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.     

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.     

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.     

Symptomatic perineal hernia after an abdominoperineal resection following a transsacral resection of the middle rectum: Report of a case

We herein report the unusual case of a 75-year-old woman who developed a perineal hernia of the small bowel after undergoing abdominoperineal resection following a transsacral resection of the middle rectum for rectal cancer.     

Long-term comorbidity of diabetes mellitus is a risk factor for perineal wound complications after an abdominoperineal resection

Background  This report is an attempt to clarify the effect of diabetes mellitus on perineal wound complications including infectious entities and delayed wound healing after abdominoperineal resection and also tried to show the risk factors for perineal wound complications. Material and methods  The data of 80 patients who underwent an abdominoperineal resection were reviewed from April 1996 to March 2006. Results  The rate of perineal wound complications is higher in diabetics (67%) than in nondiabetics (18%, p = 0.005). In a multivariate analysis, diabetes mellitus and operation time (≥420 min) were the risk factors for perineal wound complications (p = 0.040, p = 0.027, respectively). Infectious perineal wound complication was associated with diabetes mellitus (p < 0.001) but not with the operation time (p = 0.097). Furthermore, a longer comorbid duration of diabetes (≥10 years) was a significant predictor for perineal wound complications (p = 0.008). Conclusion  This study demonstrated diabetes mellitus to be independently associated with perineal wound complications, and when the patients have diabetes mellitus, especially with a longer comorbid duration and longer operation time, the clinical path should be changed to reduce perineal wound complications.     

腹腔镜腹会阴联合切除术治疗低位直肠癌疗效评价

目的前瞻性评估腹腔镜直肠癌腹会阴联合切除术的临床优劣性。方法将2003年7月至2006年4月收治的低位直肠癌患者随机分为两组，37例行腹腔镜腹会阴联合切除术（腹腔镜组），另37例常规开腹行腹会阴联合切除术（开腹组）；比较两组的手术时间、清除淋巴结数目和腹部出血量、术后排气时间、起床活动时间、住院时间、并发症发生率和复发转移率及卫生经济学情况。结果腹腔镜全组患者均顺利完成手术，无中转开腹者；手术时间两组比较差异无统计学意义（P〉0．05），但前10例手术时间比开腹组长（P〈0．01）；腹部出血量少于开腹组（P〈0．01）．但前10例较开腹组多（P〈0．01）；术后肛门排气时间两组差异无统计学意义（P〉0．05）；起床活动时间腹腔镜组早于开腹组（P〈0．01）；住院时间长短两组无差异，但腹腔镜会阴闭合较开腹组早：腹腔镜组腹部创口相关并发症明显少于开腹组（P〈O．05）；两组的清除淋巴结枚数、局部复发及远处早期复发率差异无统计学意义（P〉0．05）；手术费用腹腔镜组明显高于开腹组，但医疗总费用两组差异无统计学意义（P〉0．05）。结论腹腔镜直肠癌腹会阴联合切除术不仅创口小、术中出血少、与腹部创口相关并发症少、术后恢复快，且其手术时间、医疗总费用和肿瘤根治性与开腹手术无差异。     

低位直肠癌腹腔镜腹会阴切除术经腹膜外隧道径路造口的疗效观察

目的：评价腹腔镜低位直肠癌腹膜内与腹膜外两种结肠造口方式的临床疗效。方法：回顾分析2009年1月至2012年1月为68例患者行腹腔镜直肠癌腹会阴切除术（abdominoperinealreseetion,APR）的临床资料,其中55例经腹膜外隧道径路行结肠造口（观察组）,13例经腹膜内行结肠造12（对照组）,对比分析两种造12：7方式的安全性、相关并发症及造12功能的恢复情况。结果：术后患者均获随访,随访3～50个月,中位随访期24个月。观察组术后发生造口相关并发症5例（9．09％）,术后6个月造12功能临床优良率为63．6％;对照组术后发生造口相关并发症4例（30．8％）,术后6个月造口功能临床优良率为30．8％。观察组结肠造口功能明显优于对照组。两组均无中转开腹及手术死亡病例。结论：腹腔镜APR经腹膜外隧道径路行结肠造口操作简单,可有效减少造口相关并发症的发生,提高患者生活质量,是理想术式。     

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.     

