Symptomatic Perineal Hernias : A Rare but Challenging Problem after Laparoscopic Abdominoperineal Resection for Rectal Cancers . Combined Abdominoperineal Approach and Biological Mesh Repair

Citation: Ýmisson B, Hamad A, Govindarajah N, Khan A (2018) Symptomatic Perineal Hernias: A Rare but Challenging Problem after Laparoscopic Abdominoperineal Resection for Rectal Cancers. Combined Abdominoperineal Approach and Biological Mesh Repair. Int J Surg Res Pract 5:077. doi. org/10.23937/2378-3397/1410077 Accepted: June 04, 2018; Published: June 06, 2018 Copyright: © 2018 Ýmisson B, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. International Journal of Surgery Research and Practice Open Access ISSN: 2378-3397


Introduction
Postoperative perineal hernia is a rare complication after abdominoperineal resection (APR), proctectomy, or pelvic exenteration.It is the protrusion of intra-abdominal contents through a defect in the pelvic floor.It may contain small bowel, large bowel, bladder, uterus and omentum [1].
Prevalence after open abdominoperineal resections is 0.34%.The incidence after a laparoscopic APR remains unknown at present [2].
The defect was then repaired utilising a Cook Biodesign ™ (10 × 10 cm) biological mesh (Figure 5).The mesh was sutured to the sacrum posteriorly, lateral pelvic wall fascia and anteriorly to peritoneum over the bladder (Figure 6).Normal anatomy was restored, followed by closure of the laparotomy wound and closure of the perineal wound with a perineal suction drain in place.a thin, tense layer of skin which was reducible with the patient lying in the supine position (Figure 1).The cough impulse was preserved and there were no features of bowel obstruction or strangulation.The decision was made to operate electively, owing to the potential threat of skin compromise leading to development of an enterocutaneous fistula.
At operation, the patient was placed in the Lloyd Davies position (Figure 2) and a lower midline laparotomy was used to open the abdomen.Exploring the abdominal cavity revealed minimal intraperitoneal adhesions from previous surgery.In the pelvis, the small bowel had herniated through into the perineal space and formed dense adhesions which could not be visualised clearly from the abdomen.Due to high risk of bowel injury, transabdominal dissection was halted, and a midline perineal incision was made through the thin skin overlying the hernia (Figure 3).The hernial sac was opened.This revealed dense adhesions with the prostate anteriorly and right lateral pelvic wall.The small bowel was then carefully dissected from the right pelvic wall and mobilised back into the abdomen with no subsequent iatrogenic injury noted (Figure 4).Surgical approach to treatment can be perineal or the abdomen, with the latter being either open or laparoscopic.Alternatively, a combined abdominoperineal approach can be used.Different repair techniques have been described including primary suturing of the perineal defect which is usually not feasible because of the size of the defect.The defect has to be strengthened with synthetic or biological meshes or autologous tissue such as peritoneal grafts, dura and fascia lata grafts, omental carpet, uterus and even the bladder [2].
In our case, an open combined abdominoperineal approach was successfully utilised, and repair was feasible using a biological mesh.The patient is still under follow up and at the time of publication there have been no post-operative complications.

Discussion
Perineal hernia is an uncommon complication of abdominoperineal resection of the rectum.Prevalence estimates range from 0.34% to 7% [4].
Prevalence is thought to be higher after laparoscopic approach as this is associated with less intra-abdominal adhesions allowing abdominal contents to fall into the perineum.This can also be due to loss of pneumoperitoneum is as soon as the rectum is removed, and this is a convenient point in the operation to construct the colostomy and close the perineum, leaving the pelvic peritoneum unsutured [5].
The risk of developing such hernias is higher in females due to wider pelvis, previous hysterectomy, radiotherapy, coccygectomy, higher length of small bowel mesentery, and perineal post-operative infection.

Figure 4 :
Figure 4: Small bowel freed of dense adhesions with prostate anteriorly.

Figure 1 :
Figure 1: Clinical examination of the perineum showing hernia.

Figure 6 :
Figure 6: Mesh sutured to sacrum posteriorly, lateral pelvic wall fascia and anteriorly to peritoneum over bladder.