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(A) Preoperative picture showing the perineal hernia defect; (B) X-ray of the abdominal orthostatic showing hernia; (C) Computed tomography (CT) scan showing the small bowel sliding through the pelvic floor into the perineal area.
Contexts in source publication
Context 1
... 6 months after L-APR, the patient complained of a reducible, slight painful perineal swelling, which made her uncomfortable. On examination, manual palpation of the perineal can suggest a perineal soft lump bulging in the subcutaneous (Figure 1(A)), especially on standing. When ausculta- tion, bowel sounds could be heard. ...
Context 2
... patient wore a self-designed T hernia bandage to prevent enlargement of the perineal hernia. X-ray of the abdominal orthostatic and computed tomography (CT) showed the small intes- tine protruding through the pelvic floor into the perineal area (Figure 1(B) and Figure 1(C)). ...
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Citations
... He et al. [11] 1 ...
... Other factors that improve oncological outcome, such extralevator APE (eLAPE), end up creating a wider pelvic floor defect. Due to significant width of the pelvic defect and tissue fibrosis/retraction resulting from preoperative chemoradiotherapy, suture closure may not be feasible and hence, pelvic peritoneum may be left open at the end of a minimally invasive procedure, predisposing to development of PH [6,11]. However, the cause-effect relationship with peritoneal suturing is not clearly established [4]. ...
b>Introduction: Perineal hernia (PH), also termed pelvic floor hernia, is a protrusion of intraabdominal viscera into the perineum through a defect in the pelvic floor. Aim: The study was conducted to evaluate the cases of perineal hernia resulting as a complication of abdominoperineal resection (APR) of rectal cancer. Material and methods: 30 cases from 24 articles published in reputable peer reviewed journals were evaluated for eight variables including [I] patient age, [II] gender, [III] time since APR, [IV] clinical presentation, [V] approach to repair, [VI] type of repair, [VII] presence/absence of pelvic adhesions [VIII] complications. Results: There was a total of 30 cases (18 males and 12 females) with a mean age of 71.5 years. The time of onset of symptoms ranged from 6 days to 12 years. Perineal lump with pain was the chief presenting feature followed by intestinal obstruction. Different approaches were adopted to repair by various methods. Conclusions: Perineal hernia as a complication of abdominoperineal resection is reported increasingly nowadays, as the approach to management of rectal cancer has gradually got shifted from open to minimally invasive in recent years. There is a need to spread awareness about this condition, so that it is actively looked for, during the postoperative follow-up. Management is surgical repair; the approach and type of repair should be individualized.
... While the use of myocutaneous flaps is sometimes advocated to prevent hernia, patients with a myocutaneous flap in our series were more likely to experience a perineal hernia (p = 0.001) [4,22]. This is likely due to patient selection and the increased complexity of the surgery. ...
... If there is a real association between LAPR and perineal hernia, the prevalence of perineal hernia will likely rise as the laparoscopic approach to an APR continues to become more popular, unless new strategies to prevent them are developed [4]. These strategies can include minimizing identified risk factors or possibly inserting pelvic mesh or an omental flap during the LAPR [22,24,25]. Further study of this vexing survivorship issue is necessary. ...
Aim
To determine the impact of surgical technique on the incidence of perineal hernia after abdominoperineal resection (APR).
Methods
A retrospective analysis was performed on patients who underwent APR between May 2007 and March 2018 at our institution using our prospectively maintained Colorectal Cancer Database. Demographic and clinical parameters were compared between the open APR (OAPR) and laparoscopic APR (LAPR) groups using Student’s t test, chi-squared, or Fisher’s exact test. Putative risk factors were then analyzed using a Cox proportional hazard model with perineal hernia as the outcome.
Results
The study included 261 patients (191 OAPR and 70 LAPR). Intraoperative blood loss (596.0 ± 633.4 vs. 307.0 ± 307.2 mL, p < 0.001), duration of OR (249.6 ± 115.6 vs. 212.6 ± 75.1 min, p = 0.004), and length of stay (15.6 ± 18.0 vs. 10.4 ± 12.6 days, p = 0.031) were all greater for OAPR than LAPR patients, but wound complications other than hernia did not differ significantly. Perineal hernia was observed in 2.1% of OAPR and 12.9% of LAPR patients. In multivariable analysis, significant risk factors for perineal hernia were age, laparoscopic technique, and closure of the perineal wound with myocutaneous flap (HR 1.08, 11.13, and 31.51, respectively, all p < 0.05).
Conclusions
LAPR, although associated with less blood loss and shorter length of hospital stay than OAPR, was a significant risk factor for perineal hernia.
The pelvic floor represents a complex anatomic region, which is prone to laxity, herniation and prolapse. Often, treatment will require a multidisciplinary approach with input from colorectal surgeons, urogynecologists and urologists. A thorough understanding of the anatomic deficit combined with its functional significance is imperative when contemplating invasive interventions. Excellent functional results are incumbent on the surgeon correlating the patients’ symptoms with the anatomic findings. Numerous approaches are available to correct pelvic floor deficits and should be tailored to the individual patient taking into account the need for a team approach and also their comorbidities.