Circumferential resection margin involvement after laparoscopic abdominoperineal excision for rectal cancer

Aim This study aimed to evaluate circumferential resection margin (CRM) involvement in patients with rectal adenocarcinoma after laparoscopic abdominoperineal excision (APR). Method Prospectively collected data were analyzed on consecutive patients who underwent laparoscopic APR for histologically proven rectal cancer following neoadjuvant chemotherapy, from 1998 to 2006. Patients with no sphincter involvement were not included and underwent intersphincteric resection with coloanal anastomosis. CRM involvement was defined as ≤ 2 mm using a standardized pathology protocol. Data were presented as mean ± SD or as median (range). Results Seventy‐four patients (60 ± 14 years of age; body mass index = 29.7 ± 7.9 kg/m²) underwent laparoscopic APR. The distance of the tumour from the anal verge was 3.1 ± 0.93 cm. All patients had sphincter involvement. The operative time was 180 ± 73 min, and estimated blood loss was 269 ± 149 ml. There were no conversions and no postoperative mortality. The adverse event rate was 11%. There were two reoperations and three readmissions. Seventy‐one patients had a T3 tumour and three patients had a T4 tumour. The median tumour size was 3.1 (range, 0–10) × 3 (range, 0–8.5) × 2 (range, 0–3.6) cm, and 26 (range, 3–41) lymph nodes were harvested. The median CRM was 7 (range, 1–11) mm. This was localized at the waist of the specimen in 12 (16.2%) of patients. Adjuvant therapy was given to 92% and 97% of patients with an involved and an uninvolved CRM, respectively. At 50 ± 27 months of follow up of 73 patients, 12 had CRM involvement and had a significantly decreased cancer‐specific survival (log rank test, P = 0.002). Conclusion Laparoscopic APR resulted in CRM involvement in 16.2% of patients with rectal cancer.     

经腹-会阴联合直肠癌根治术后经腹膜外造口对患者旁疝与排便功能的影响

目的探讨经腹-会阴联合直肠癌根治术后经腹膜外造口对患者旁疝与排便功能的影响。 方法选择2016年1月至2017年6月,广元市中心医院行经腹-会阴联合直肠癌根治术78例患者的临床资料。其中经腹膜外造口者40例为观察组,经腹膜内造口者38例为对照组,2组患者均于围手术期接受全程护理。比较2组手术指标、术后并发症发生情况及排便功能。 结果观察组术中出血量、住院时间分别为（104.24±39.08）ml和（15.62±3.10）d,与对照组（120.46±47.35）ml和（17.20±2.95）d,差异有统计学意义（P<0.05）;观察组手术时间、造口时间、术后切口愈合时间分别为（233.12±40.50）min、（21.87±9.23）min和（7.31±0.28）d,与对照组（231.38±39.04）min、（20.95±9.14）min和（7.05±0.34）d,差异无统计学意义（P>0.05）。观察组排便功能优良率显著高于对照组,差异有统计学意义（67.50% vs 34.21%,P<0.05）。观察组造口旁疝的发生率显著低于对照组,差异有统计学意义（2.50% vs 18.42%,P<0.05）;但2组间造口出血、造口水肿、造口回缩或脱垂等发生率比较,差异无统计学意义（P>0.05）。 结论经腹-会阴联合直肠癌根治术后经腹膜外造口可显著降低术后造口旁疝的发生率,促进其排便功能的恢复,整体疗效优于经腹膜内造口。     

