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CASE REPORT |
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| Ahead of print
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| Combined perineal hernia repair and abdominal parastomal hernia with mesh for sequela of an abdominoperineal resection |
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Katherine C McDonald1, Philip Borger2, Rachel Webman2, Soo Yun Kwon3
1 Department of Obstetrics and Gynecology, Division of Urogynecology, Northwell Health, North Shore University Hospital, Manhasset, New York, NY, USA
2 Department of Surgery, Northwell Health, Lenox Hill Hospital, New York, NY, USA
3 Department of Obstetrics and Gynecology, Division of Urogynecology, Northwell Health, Lenox Hill Hospital, New York, NY, USA
Click here for correspondence address and email
| Date of Submission | 14-Nov-2020 |
| Date of Acceptance | 03-Dec-2020 |
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Clinically, significant perineal hernias are rare, occurring in <1% of all hernias. They may be congenital but are most commonly acquired and secondary to abdominoperineal resection (APR) or pelvic exenteration as treatments for cancer. We report a novel case of a combined perineal hernia and abdominal parastomal hernia and our approach for repair with mesh. The perineal hernia repair utilized a composite mesh implant, which was anchored to Cooper's ligament and the anterior longitudinal ligament. The parastomal hernia required component separation and re-siting of the stoma. This case describes a unique method for repairing the uncommon sequelae of concurrent perineal and parastomal hernias after an APR for rectal cancer.
Keywords: mesh, parastomal hernia, perineal hernia
How to cite this URL:
McDonald KC, Borger P, Webman R, Kwon SY. Combined perineal hernia repair and abdominal parastomal hernia with mesh for sequela of an abdominoperineal resection. Int J Abdom Wall Hernia Surg [Epub ahead of print] [cited 2023 Mar 20]. Available from: http://www.herniasurgeryjournal.org/preprintarticle.asp?id=313328 |
| Introduction | |  |
This case is the first documented in the literature describing the repair of combined perineal and parastomal hernias. Symptomatic perineal hernias are rare, occurring in <1% of cases,[1],[2] and require surgical repair. There is no gold standard for the repair of perineal hernias; however, the most surgeons use composite mesh reconstruction[3] to decrease the risk of recurrence.
We report the case of a 67-year-old female who presented with combined perineal and parastomal hernias and an innovative repair technique that uses composite mesh reconstruction.
| Case Report | | |
A 67-year-old female presented to our practice with perineal discomfort. She had a total abdominal hysterectomy for fibroid uterus 20 years prior and an abdominoperineal resection (APR) for rectal cancer with adjuvant radiation therapy 13 years prior. She reported perineal pain with sitting and walking, and symptoms from the parastomal hernia including pain after meals and need for a manual reduction before bowel movements. On examination, she had a secondary posterior perineal hernia extending into the right labia and perineum and a parastomal hernia nearly obliterating the left rectus abdominis. Computed tomography scan was consistent with a prior hysterectomy and partial colectomy and demonstrated a large parastomal hernia containing unobstructed transverse colon and a defect in the pelvic floor with herniation of small bowel.
The patient was taken to the operating room by a general surgeon and a urogynecologist for the repair of perineal hernia with mesh, repair of the parastomal hernia with stoma relocation, component separation, and closure of abdominal wall with an onlay mesh. She was positioned in dorsal lithotomy. Bilateral ureteral stents were placed, and then a midline vertical laparotomy was performed. Both retropubic and presacral spaces were dissected to secure the composite mesh to strong fascial tissue, Cooper's ligament anteriorly, and the anterior longitudinal ligament posteriorly. A large defect was noted from the abdomen to the posterior perineum and labia majora [Figure 1]. The defect was too large for a primary closure, and a permanent synthetic biomaterial, Gore DualMesh, was selected to bridge the defect due to its distinct surfaces. The DualMesh surface with polypropylene is designed to encourage host tissue incorporation and was placed facing the perineum, while the contralateral Gortex surface which is designed to decrease adhesion formation was placed facing peritoneal cavity.[4] The 8 cm × 14 cm sheet of Gore DualMesh was cut to the size of the defect in the levator ani sutured in circumferential fashion using a running #2.0-Prolene. Anteriorly, the mesh was attached to Cooper's ligament. Laterally, it was attached to the iliococcygeus and arcus tendineus fascia pelvis and posteriorly to the anterior longitudinal ligament at the level of S2–4 [Figure 2]. The sutures were placed medial to the ureters by palpating for the ureteral catheters. An omental flap was created and sutured over the Gore DualMesh to decrease the risk of mesh complications. | Figure 1: A perineal view of the hernia with surgeon’s finger placed through abdominal incision, distending left perineum
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 | Figure 2: A coronal abdominal view of the perineal hernia after mesh placement with orientation and anatomic landmarks as noted
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Attention was turned to the parastomal hernia. The colon entered the defect adjacent to the stoma through the previous midline incision. The colon was dissected circumferentially in the hernia sac and stapled close to the stoma site, followed by mobilization of the left colon and stoma relocation through the right rectus. As the left rectus was attenuated, and the fascia would not reapproximate, closure of the abdomen required left-sided anterior component separation, followed by primary closure of the fascia with 0-Novafil buttressed with 2-Stratafix and placement of an onlay ProGrip mesh. A component separation was not performed on the right side to maintain the integrity of the new stoma site. The remnant colon from the previous ostomy site was excised, and the overlying tissue closed primarily. Cystoscopy was repeated with ureteral stents removed, and bilateral ureters were noted to be patent.
