Enlarging perineal endometrioma developing after colpoperineorrhaphy

Although endometriosis is not infrequent, the occurrence of perineal endometriomata is relatively rare and is generally attributed to seeding of endometrial cells to the perineal body during obstetrical trauma. A 45-year-old female with a history of a colpoperineorrhaphy during menses and a remote history of obstetric perineal trauma presented with an enlarging perineal mass. Excision of the mass led to a clinical and histopathologic diagnosis of perineal endometriosis. Elective surgery disrupting the vaginoperineal epithelium performed during menses may facilitate the seeding of endometrial cells to the perineal body and formation of perineal endometriomata.     

Previously undescribed treatment for persistent peritoneal-perineal fistula following proctectomy

Persistent perineal sinus is a common complication following proctectomy for inflammatory bowel disease. Complete excision of the sinus tract and obliteration of dead space have been stressed as important aspects of treatment. A patient is described in whom the perineal sinus persisted despite three surgical attempts at cure. Combined perineal exploration and laparotomy revealed a communicating peritoneal-perineal fistula. A combined perineal and peritoneal approach may be indicated in treating the perineal sinus that persists despite perineal excision.     

Lotus petal flap for unusual indication: A recto-vaginal fistula with perineal defect after vaginal delivery

Introduction and importanceThree to five percent of vaginal deliveries are complicated by third or fourth degree perineal laceration. Misdiagnosed perineal injuries may be associated with a poor sexual and psychological prognosis. Management of old perineal tears and laceration is challenging with a high failure rate. In such condition, interposition tissue technic or local flap can be a good surgical alternative. Lotus petal Flap, usually indicated in management of large perineal defect in gynecological oncology can be used.Case presentationWe report a case of 32-year-old women presenting complex and relapsed perineal fistula after vaginal delivery associated with perineal defect treated by lotus petal flap with a good outcome.DiscussionPerineal defects are commonly encountered after oncologic, traumatic or infectious perineal excisions and described as a challenging situation. In case of perineal defects after obstetrical tears, no validated surgical filler technics are recommended. Inspired from oncologic surgical technics to fill perineal defects, Lotus Flap can be used. Its advantages are to mobilize a satisfactory tissue volume to fill important perineal defect compared to the small bulbocavernous flap with a hidden scar comparing to gracilis muscle flap. This technic is associated with a good sexual and self-imaging outcome.ConclusionLotus petal flap may be required as a solution to manage perineal defect in case of perineal fistula. This technique provides aesthetic and good results for perineal reconstruction.     

Perineal lipoma in association with scrotal anomalies in children

OBJECTIVE: To analyse the characteristics of the perineal lipoma and speculate on its development, as an associated perineal lipoma is implicated in the occurrence of scrotal anomalies in children. PATIENTS AND METHODS: Five children with a perineal lipoma in association with various scrotal anomalies were included in the study. We analysed the types of scrotal anomalies and their anatomical relationship with the perineal lipomas. RESULTS: One child had a supra-inguinal ectopic scrotum, and the others had penoscrotal transposition, either symmetrical or asymmetrical; they included two who had an accessory scrotum combined with a perineal lipoma. The perineal lipoma was on the ipsilateral side of the upward-positioned hemiscrotum in the ectopic scrotum or the asymmetrical penoscrotal transposition, or it was on the mid-perineum in the symmetrical penoscrotal transposition. CONCLUSIONS: The perineal lipoma can be found combined with various scrotal anomalies, including ectopic scrotum as well as an accessory scrotum or penoscrotal transposition; this is the first report describing a perineal lipoma associated with an ectopic scrotum. We speculate that the development of the perineal lipoma is closely related to scrotal anomalies, which result from early division and/or abnormal migration of the labioscrotal swelling. The concomitant perineal lipoma might be formed during the process, and might affect abnormal scrotal development.     

Pelvic leiomyoma presenting as perineal hernia

Primary perineal hernias are rare and can be a diagnostic challenge. We report the case of a 45-year-old female patient who presented with painless perineal swelling suggestive of perineal hernia. Computed tomography (CT) scanning revealed a pelvic mass herniating through the pelvic floor into the perineum. The lesion was completely excised by an abdominoperineal approach. Histopathological examination of the lesion revealed a leiomyoma. This case report suggests that the possibility of perineal herniation of a pelvic leiomyoma should be considered in a female patient with suspected primary perineal hernia. We recommend an abdominoperineal approach for the surgical management of such a lesion.     