腹腔镜直肠癌腹会阴联合切除术的三大难题及其解决方案

目的探讨腹腔镜直肠癌腹会阴联合切除术（APR）中的三大难题（腹部无切口的前提下完成腹膜外乙状结肠造口、缝合封闭盆底腹膜和预防术后会阴切口感染）及其解决方案。方法回顾性分析2010年9月至2013年5月间在北京协和医院基本外科接受择期腹腔镜APR手术60例低位直肠癌患者的临床资料。术中在完成淋巴结清扫及肿瘤切除后,以左下腹穿刺点为中心行腹腔镜下腹膜外乙状结肠造口术：并借鉴经肛门内镜微创手术（TEM）独特的腔内缝合技术,使用TEM持针钳,用可吸收线连续缝合关闭盆底腹膜;对成功关闭盆底腹膜的患者于术后第3天开始行骶前间隙持续灌洗预防会阴切口感染。结果计划实施腹腔镜APR的60例患者中,除1例（1．7％）中转开腹外,59例（98-3％）顺利完成腹部无切口的腹膜外乙状结肠造VI术,造口并发症发生率3．4％（2／59）。56例（94．9％）成功缝合关闭盆底腹膜,中位缝合耗时为15min,术后无一例出现会阴疝、腹内疝或粘连性肠梗阻。57例（包括中转开腹1例）成功关闭盆底腹膜后行骶前间隙持续灌洗者,骶前引流管留置的中位时间为7．8d;术后未并发粘连性肠梗阻：会阴切口甲、乙和丙级愈合率分别为87．7％（50／57）、8．8％（5／57）和3．5％（2／57）。盆底腹膜缝合失败、骶前间隙自然引流的3例患者术后1例发生粘连性肠梗阻,1例会阴切口丙级愈合。结论腹腔镜APR手术中腹膜外乙状结肠造口可行且安全;采用TEM腔内缝合技术关闭盆底腹膜便捷而有效;术后持续骶前灌洗对预防会阴切口感染的作用值得深入探讨。     

封闭式高压负压吸引对直肠肿瘤腹会阴联合切除会阴切口愈合的促进作用

目的探讨封闭式高压负压吸引对直肠肿瘤腹会阴联合切除术（APR）后会阴切口一期愈合的影响。方法按随机数字表法．将2009年1月至2011年1月间武汉同济医院胃肠外科中心收治并行APR手术的120例直肠肿瘤患者．随机分为试验组（61例,行封闭式高压负压吸引）和对照组（59例,行骶前引流）。比较两组术后会阴切口引流量、一期愈合率及愈合时间。结果试验组和对照组术后前3d会阴切口引流量分别为（448．1±142．9）ml和（548．3±190．6）ml,第3天引流量分别为（28．1±12．7）ml和（125．9±84．3）ml,一期愈合率分别为93．4％（57／61）和74．6％（44／59）,愈合时间分别为（13．5±3．5）d和（20．1±5．1）d,差异均有统计学意义（均P〈0．01）。结论封闭式高压负压吸引能促进APR手术后会阴切口的一期愈合。     

Pneumomediastinum as a complication of extraperitoneal laparoscopic inguinal hernia repair.

A 52-year-old man with left indirect groin hernia was admitted for elective inguinal repair using the totally extraperitoneal (TEP) approach. After an uneventful intubation, TEP repair of the hernia was performed with three midline trocars. Immediately after extubation, the patient noted severe chest pain. There was a decrease in PaO2 saturation, and neck subcutaneous emphysema was detected. There was no emphysema of the abdomen or of the back. A chest film and thoracic computed tomographic (CT) scan confirmed the presence of pneumomediastinum without pneumothorax. The patient was discharged without complications.     

腹腔镜下腹会阴切除术两种结肠造口方式的比较

目的探讨腹腔镜下腹会阴切除术（LAPR）乙状结肠单腔造口的手术方式，以减少造口并发症的发生。方法63例患者中，低位直肠癌53例，直肠肛管癌10例。有61例用圆形吻合器行乙状结肠与腹壁皮肤吻合造口，2例手工缝合乙状结肠造口。腹腔内腹直肌型结肠造口37例（A组）；腹膜外隧道腹直肌型结肠造口26例（B组）。结果全组在腹腔镜下完成降结肠、乙状结肠和直肠的分离以及会阴部的直肠肛门开放性切除。无中转开腹，无手术死亡。两组的平均手术时间差异无统计学意义（P〉0．05）；而术后人工肛门排气时间[A组（2．4±1．1）d与B组（1．9±0．8）d比较，P〈0．05]、术后平均住院日[A组（19．9±7．8）d与B组（14．5±3．9）d比较，P〈0．01]及造口相关并发症的发生率（A组29．4％，B组4．0％；两组比较P〈0．05）差异均有统计学意义；B组患者术后平均住院日较A组短，造口相关并发症低于A组。结论LAPR手术中。采用圆形吻合器经腹膜外隧道和腹直肌行乙状结肠单腔造口，可有效地减少造口并发症的发生和缩短手术后的住院时间。     