The patient had postoperative perineal and parastomal fluid collections which were drained on postoperative day 7. Her course was otherwise uncomplicated, and she was discharged on postoperative day 8. Four months after surgery, the patient has a resolution of her initial symptoms and no recurrence on examination.
| Discussion | | |
Perineal hernias are defined as the protrusion of intraperitoneal organs through a defect in the pelvic diaphragm into the perineum. They may be congenital but are most commonly acquired and secondary to APR or pelvic exenteration as treatments for cancer. Radiation is a risk factor for poor perineal wound healing and doubles the rate of both total and major perineal wound complications after APR.[5]
Clinically, significant perineal hernias occur in <1% of cases.[1],[2] Surgical repair becomes necessary for perineal pain, swelling, risk of intestinal obstruction, evisceration, or perineal breakdown. Perineal hernia repairs are performed by perineal (69%) or laparoscopic approach (23%), with rare indication for an open abdominal approach (2.7%).[3] Abdominal approach is typically chosen if there is an indication for a concomitant abdominal procedure, as in our case.[6] Primary closure is less common, and the most surgeons use a mesh (nonabsorbable 37%, composite 18%, or biologic 17%) or flap reconstruction.[3] Mesh repair is preferred to primary closure or flap reconstruction given the decreased incidence of recurrence.[7]
Parastomal hernias are incisional hernias located adjacent to stomas and occur in up to 76% of patients with a stoma.[8] While re-siting a stoma is not the standard of care for parastomal hernias,[9] the fascial defect and lack of rectus muscle to support the stoma in its preoperative position presented a unique challenge. This necessitated the departure from the commonly used Sugarbaker technique and closure required component separation to alleviate tension that would have compromised the repair.
| Conclusion | | |
This case presents a unique method for repairing the uncommon sequelae of concurrent perineal and parastomal hernias after an APR for rectal cancer. The perineal hernia repair utilized a composite mesh implant, which was anchored to Cooper's ligament and the anterior longitudinal ligament, while the parastomal hernia required component separation and re-siting of the stoma. The patient recovered well after surgery and has no recurrence of either hernia. We present this case as a novel approach to concurrent repair of perineal and parastomal hernia.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Levic K, Rosen KV, Bulut O, Bisgaard T. Low incidence of perineal hernia repair after abdominoperineal resection for rectal cancer. Dan Med J 2017;64:A5383.  |
| 2. | So JB, Palmer MT, Shellito PC. Postoperative perineal hernia. Dis Colon Rectum 1997;40:954-7. |
| 3. | Balla A, Batista Rodríguez G, Buonomo N, Martinez C, Hernández P, Bollo J, et al. Perineal hernia repair after abdominoperineal excision or extralevator abdominoperineal excision: A systematic review of the literature. Tech Coloproctol 2017;21:329-36. |
| 4. | Koehler RH, Begos D, Berger D, Carey S, LeBlanc K, Park A, et al. Minimal adhesions to ePTFE mesh after laparoscopic ventral incisional hernia repair: Reoperative findings in 65 cases. J Soc Lapar Surg 2003;7:335-40. |
| 5. | 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;48:438-43. |
| 6. | Stamatiou D, Skandalakis JE, Skandalakis LJ, Mirilas P. Perineal hernia: Surgical anatomy, embryology, and technique of repair. Am Surg 2010;76:474-9. |
| 7. | Mjoli M, Sloothaak DA, Buskens CJ, Bemelman WA, Tanis PJ. Perineal hernia repair after abdominoperineal resection: A pooled analysis. Colorectal Dis 2012;14:e400-6. |
| 8. | Dapri G, Gerard L, Cardinali L, Repullo D, Surdeanu I, Sondji SH, et al. Laparoscopic prosthetic parastomal and perineal hernia repair after abdominoperineal resection. Tech Coloproctol 2017;21:73-7. |
| 9. | Hansson BM, Slater NJ, van der Velden AS, Groenewoud HM, Buyne OR, de Hingh IH, et al. Surgical techniques for parastomal hernia repair: A systematic review of the literature. Ann Surg 2012;255:685-95. |
Correspondence Address:
Katherine C McDonald,
Department of Urogynecology, Northwell Health, 865 Northern Blvd Suite 202, Great Neck, NY 11021
USA
 Source of Support: None, Conflict of Interest: None
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