Hindawi Publishing Corporation

Case Reports in Medicine

Volume 2010, Article ID 126483, 3 pages
doi:10.1155/2010/126483

Case Report
Laparoscopic Repair of Postoperative Perineal Hernia

Stephen Ryan, Dara O. Kavanagh, and Paul C. Neary

Department of Colorectal Surgery, The Adelaide and Meath Hospital incorporating the National Children’s Hospital, 24 Dublin, Ireland

Correspondence should be addressed to Stephen Ryan, stephen.ryan@ucd.ie

Received 24 May 2010; Accepted 21 July 2010

Academic Editor: Robert A. Kozol

Copyright © 2010 Stephen Ryan et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Perineal hernias are infrequent complications following abdominoperineal operations. Various approaches have been described
for repair of perineal hernias including open transabdominal, transperineal or combined abdominoperineal repairs. The use of
laparoscopic transabdominal repair of perineal hernias is not well-described. We present a case report demonstrating the benefits of
laparoscopic repair of perineal hernia following previous laparoscopic abdominoperineal resection (APR) using a nonabsorbable
mesh to repair the defect. We have demonstrated that the use of laparoscopy with repair of the pelvic floor defect using a
non absorbable synthetic mesh offers an excellent alternative with many potential advantages over open transabdominal and
transperineal repairs.

1. Introduction the benefits of laparoscopic repair of postoperative perineal

hernia following laparoscopic abdominoperineal resection
Postoperative perineal hernia may be defined by the protru- (APR) using a nonabsorbable mesh to repair the defect.
sion of intra-abdominal viscera through a defect in the pelvic
floor into the perineal region. Perineal hernias are infrequent
complications following abdominoperineal operations with 2. Case Presentation
a recent retrospective study estimating the prevalence to be
0.34% [1]. The most common presenting symptoms are that A 69-year-old man presented with a history of rectal
of pain and a dragging sensation or discomfort on standing, bleeding. Digital rectal examination revealed a palpable,
but urinary symptoms, intestinal obstruction, or perineal fungating rectal lesion. Following EUA and biopsy, the
skin breakdown may also occur. Various approaches have lesion was confirmed as squamous cell carcinoma. Staging
been described for repair of perineal hernias including open computed tomography scans did not reveal any distant
transabdominal, transperineal, or combined abdominoper- metastasis. Following neoadjuvant chemoradiotherapy a
ineal repairs [2–5]. preoperative MRI showed reduction in tumour size from 8.5
The use of laparoscopic transabdominal repair of per- to 4.7 cm. The patient successfully underwent laparoscopic
ineal hernias is not well-described in the medical literature abdominoperineal resection of the rectum and formation
to date [6–10]. Concerns about the insertion of intra- of colostomy. He was discharged day 6 postoperatively with
abdominal meshes to close peritoneal defects are largely wounds intact.
founded upon the risk of adhesions, mesh infection, and Histology revealed an invasive poorly differentiated squa-
the potential for fistula formation. These concerns, however, mous cell carcinoma with extension into the perianal soft
are tempered by the development of new synthetic meshes tissues. Lymphovascular space and perineural invasion were
used in the increasingly popular technique of laparoscopic identified but all resection margins were negative for tumour.
incisional hernia repairs. These meshes are reported to The tumour was classified as a yT2 N0 M0 lesion.
reduce the incidence of mesh-related morbidity and facilitate At six-month clinical followup, he complained of a
a minimally invasive approach to reconstructive surgery for reducible, painless incisional perineal hernia extending into
large abdominal wall defects with the recognised benefits the scrotum (Figure 1). He subsequently underwent elective
of laparoscopy. We present a case report demonstrating laparoscopic mesh repair of this perineal hernia.
2 Case Reports in Medicine

Figure 1: Preoperative picture showing the perineal hernia defect. Figure 3: Five months postoperative perineal hernia repair with no
evidence of recurrence.

(StatTack, Autosuture, Tyco Healthcare UK Ltd). It was

anchored to the sacrum using the endotacker. The remaining
mesh was laparoscopically sutured to the surrounding pelvic
brim and lateral abdominal wall, taking great care to avoid
the ureters, iliac vessels and inferior epigastric vessels, using
interrupted 3/0 vicryl sutures (Ethicon.Inc).
The patient made an uneventful recovery and was dis-
charged 2 days later. Following repair, the patient remained
asymptomatic with no evidence of recurrence of the perineal
hernia (Figure 3, five months post repair) at 18-month
Figure 2: Intra-abdominal view of bowel loops mobilised from followup.
perineal wall defect.
3. Discussion
The operation was performed in lithotomy position. Perineal hernias may be classified as primary (congenital or
A urethral catheter was placed to decompress the blad- acquired) or secondary (postoperative). They are infrequent
der. Pneumoperitoneum was established using the Hassan complications of major pelvic surgery and when present are
technique via a curvilinear infraumbilical incison. Three usually asymptomatic. Aboian et al. [1] recently showed in
additional 5 mm ports were placed under direct vision using a retrospective study a prevalence rate of symptomatic post-
a 10 mm 0◦ laparoscope. One was positioned in the right operative perineal hernias of 0.34% with a more common
lower quadrant, one in the right upper quadrant, and a prevalence associated with those who have had cancer oper-
third was placed in the left lower quadrant. At laparoscopy, ations. Smoking, female gender, and chemoradiotherapy are
there was no evidence of disease recurrence. Placement other important risk factors. The duration between surgery
of the patient in a steep trendelenburg position facilitated and hernia formation is usually between six months and five
division of adhesions with mobilisation of the small bowel years [5]. The patient described in this case report had many
loops out of the hernial defect (Figure 2). Both ureters were of these risk factors including a rectal tumour, neoadjuvant
identified. The defect was repaired using a nonabsorbable chemoradiotherapy, and smoking.
composite mesh (Composix E/X Oval, 18 × 23 cms (Bard Surgical repair of a postoperative perineal hernia is
Nordic, Sweden) ellipse mesh, 7 × 9 ). The mesh was inserted indicated if there is pain or discomfort, skin erosion over
through the 12 mm optical port and tacked anteriorly to the herniated sac, or intestinal obstruction and involves
the symphysis pubis and pelvic brim using a stapler device mobilisation and reduction of the contents of the hernial
Case Reports in Medicine 3