Perineal hernia after abdominoperineal amputation. Role of epiploplasty and/or irradiation]

Healing of the perineal wound after abdominoperineal amputation is a difficult technical problem for surgeons to resolve. The majority of current therapeutic protocols include pre- or post-operative radiotherapy, and most study results show a reduction in perineal relapses when compared with a control group, but at the price of delayed healing of the perineal wound. This delayed healing reaction varies with the radiation dose. The use of epiploplasty shortens the healing period, but when performed after pre-operative radiotherapy it can predispose to the development of a perineal hernia. Four cases of this complication are described. No standard procedure for treatment of these hernias exists, and although it is possible to use the uterus to fill the perineal cavity, the most effective method appears to be a double perineal and abdominal pathway using a plate.     

不同指法着力点的会阴保护技术对初产妇分娩结局的影响

目的 探讨2种指法保护着力点的会阴保护技术对初产妇分娩结局的影响。方法 将329例经阴道分娩的初产妇随机分为观察组165例和对照组164例。对照组以距离会阴后联合2 cm处为指法着力点进行适度会阴保护,观察组以胎儿额骨最高点与会阴中心腱交汇点为指法着力点进行适度会阴保护。比较两组第二产程时间、会阴裂伤程度、伤口缝合时间、产后2 h出血量、产后24 h会阴水肿情况、产后48 h会阴疼痛程度及新生儿Apgar评分。结果 观察组会阴裂伤程度、伤口缝合时间、产后2 h出血量、产后48 h会阴疼痛程度显著低于对照组（均P<0.05）;两组产妇第二产程时间、产后24 h会阴水肿程度、1 min新生儿Apgar评分比较,差异无统计学意义（均P＞0.05）。结论 以胎儿额骨最高点与会阴中心肌腱交汇点为指法着力点的适度会阴保护技术能有效保护会阴,降低会阴损伤程度,提升产妇产后舒适度。     

Radical prostatectomy in patients with previous groin hernia repair using synthetic nonabsorbable mesh

OBJECTIVE: Identification of patients in whom the perineal route is the optimal approach to perform radical prostatectomy. MATERIAL AND METHODS: During 1992-1999, 376 patients with prostate cancer underwent radical perineal prostatectomy. Four patients were identified in whom the perineal approach was indicated because of previous bilateral groin hernia repair using synthetic meshes. In addition, 1 patient underwent perineal prostatectomy elsewhere for similar reasons. RESULTS: The perineal approach offered an uneventful surgical solution for an adequate and straightforward radical perineal prostatectomy without complications and without biochemical recurrence during the follow-up. CONCLUSION: Radical perineal prostatectomy is suggested to be the optimal approach in patients with previous bilateral groin hernia repair using synthetic, nonabsorbable meshes.     

Laparoscopic repair of primary perineal hernias: the approach of choice in the 21st century

Perineal hernias are rare and result from the herniation of a viscus through the pelvic floor. Symptomatic perineal hernias are repaired surgically, historically via an open perineal, abdominal or abdominoperineal approach. We describe laparoscopic repair of a primary perineal hernia with mesh using the transabdominal approach. We believe that for uncomplicated primary perineal hernias laparoscopic repair is technically feasible, and associated with rapid recovery and minimal complications.     

Small bowel occlusion due to giant perineal hernia: abdominal approach with plastic perineal reconstruction

A perineal hernia is defined as a protrusion of peritoneal or extraperitoneal content through a pelvic floor defect. A 64-year-old woman with a bowel occlusions due to a giant postoperative perineal hernia was admitted to our hospital. We describe abdominal approach with plastic perineal reconstruction.     

Pelvic reconstruction using vertical rectus abdominis musculocutaneous flaps

Coverage of complex perineal wounds resulting from surgical and radiation therapy results in significant morbidity. Acute complications occur in 25% to 60% of patients. Serious complications occur in 25% to 46% of patients. Musculocutaneous or omental flaps are used as primary or salvage procedures for nonhealing perineal wounds. Vertical rectus abdominis flaps are ideally suited to bring nonirradiated tissue into defects associated with radical surgical extirpation procedures and irradiated fields.A retrospective review of 73 cases using a vertical rectus abdominis flap for perineal reconstruction is reported. Acute perineal wound complications occurred in 17.8%, while serious complications requiring reoperation occurred in only 3.5%. There was 1 complete flap failure. Primary healing occurred in 84.9% of patients, with 94.5% of patients obtaining a healed perineal wound within 30 days. These results support the use of the transpelvic vertical rectus flap in difficult perineal wound reconstruction.     

