Secondary perineal hernia following open abdominoperineal excision of the rectum: report of a case and review of the literature

This is a case report of a 46-year-old man who presented with a painful perineal lump four months after abdominoperineal excision of the rectum (APER) with pre-operative radiotherapy and adjuvant chemotherapy. Perineal hernia (suspected clinically) was confirmed by magnetic resonance imaging, and the patient underwent open Permacol mesh repair via a perineal approach. Symptomatic perineal herniation after surgical resection is a rare phenomenon, and the approach to management remains challenging. Several different surgical approaches and techniques of repair have been described. In this report, we review the literature surrounding the presentation, aetiology and repair of this unusual post-operative complication. Furthermore, our case confirms that closure of the hernial orifice with mesh via a perineal approach is a satisfactory technique.     

Central perineal hernia mimicking rectocele: a case report

Background A perineal hernia is a very rare clinical finding. Three forms are distinguished: anterior, posterior, and central. Diagnosis of the last one is difficult, and sometimes, it is falsely named a posterior rectocele. Aim This work presents a successfully treated case of central perineal hernia and makes a brief summary of existent literature on the problem. Presentation of the case We report of a 67-year-old female patient with a symptomatic central pelvic floor hernia. After radiological confirmation of the diagnosis, a transperitoneal approach was chosen to reposition the protruded segment of the small bowel. The hernial orifice was closed by extraperitoneal implantation of a polypropylene mesh. Discussion In the present case, the use of a laparoscopic technique seemed unsuitable due to the extension of the findings. For the repair of perineal hernia, we followed the principles of the “tension-free” concept. If there are no signs of a pelvic floor infection and if the mesh can be implanted totally extraperitoneally, we recommend the use of nonabsorbable alloplastic material (polypropylene) for reinforcement of the pelvic floor as a suitable technique for the repair of large perineal hernias.     

Robot-assisted laparoscopic repair of perineal hernia after abdominoperineal resection: A case report and review of the literature

IntroductionPerineal hernia is a protrusion of the pelvic floor containing intra-abdominal viscera. The occurrence of postoperative perineal hernia after abdominoperineal resection (APR) is rare, but reports have indicated a recent increase in occurrence following surgical treatment for rectal cancer. This has been attributed to a shift towards extralevator abdominoperineal resection, together with more frequent and long-term use of neoadjuvant therapy.Presentation of caseHere, we report the case of a patient who underwent APR for cancer. Twenty months postoperative, a perineal hernia was detected. The patient was electively scheduled for surgery. Robot-assisted laparoscopy was performed using the da Vinci Surgical System. The perineal hernia was repaired by primary closure with the placement of Symbotex Composite mesh as reinforcement for the pelvic floor. The surgery was performed without any adverse events, and the patient was discharged the day after surgery. Clinical follow-up proceeded at the designated time intervals without difficulties.DiscussionRecurrence rates of perineal hernia remain high, and surgeons face numerous challenges related to poor view, suturing and mesh placement in the deep pelvis. Numerous approaches have been described, but there is still no consensus as to the optimal repair technique for perineal hernia.ConclusionSymptomatic perineal hernias can feasibly be repaired with robot-assisted laparoscopy. Furthermore, suturing and mesh placement require less effort with the robot approach when compared to the open and laparoscopic approaches. These promising findings are demonstrated in the included video.     

Parapubic hernia: case report and review of the literature

Parapubic hernia is considered rare, with 18 hernias described in five articles published since 1971. The hernia results from iatrogenically or traumatically detached rectus abdominis muscles at the pubic bone and presents a therapeutic challenge because there is no strong aponeurotic anchoring structure in the defect's caudal aspect. We describe a patient with a large parapubic hernia repaired by a combined preperitoneal and onlay prosthetic method. This report adds another dimension to the prosthetic repair options in parapubic hernias and illustrates the effectiveness of the tension-free repair principle in their definitive management. Electronic Publication     