sac with closure of the defect. Many techniques have [5] J. B.-Y. So, M. T. Palmer, and P. C. Shellito, “Postoperative
been reported including transperineal, transabdominal and perineal hernia,” Diseases of the Colon and Rectum, vol. 40, no.
the combined abdominoperineal approach. Given the low 8, pp. 954–957, 1997.
prevalence of such hernias there is, however, no consensus as [6] A. Gómez Portilla, I. Cendoya, E. Uzquiza et al., “Giant
to which approach is best. Aboian et al. [1] in their review perineal hernia: laparoscopic mesh repair complemented by a
suggest that the abdominal approach has advantages that perineal cutaneous approach,” Hernia, vol. 14, no. 2, pp. 199–
confer superiority over the transperineal option, with better 201, 2010.
exposure for dissecting out sac contents, hernial boundaries [7] J. Rayhanabad, P. Sassani, and M. A. Abbas, “Laparoscopic
and pelvic contours. In addition, it also provides good access repair of perineal hernia,” Journal of the Society of Laparoen-
for mesh positioning and allows for exclusion of small bowel doscopic Surgeons, vol. 13, no. 2, pp. 237–241, 2009.
from the repair. Despite the increase use of laparoscopy as [8] J.-L. Dulucq, P. Wintringer, and A. Mahajna, “Laparoscopic
a surgical technique, to date there have been few reports repair of postoperative perineal hernia,” Surgical Endoscopy
and Other Interventional Techniques, vol. 20, no. 3, pp. 414–
of its application to repair of postoperative perineal hernias
418, 2006.
[9]. Laparoscopy has the advantage of quicker recovery time,
[9] M. E. Franklin Jr., D. Abrego, and E. Parra, “Laparoscopic
faster recovery of bowel function, and decreased immuno-
repair of postoperative perineal hernia,” Hernia, vol. 6, no. 1,
logical stress while offering the same advantages as open pp. 42–44, 2002.
abdominal surgery including good visualisation of intra-
[10] A. M. Ghellai, S. Islam, and M. E. Stoker, “Laparoscopic
abdominal contents and the ability to survey for evidence of
repair of postoperative perineal hernia,” Surgical Laparoscopy,
tumour recurrence intraoperatively [8]. In support of this, Endoscopy and Percutaneous Techniques, vol. 12, no. 2, pp. 119–
our results using laparoscopic repair demonstrate that it is an 121, 2002.
excellent alternative to other surgical repair techniques with [11] M. W. H. Erdmann and N. Waterhouse, “The transpelvic
good early postoperative outcomes. rectus abdominis flap: its use in the reconstruction of extensive
Various techniques to repair the defect in the pelvic floor perineal defects,” Annals of the Royal College of Surgeons of
have previously been used. These include synthetic mesh England, vol. 77, no. 3, pp. 229–232, 1995.
repair, omentoplasty, musculocutaneous rotation flaps, and [12] E. Ego-Aguirre, J. S. Spratt Jr., H. R. Butcher Jr., and E. M.
free facia lata flaps [11, 12]. Nonabsorbable meshes, such Bricker, “Repair perineal hernias developing subsequent to
as that used in this case report, are increasingly being used pelvic exenteration,” Annals of Surgery, vol. 159, pp. 66–71,
to provide a new pelvic floor in cases of large defects. The 1964.
composite mesh which has a hydrophilic film reduces the risk [13] J. P. Arnaud, S. Hennekinne-Mucci, P. Pessaux, J. J. Tuech,
of visceral adhesions while the nonresorbable polyester mesh and C. Aube, “Ultrasound detection of visceral adhesion after
provides long-term reinforcement of soft tissues [13]. Again, intraperitoneal ventral hernia treatment: a comparative study
we have demonstrated good early results with the use of this of protected versus unprotected meshes,” Hernia, vol. 7, no. 2,
mesh but further long-term followup is warranted. pp. 85–88, 2003.
In conclusion, symptomatic perineal hernias, which are
rare complications of pelvic surgery, require surgical repair.
Many approaches have previously been described. We have
demonstrated that the use of laparoscopy with repair of the
pelvic floor defect using nonabsorbable synthetic meshes
offers an excellent alternative with many potential advantages
over open transabdominal and transperineal repairs.

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