改良的会阴操作法在经腹会阴联合直肠癌根治术中的应用

目的 比较两种会阴操作方法在经腹会阴联合直肠癌根治术(abdominoperineal resection,APR)中的应用.方法 回顾性分析2007-2009年收治的60例直肠癌患者的临床资料.60例直肠癌的肿瘤均位于直肠前壁,30例采用改良会阴操作法(改良组)实施APR手术,另30例采用传统会阴操作法(传统组)实施APR手术,比较两组手术的时间、会阴操作时的直肠(肿瘤)破裂、尿道(阴道)损伤、术后会阴并发症发生等情况.对数据进行t检验或χ2检验.结果 会阴操作时间:改良组平均为45(45±15)min,传统组平均为70(70±20)min,两组比较差异有统计学意义(t=5.48,P＜0.05);术中直肠(肿瘤)破裂:改良组2例,传统组5例,两组差异无统计学意义(χ2=0.64,P＞0.05);尿道(阴道)损伤:改良组无,传统组1例,两组比较差异无统计学意义(χ2=0,P＞0.05);会阴切口感染/裂开:改良组2例,传统组9例,两组比较差异有统计学意义(χ2=4.01,P＜0.05).结论 改良组会阴操作比传统组手术时间短,手术更安全,术后并发症少.

Abstract：

Objective To compare the safety and effectiveness of two methods of perineal dissection in 60 consecutive patients of rectal carcinoma undergoing combined abdominoperineal resection.Methods In this retrospective study from 2007 to 2009, 30 cases underwent Miles' operation using modified method of perineal dissection( MM group) and 30 cases undergoing Miles' operation using classic method of perineal dissection ( CM group). Operative time, accidental tumor ( or rectal) perforation during the procedure, iatrogenic injury to the urethra ( or vagina) and postoperative perineal complications were compared between the two groups. Results The mean perineal operative time was (45±15) min in MM group and ( 70 ± 20) min in CM group respectively ( t = 5. 48, P ＜ 0. 05 ). There were no significant differences in the rate of tumor ( or rectal) perforation and that of urethral (vaginal) injury. There were significant difference in the rate of postoperative perineal complications (χ2=4.01, P＜0.05).Conclusions Modified method of perineal dissection is effective and safe, and this method offers a new approach for the perineal dissection during Miles' operation.     

A simple technique for vascular control during hepatectomy: the half-Pringle

Persistent perineal sinus is a common and serious cause of morbidity after proctectomy for Crohn's disease. Recently we have performed excision and omentoplasty on 6 patients with persistent perineal sinus. The perineal sinus was completely excised and communication was established with the pelvis. In 4 patients, the left gastroepiploic vessels were divided close to their origins and in 2 other patients the right gastroepiploic vessels were divided. The omentum was brought down to the perineum and it was lightly sutured to the perineal skin. After a median follow-up of 28 months, the perineal sinus had healed in 5 patients. In 1 patient the omentum became necrotic and infected 1 month after omentoplasty, and this patient still has a complex sinus. Although the number of patients is small, omentoplasty may be an effective procedure for the treatment of persistent perineal sinus after proctectomy for Crohn's disease.     

Postoperative perineal hernia

Abstract. Large perineal hernia is an uncommon complication following abdominoperineal resection of the rectum, but it does present a difficult surgical dilemma. Repair of this hernia is a challenging surgical problem. Various methods of repair have been proposed and include an abdominal, perineal, or combined abdominoperineal approach to the hernia. This report describes a patient with a large perineal hernia after an abdominoperineal resection. The spectrum of perineal hernias, the aetiology, and the different techniques of surgical repair are discussed. Electronic Publication     

Substantiation of perineal access to internal pudendal artery

Perineal access to a. pudenda interna (API) was elaborated. Variants of the a. iliaca interna and her branches localization and topographic-anatomic peculiarities of perineal portion of API were studied. The proposed perineal (extraperitoneal) access to API is most expedient in the perineal region bleeding stopping. Morphometrical parameters of perineal portion of API permit to apply her for formation of vascular anastomosis in the procedure of revascularization of the descended colon while the intestinal continuity restoration.     