Laparoscopic repair of postoperative perineal hernia

Background Perineal hernia is an uncommon complication following abdominoperineal resection of the rectum. There are only a few reports concerning the management of this unusual problem. Various methods of repair have been described, but none of them is well established. The purpose of our study is to present our experience and to discuss the pathogenesis and the different surgical repair techniques of these hernias. Methods Between September 2003 and December 2004, four patients with perineal hernia observed several months following laparoscopic abdominoperineal resection for adenocarcinoma of the lower rectum were treated. All patients underwent the transabdominal laparoscopic approach using synthetic mesh for repair. Results In all patients, the hernia was repaired by the laparoscopic transabdominal approach using synthetic mesh. The blood loss was minimal and mean operating time was 54 ± 10 min. There were no cases that required conversion to laparotomy and there were no intraoperative or postoperative complications. Beginning of soft diet intake and ambulation times were on the second day following surgery. The average length of hospital stay was 4 ± 1 days. During 8.3 ± 6 months of follow-up, there was no recurrence of the hernia. Conclusion Perineal hernias are rare complications of major pelvic surgeries. Symptomatic hernias should be repaired surgically. The transabdominal laparoscopic approach using synthetic mesh provides an appropriate solution for these hernias.     

Tension free perineal hernioplasty: report of a case

Summary Perineal hernias are extremely rare in clinical practice, most being secondary to radical pelvic surgery. Different surgical approaches have been described, with primary closure as well as with the use of flaps and mesh. We report the case of a 35 year old female with a primary anterior perineal hernia, that was repaired using a cone of polypropylene mesh through a perineal approach under regional anaesthesia. Two years later she remains asymptomatic without recurrence. We believe this is the first report of such repair for a primary perineal hernia.     

Use of bone anchors in perineal hernia repair: a practical note

Background Bone anchoring systems are used extensively in orthopaedic surgery but have scarcely been reported as useful in abdominal wall or perineal hernia repair. After coccygectomy or sacrectomy the development of bowel herniation is not uncommon. Considering repair of such a perineal hernia, adequate fixation of the prosthetic mesh is difficult and, therefore, recurrence is rather frequent, mostly due to insufficient anchoring of the mesh to the bony structures.Methods We discuss a patient in which the Mitek GII anchoring system was used to overcome the problem of soft-tissue-to-bone attachment in such cases.Conclusion Bone anchoring systems seem to be an efficient method to overcome the problems of soft-tissue-to bone attachment in both abdominal and perineal hernia repair.     

Spigelian hernia in a child: case report and review of the literature

Abstract. Spigelian hernias (SHs) are rarely observed among children. The diagnosis is not difficult to make once it has been considered. The condition requires a high index of suspicion because of its high potential for life-threatening complications. A 12-year-old boy underwent open appendectomy for presumed acute appendicitis. A normal appendix found at laparotomy suggested another etiology for the acute abdomen. Incarceration of the greater omentum in a spigelian hernia was found, and the hernia repaired. The repair of pediatric SH is straightforward and utilizes endogenous tissues. Patients should be followed up for as long as possible to develop data on the durability of the repair technique selected. Electronic Publication     

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.     

Two case reports of perineal hernia after laparoscopic abdominoperineal resection with a proposed modification to the operative technique

Perineal hernia is a rare complication following laparoscopic abdominoperineal resection (APR) for rectal cancer. We present two case reports of perineal hernia following laparoscopic APR and discuss their management. We suggest that they developed because the pelvic peritoneum was left open during laparoscopic APR and propose that closure of the pelvic peritoneum should be routine in this operation.     

Laparoscopic repair of a spigelian hernia: a case report and literature review.