Congenital Perineal Hernia: Report of a Case

Congenital perineal hernia is one of the rarest childhood hernias. We report a case of an infant with a congenital perineal hernia which was successfully repaired.     

Laparoscopic repair of postoperative perineal hernia

Perineal hernia is an uncommon complication of abdominoperineal resection and pelvic exenteration. We present an alternative not previously described for the surgical repair of this type of hernia: laparoscopic repair of postoperative perineal hernia. Electronic Publication     

Incisional hernia after open versus laparoscopic sigmoid resection

Background  Incisional hernia after open surgery is a well-known complication with an incidence of up to 20% after a 10-year period. Data regarding the long-term hernia risk after laparoscopic colonic surgery are lacking in the literature. In the present study we compared the long-term hernia incidence after laparoscopic versus open sigmoid resection. Methods  The study included patients undergoing laparoscopic sigmoid resection in the period January 1995 to December 2004 in the eastern part of Denmark. This group was matched with a consecutive group of patients undergoing open surgery in our department in the same period. Patients were contacted by telephone, and a questionnaire was completed for each patient. If the patient was believed to have a hernia or if there was any suspicion of a hernia, a consultant surgeon examined the patient and completed the questionnaire. Factors related to the primary operation, the hernia and general risk factors were registered for all patients. Results  A total of 201 patients answered the questionnaire (95.3%). The laparoscopy group was comprised of 58 patients and 143 patients were included in the laparotomy group. The patients had a median follow-up of 4.6 years (range 2.4–11.7 years) and 4.9 years (range 2.4–8.5 years) after laparoscopic and open surgery, respectively (P = 0.326). Incisional hernia was found in two of 58 patients (3.4%, 95% CI -1.4–7.4) in the laparoscopic surgery group compared with 21 of 143 patients (14.7%, 95% CI 8.9–20.5) in the open surgery group (P = 0.026). There were no significant differences in demographic data or the occurrence of risk factors between the two groups. Conclusion  Laparoscopic sigmoid resection leads to a significantly lower incidence of incisional hernia compared with the open surgical technique.     

低位直肠癌行腹腔镜腹会阴联合切除术临床分析

目的探讨腹腔镜直肠癌腹会阴联合切除术手术方法、技巧及临床应用价值。方法回顾性分析2003年7月至2010年6月30例行腹腔镜直肠癌腹会阴联合切除术（Miles术）患者（腹腔镜组）的围手术期情况,并按年龄、性别、肿块下缘距肛门距离、Dukes分期等匹配条件从同期开腹直肠癌手术（Miles术）中抽取30例（开腹组）作为参照,并对两组肿瘤手术情况、术后恢复情况、并发症发生率、随访结果等进行分析比较。结果腹腔镜组手术时间略多于开腹组,两组术中平均出血量、肠道功能恢复时间比较,差异有统计学意义（P〈0.005）。两组肠段切除长度、清扫淋巴结数目、术后并发症发生率、局部复发率比较,差异无统计学意义。腹腔镜组除1例中转开腹手术外,其余29例均在腹腔镜下完成手术,手术时间平均（185±30）min,术中出血量平均（80.0±30.5）ml,术后肠蠕动恢复时间平均为（30±10）h。1例术后并发肠梗阻,1例并发造瘘口肠管缺血坏死,无死亡病例。结论低位直肠癌更加适合在腹腔镜下进行手术切除,视野暴露充分,安全可靠,出血量少,肠道功能恢复快,具备操作安全、精细,术后恢复快的优点。