flap failure was observed. No perineal hernias were observed. There were no surgical mortalities. The RAM flap has a high success rate and an acceptable morbidity rate and is a useful tool in the reconstruction of complex perineal wounds. Modifications to the standard surgical technique may reduce complications and improve the versatility of this flap.

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

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

Epidermal growth factor and active caspase-3 expression in the levator ani muscle of dogs with and without perineal hernia

To perform a histological and immunohistochemical study of epidermal growth factor, transforming growth factor-alpha and their receptor, as well as the apoptotic signal active caspase-3 in the levator ani muscle of dogs with and without perineal hernia. Biopsy specimens of the levator ani muscle were obtained from 25 dogs with perineal hernia and 4 non-affected dogs and were processed for Masson and immunohistochemical staining. The affected dogs exhibited myopathological features, internalised nuclei, destruction and abnormal size of muscle fibres, which were replaced by collagen. The immunohistochemical study revealed active caspase-3, epidermal growth factor, transforming growth factor-alpha and epidermal growth factor receptor in the levator ani. Compared to the healthy muscle, transforming growth factor-alpha staining intensity was lower in the affected muscle, whereas epidermal growth factor receptor and active caspase-3 staining were higher. Pelvic diaphragm muscle weakening is the leading cause of perineal hernia in the dog. Survival and death signals expressed in these muscles may contribute to the pathogenesis of this disease. This study reports epidermal growth factor, transforming growth factor-alpha and epidermal growth factor receptor immunohistochemical expression in the skeletal muscle and suggests that perineal hernia in the dog is accompanied by levator ani muscle atrophy, increased expression of epidermal growth factor receptor, caspase-3 activation, and decreased expression of transforming growth factor-alpha.

Perineal hernia after laparoscopic abdominoperineal resection—reconstruction of the pelvic floor with a biological mesh (Permacol™)

Perineal hernia after laparoscopic abdominoperineal resection—reconstruction of the pelvic floor with a biological mesh (Permacol™)

Perineal Repair After Extralevator Abdominoperineal Excision for Low Rectal Cancer

Extralevator abdominoperineal excision for low rectal cancer includes resection of the pelvic floor as a part of the operative technique to reduce the risk of tumor-involved section margins. This study aimed to compare perineal defect reconstruction with a fasciocutaneous gluteal flap vs biological mesh regarding healing and occurrence of perineal hernia. Retrospective review of medical records comparing surgical methods during 2 consecutive periods. Tertiary care university medical center (Colorectal Section, Surgical Department P, Aarhus University Hospital, Denmark). Patients with low rectal cancer who underwent extralevator abdominoperineal excision from December 2005 through October 2008 were included. The perineum was reconstructed with a fasciocutaneous gluteal flap in the first period and with a biological mesh in the second period. We assessed rates of perineal wound infection requiring surgical intervention and perineal hernia diagnosed by clinical examination. The study comprised 57 patients: 33 patients with gluteal flap and 24 with biological mesh reconstruction. Perineal hernia developed in 7 (21%) patients in the gluteal flap group and in none (0%) of the patients in the mesh group (P < .01). Median follow-up was 3.2 (1.7-4.3) years for gluteal flap and 1.7 (0.4-2.2) years for biologic mesh. All hernias occurred within the first postoperative year (median, 6 months; range, 1-12 months). Infectious complications were seen in 2 patients (6%) with a gluteal flap and in 4 patients (17%) with mesh repair (P = .26). After 3 months, all patients were completely healed except for 1 patient in each group with a persistent perineal sinus. The median (range) hospital stay was 14 (8-23) days in the flap group and 9 days (6-35) in the mesh group (P < .05). This was a nonrandomized retrospective observational study comparing 2 methods used in different time periods. We recommend biological mesh reconstruction of the pelvic floor after extralevator abdominoperineal resection because this method can achieve a high healing rate with an acceptable risk of infection, a low hernia rate, and a shorter hospital stay without donor-site morbidity.