BACKGROUND: We present a case in which laparoscopy was both diagnostic and therapeutic in a patient with a spigelian hernia. CASE REPORT: A 35-year-old man was referred to the General Surgery Service for evaluation of right lower quadrant abdominal pain of approximately 6 months. The pain was not disabling but was a constant discomfort. The patient did not have any significant past medical or surgical history, and the physical examination was significant only for an area of focal tenderness in the right lower quadrant. Ultrasound and CT scans of the patient's abdomen were unremarkable. A laparoscopic exploration of the area revealed a defect in the area of semilunar and semicircular lines consistent with a spigelian hernia. The patient underwent a laparoscopic herniorrhaphy with placement of a polypropylene mesh. CONCLUSION: This case illustrates the role of laparoscopy in the diagnosis and treatment of spigelian hernias.     

Rare case of incarcerated obturator hernia: Case report and review of literature

IntroductionObturator hernia is a rare condition accounting for less than 1% of all intra abdominal hernias. Clinical diagnosis is considered a challenge for most surgeons. It usually appears as an intestinal obstruction. Confirmation of diagnosis is carried out by means of imaging or during surgery.Case reportAn 85-year-old female patient, with symptoms of intestinal obstruction of 24 h duration was admitted to the emergency room of Unimed Hospital – Belo Horizonte. Abdominal computed tomography (CT) demonstrated a herniation of the small bowel through the right obturator canal with an intestinal distension proximally. At laparotomy, the presence of a right obturator hernia with an ileal strangulation was confirmed. Segmental enterectomy with primary anastomosis and herniorrhaphy for the closure of the obturator foramen were performed.DiscussionObturator hernias typically affect women, elderly, emaciated and multiparous. Symptoms are non-specific and associated with an intestinal obstruction. Howship-Romberg sign, considered pathognomonic, is generally absent. Abdominal CT scan can aid in pre-operative diagnosis and the treatment is surgical.ConclusionEarly diagnosis and surgical treatment are imperative in obturator hernias due to the high morbidity and mortality that occur in cases where the intervention is delayed.     

Ileal strangulation by a secondary perineal hernia after laparoscopic abdominoperineal rectal resection: A case report

IntroducitonWe report a recent case of strangulated bowel obstruction due to an incarcerated secondary perineal hernia that developed after laparoscopic rectal resection.Presentation of caseA 75-year-old man undergoing treatment for alcoholic cirrhosis underwent laparoscopic abdominoperineal resection of the rectum (APR) for lower rectal cancer after preoperative chemoradiotherapy. Lung metastases were diagnosed 2 months postoperatively. Ten days after chemotherapy initiation, the patient was hospitalized on an emergency basis due to hepatic encephalopathy. Ten days thereafter, we observed perineal skin protrusion. Moreover, the skin disintegrated spontaneously, resulting in ascetic fluid outflow. Pain and fever developed, with inflammatory reactions. Contrast-enhanced computed tomography showed strangulated small bowel obstruction due to perineal hernia. We performed an emergency surgery, during which we found small intestine wall incarcerated in the pelvic dead space, with thickening and edema; no necrosis or perforation was observed. We performed internal fixation by introducing an ileus tube into the ileocecum and fixing its balloon at the cecal terminus.DiscussionSecondary perineal hernia is rare and can develop after APR. Its prevalence is likely to increase in future because of the increasing ubiquity of laparoscopic APR, in which no repair of peritoneal stretching to the pelvic floor is performed. However, only two case of secondary perineal hernia causing strangulated bowel obstruction has been reported in the literature. The follow-up evaluation of our procedures and future accumulation of cases will be important in raising awareness of this clinical entity.ConclusionWe suggest that the pelvic floor and the peritoneum should be repaired.     

Right-sided Bochdalek hernia obstructing in an adult: case report and review of the literature

Bochdalek hernias on the right side of the diaphragm are very rarely diagnosed in adults. We review a case of a 35-year-old female who presented acutely with intestinal obstruction. Plain and cross-sectional imaging identified a large right-sided Bochdalek hernia, containing colon, causing a mechanical obstruction and, surprisingly, concurrent appendicitis. The patient underwent an emergency laparotomy. At surgery the colon was reduced and was viable. The diaphragmatic defect was repaired using non-absorbable sutures and an appendicectomy was then performed for purulent appendicitis. She made an uneventful recovery and remains well at 9-month follow-up. We discuss what we believe to be the first reported case of an obstructed right-sided Bochdalek’s hernia associated with appendicitis in an adult and review the published literature on this rare condition.     