Cortical evoked responses from the perineal nerve

PURPOSE: We characterize and determine normal reference latencies for the cortical evoked response from the perineal nerve. MATERIALS AND METHODS: A total of 15 healthy, potent men with a mean age of 31.3 +/- 6.8 years underwent genital electrophysiological testing. Square wave stimuli were applied to the perineal nerve at the ventral base of the penis and the perineal floor. Cortical evoked responses were recorded, and onset latencies were measured at baseline and after anesthetization of the dorsal nerve of the penis. RESULTS: In all 15 subjects a cortical evoked response was elicited after stimulation of the perineal nerve at the ventral base of the penis with a mean latency measured from the first positive deflection (P1) of 48.4 +/- 7.8 milliseconds. Penile block of the dorsal nerve of the penis did not change or abolish the cortical evoked response. A similar cortical evoked response was obtained, although less consistently, after stimulation of the perineal nerve through its course in the perineal floor. CONCLUSIONS: A cortical evoked response from the perineal nerve can be elicited reliably at the ventral penis. This neural pathway is independent of the dorsal nerve of the penis. The study of perineal somatic innervation may prove important in understanding the physiology of ejaculatory and erectile dysfunction.     

Repair of symptomatic perineal hernia with a titanium mesh

Purpose

Surgical repair of symptomatic perineal hernia is challenging, especially via a perineal approach with limited exposure of the hernia sac. Furthermore, insecure fixation of autologous or synthetic materials to bony structures often results in recurrence. Here, we describe the application of a titanium mesh for perineal hernia repair.

Methods

We performed hernia repair with a thin titanium mesh via a perineal approach in three patients who developed secondary perineal hernia following abdominoperineal resection. After the hernia sac was isolated and dissected, the titanium mesh was molded and placed over the ischium and coccyx to support the pelvic floor.

Results

No major complications occurred, and all three patients were free of recurrence at follow-up after 73, 109, and 6 months, respectively. The patients experienced slight pain in the perineal region when sitting, which resolved within 6 months.

Conclusion

Our successful preliminary results indicate that a titanium mesh is useful for perineal hernia repair by the perineal approach, as it can provide rigid support for the pelvic floor by its entire surface while ensuring stability without any fixation.     

The bottom end. Handling of the perineal wound after abdominoperineal resection

There are a number of options for handling the perineal wound following abdominoperineal resection, including open packing or primary closure with suction drainage. Open packing has not been widely accepted, fearing that it may delay perineal wound healing. The purpose of this paper, therefore, was to retrospectively evaluate, the experience at Ferguson Hospital with abdominoperineal resection from 1977 through 1986. The study population consisted of 288 patients undergoing abdominoperineal resection for rectal adenocarcinoma. Forty-six patients had the perineal wound closed primarily and 242 had the perineal wound packed open. Ninety-four patients had the pelvic peritoneum left open and 194 underwent closure of the pelvic peritoneum. Overall operative mortality was 2.1 per cent, and there was no significant difference between primary closure and open packing of the perineal wound with respect to hospital stay, operating time, operative blood loss, perioperative mortality, incidence of postoperative bowel obstruction, incidence of postoperative complications, or average time for perineal wound healing. Therefore, it would appear that packing the perineal wound following abdominoperineal resection is a viable means of handling the bottom end.     

Primary suture of the perineal wound using constant suction and irrigation, following rectal excision for inflammatory bowel disease.

Thirty-four consecutive patients with inflammatory bowel disease underwent proctectomy with primary closure of the perineal wound. Throughout this period neither preoperative perineal sepsis nor intraoperative soiling was a contraindication to primary closure. An overall primary healing rate of 82% was obtained. It appears that the commonest cause of perineal wound breakdown is the inability of the suction catheter to drain all the serous fluid from the perineal space, resulting in discharge from the suture line and wound breakdown.     

A novel approach to closure of perineal wounds during abdominoperineal resection: use of fibrin sealant

Abdominoperineal resection is associated with significant morbidity. The perineal wound poses a unique risk and complications are common, including skin breakdown, abscess, sinus tracts, perineal herniation, and evisceration. A 2-component fibrin sealant made from pooled human plasma has been proven to achieve hemostasis and tissue sealing. We report a case series of 5 consecutive patients in whom we used this fibrin sealant during perineal wound closure. Of our patients, 2 patients (40%) were diabetic and 4 patients (80%) received preoperative radiotherapy. The median body mass index was 32 (calculated as weight in kilograms divided by height in meters squared). The patients were at increased risk of perineal wound dehiscence and infection. Median follow-up was 6 months, and no patients had perineal wound complications. A fibrin sealant could be used as an alternative to more invasive procedures, such as flap reconstruction, in patients at high risk of perineal wound dehiscence.