RECURRENT PERINEAL HERNIA — LAPAROSCOPIC SURGICAL TREATMENT: CLINICAL CASE

Background: Recurrent postoperative perineal hernia is a rare complication of such operation as posterior pelvic evisceration. This condition can reduce the quality of life in the postoperative period and requires surgical restoration of the impaired pelvic anatomy.
Clinical case: A 54-year old female patient applied to the MSU University clinic in July 2020 with the protrusion in the perineal area. She was diagnosed with recurrent perineal postoperative hernia. She was diagnosed with rectal cancer T4N1M0 and uterine dysplasia in 2017, 6 courses of neoadjuvant polychemoradiation therapy were performed; she underwent extralevator abdominal-perineal resection with uterine extirpation and the permanent colostomy formation in 2018. A perineal postoperative hernia was diagnosed in March 2020, perineal transabdominal plastic surgery was performed with a mesh implant. A recurrent perineal hernia was diagnosed in April 2020, the patient underwent laparoscopic alloplasty with a composite mesh implant. On the 9th postoperative day, she was discharged in a satisfactory condition without any complaints.
Conclusion: Postoperative perineal hernia is a fairly rare complication in surgical practice. The recurrent rate is quite high. The insufficient number of patients, the short follow-up period and the wide range of surgical treatment methods do not allow evaluating the results adequately. It is necessary to conduct large randomized clinical trials to assess the efficacy of surgical interventions and to determine the indications for certain procedures.

1. Bullard KM, Trudel JL, Baxter NN, Rothenberger DA. Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure. Dis Colon Rectum 2005;48:438–443.

2. Brotschi E, Noe JM, Silen W (1985) Perineal hernia after proctectomy. Am J Surg 149: 301–305

3. Bech DE, Fazio VW, Jagelman DG, Lavery IC, McGonagle BA (1986) Post-operative perineal hernia. Dis Colon Rectum 29: 21–24

4. Pearl RK (1989) Perineal hernia. In: Nyhus LM, Condon RE, (eds) Hernia. Philadelphia: JB Lippincott: pp 441–446

5. Levic K, Rosen KV, Bulut O, Bisgaard T. Low incidence of perineal hernia repair after abdominoperineal resection for rectal cancer. Dan Med J. 2017 Jul;64(7):A5383. PMID: 28673377.

6. Billig JI, Hsu JJ, Zhong L, Wang L, Chung KC, Kung TA. Comparison of Effective Cost and Complications after Abdominoperineal Resection: Primary Closure versus Flap Reconstruction. Plast Reconstr Surg. 2019;144(5):866e-875e. doi:10.1097/PRS.0000000000006158

7. Chessin DB, Hartley J, Cohen AM, et al. Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: A cohort study. Ann Surg Oncol. 2005;12:104–110.

8. Althumairi AA, Canner JK, Gearhart SL, et al. Risk factors for wound complications after abdominoperineal excision: Analysis of the ACS NSQIP database. Colorectal Dis. 2016;18:O260–O266.

9. Chang CC, Lan YT, Jiang JK, Chang SC, Yang SH, Lin CC, Lin HH, Wang HS, Chen WS, Lin TC, Lin JK. Risk factors for delayed perineal wound healing and its impact on prolonged hospital stay after abdominoperineal resection. World J Surg Oncol. 2019 Dec 21;17(1):226. doi: 10.1186/s12957-019-1768-4. PMID: 31864365; PMCID: PMC6925835.

10. Kamrava A, Mahmoud NN. Prevention and management of nonhealing perineal wounds. Clin Colon Rectal Surg. 2013;26:106–111.

11. Musters GD, Sloothaak DA, Roodbeen S, van Geloven AA, Bemelman WA, Tanis PJ (2014) Perineal wound healing after abdominoperineal resection for rectal cancer: a two-centre experience in the era of intensified oncological treatment. Int J Colorectal Dis 29(9):1151–1157. https://doi.org/10.1007/s00384-014-1967-y

12. Han JG, Wang ZJ, Gao ZG, Wei GH, Yang Y, Zhai ZW, Zhao BC, Yi BQ. Perineal Wound Complications After Extralevator Abdominoperineal Excision for Low Rectal Cancer. Dis Colon Rectum. 2019 Dec;62(12):1477-1484. doi: 10.1097/DCR.0000000000001495. PMID: 31567926.

13. Asplund D, Prytz M, Bock D, Haglind E, Angenete E (2015) Persistent perineal morbidity is common following abdominoperineal excision for rectal cancer. Int J Colorectal Dis 30(11):1563–1570. https://doi.org/10.1007/s0038 4-015-2328-1

14. Hullsiek HE (1956) Perineal Hernia after abdominoperineal resection. Am J Surg 92: 735–738

15. Balla A, Batista Rodríguez G, Buonomo N, Martinez C, Hernández P, Bollo J, Targarona EM. Perineal hernia repair after abdominoperineal excision or extralevator abdominoperineal excision: a systematic review of the literature. Tech Coloproctol. 2017 May;21(5):329-336. doi: 10.1007/s10151-017-1634-8. Epub 2017 May 15. PMID: 28508281.

16. Blok RD, Musters GD, Borstlap WAA, Buskens CJ, Bemelman WA, Tanis PJ, Collaborative Dutch Snapshot Research G (2018) Snapshot study on the value of omentoplasty in abdominoperineal resection with primary perineal closure for rectal cancer. Ann Surg Oncol 25(3):729–736. https ://doi.org/10.1245/ s10434-017-6273-9

17. De Campos FGCM, Habr-Gama A, Araújo SE et al. Incidence and management of perineal hernia after laparoscopic proctectomy. Surg LaparoscEndosc Percutan Tech 2005;15:366-70.

18. Mjoli M, Sloothaak DAM, Buskens CJ et al. Perineal hernia repair after abdominoperineal resection: a pooled analysis. Colorectal Dis 2012;14:e400-e406.

19. Martijnse IS, Holman F, Nieuwenhuijzen GAP et al. Perineal hernia repair after abdominoperineal rectal excision. Dis Colon Rectum 2012;55:90-5.

20. Svane M, Bulut O, Svane M et al. Perineal hernia after laparoscopic abdominoperineal resection – reconstruction of the pelvic floor with a biological mesh (PermacolTM). Int J Colorectal Dis 2012;27:543-4.

21. Dulucq J-L, Wintringer P, Mahajna A. Laparoscopic repair of postoperative perineal hernia. Surg Endosc 2006;20:414-8.

22. Musters GD, Lapid O, Stoker J et al. Is there a place for a biological mesh in perineal hernia repair? Hernia 2016;20:747-54.