Handlebar hernia: traumatic abdominal wall hernia with multiple enterotomies. A case report and review of the literature

Handlebar hernia, caused by low-energy impact against a handlebar, is a localized abdominal wall hernia that is blunt enough not to penetrate the skin but severe enough to cause the disruption of abdominal wall musculature. In 1964, Roberts (Br J Surg 1964;51:153) reported the first case of a traumatic abdominal wall hernia that occurred in a 9-year-old boy after a fall upon a bicycle handle. Since then, 12 other cases have been reported. To the best of our knowledge, the case described here is the first documented case of an incarcerated handlebar hernia associated with a small bowel perforation and mesenteric disruption.     

Adrenal ectopy and lipoma of an inguinal hernia sac: A case report & literature review

Introduction & importanceEctopic adrenocortical tissue is the presence of accessory adrenal cortex tissue located outside of the adrenal glands. It is a rare, incidental finding during inguinal hernia repair. This case report aims to discuss the anatomy and important patient implications related to this finding.Case presentationA 61-year-old male presented with a long-standing right direct inguinal hernia increasing in size and pain frequency. During open right anterior inguinal hernia repair, a lipoma was identified inside the hernia sac and removed. Further histopathological examination of the specimen revealed the presence of adrenocortical tissue inside the lipoma. No further interventions were performed. The postoperative and 2-year follow-up course were uneventful.Clinical discussionAdrenocortical tissue can parallel the descent of the gonads during embryogenesis, arresting at any point along this path, including the inguinal region. Ectopic adrenocortical tissue is commonly found during inguinoscrotal procedures in infants, suggesting early involution. Its incidence in hernia sacs should be recognized to prevent misdiagnosis as neuroendocrine tumors or melanomas. If adrenocortical tissue is identified during hernia reduction, further surgical exploration is not recommended. In terms of prognosis, endocrine imbalances following surgical removal cannot be ruled out, promoting careful patient monitoring. The lipoma containing the adrenal tissue in our case is a common finding during hernia repair, identified in 22% of patients at operation.ConclusionEctopic adrenocortical tissue is a rare, incidental finding during inguinal hernia sac analysis in adults. This finding should be well-documented following removal and further studies are required to evaluate long-term outcomes.     

Recurrent paraesophageal hernia due to diaphragm rupture: a case report

A 58-year-old male patient was operated for complaints of dysphagia, anemia and retrosternal discomfort due to a type II hiatal hernia. A complete hernia sac excision and posterior crural repair was performed laparoscopically with support of the da Vinci™ robotic system. An antireflux procedure was not performed because of the absence of gastroesophageal reflux disease. Nine months after surgery the patient presented with recurrent complaints of dysphagia and retrosternal pain. Barium esophagram series revealed a recurrent paraesophageal hernia which was confirmed on esophagogastroscopy. A robot-assisted re-laparoscopy was performed. Left to the still intact hiatoplasty of the original operation a tear in the diaphragm, through which part of the stomach covered with peritoneum had herniated, was encountered. The hernia sac was excised, the diaphragmatic defect closed and reinforced with an expanded polytetrafluoroethylene strip of 5×8 cm. After surgery the patient recovered quickly, oral intake was resumed on the first postoperative day and the hospital stay was 3 days. The use of prosthetic mesh to reinforce the hiatoplasty and the addition of an antireflux procedure after hiatal hernia repair are ongoing controversial aspects of hiatal hernia repair. Reports on laparoscopic redo surgery for recurrent diaphragmatic hernia are limited and will be addressed in this case report, in perspective of the aforementioned controversial components.