Recurrent perineal hernia repair: a novel approach

Postoperative perineal hernias are rare complications from procedures, which compromise the pelvic floor, mainly abdominoperineal resection, proctocolectomy, and partial or total pelvic exenteration. Surgical repair can be accomplished through abdominal, laparoscopic, or transperineal approaches. We present a case report of a 70-year-old man who underwent two prior operations for recurrent perineal hernia and was ultimately successfully treated with a third operation, a synthetic mesh redo procedure that utilized a synthetic mesh system marketed for women with pelvic organ prolapse. Although there is no "gold standard" for perineal hernia repair, our patient had multiple surgeries employing a variety of approaches. Final success was achieved using a mesh system with improved fixation to secure pelvic ligaments, using an exclusive perineal approach. Now, more than five years following the final surgery, the patient remains symptom free with no clinical evidence of perineal hernia recurrence. To date, this is the only report of using this mesh system in a male. The advantages of using this mesh system are (1) exclusive perineal approach without the accompanying risks of abdominal or laparoscopic approach; (2) improved fixation of mesh to secure pelvic ligaments; and (3) lightweight, flexible, and large mesh shape that can easily be trimmed to allow versatility in procedures.

Perineal hernia – different surgical approaches and treatment techniques. A case report

This is a case report of a 69-year-old woman who presented major perineal hernia in the scar after a surgical resection of rectal cancer (adenocarcinoma) and hysterectomy. She was repaired by an open repair using a partially absorbable anti-adhesive intraperitoneal implant which was styled to the size and contours of the minor pelvis. Symptomatic perineal herniation after surgical resections is a rare phenomenon so only several different surgical approaches and techniques of the repair have been described. This report presents an overview of different surgery techniques which depend on the size of the perineal ring as well as on whether plastic reconstruction of the fascia is needed or not. The analysis leads to the conclusion that all cases require tailored approaches and surgeons need to be prepared for conversion to a different technique even in the course of the surgery.

Re-ossification of the pelvis following hemipelvectomy for trauma

We present a patient who underwent delayed sub-periosteal hemipelvectomy for control of infection and to enable soft-tissue cover after trauma. At four months after amputation, clinical examination and radiographs demonstrated almost complete re-ossification of the hemipelvis. This has allowed the patient to regain sitting balance and to use a walking prosthesis designed for patients following disarticulation of the hip. After 14 months from injury, no perineal hernia has developed, and no dysfunction of pelvic organs is attributable to heterotopic bone formation or adhesions. The patient's mobility with a prosthesis is similar to that expected of a through-hip amputee.

Paraprostatic Cyst within the Perineal Region of a Perineal Hernia in a Dog

ヘルニア内容が傍前立腺嚢胞であった会陰ヘルニアの症例（6歳、未去勢雄）に遭遇した。症例は直腸検査で会陰部に腫瘤を認め、超音波検査で腫瘤内の液体が確認された。手術時に会陰部の切開で被膜が露出し、多量の液体が排出された。摘出した被膜は病理組織学的検査で傍前立腺嚢胞と診断された。両疾患の併発は十分に考えられ、ヘルニア内容が傍前立腺嚢胞であることは稀であるが鑑別リストとして考慮する必要がある。

Pelvic reconstruction after abdominoperineal resection of the rectum

Despite the advances in the treatment of cancer of the rectum and the expansion of the multimodal therapeutic technique, abdominoperineal resection (APR) still needs to be performed as radical treatment in 20%–30% of cases.APR of the rectum involves a significant morbidity, including intestinal obstruction and wound complications, with radiotherapy-induced enteritis being able to develop in 15% of cases subjected to post-operative radiotherapy. Furthermore, with the aim of improving local oncology results, an extended APR is recommended; a technique that requires a perineal reconstruction technique that allows a tension free closure in a previously radiated tissue and may prevent perineal hernias developing.The objective of this article is to review pelvic and perineal repair methods after APR due to cancer, with special attention to the new prosthetic repair techniques.