Giant perineal hernia: laparoscopic mesh repair complemented by a perineal cutaneous approach

Symptomatic perineal herniation after abdominoperineal resection is a rare complication and its management remains challenging. Perineal laparoscopic mesh repair is safe and effective and can be performed with minimal complications. We report a giant perineal hernia treated by a combined laparoscopic mesh repair approach and plastic resection of the cutaneous perineal wound. To the best of our knowledge, this is the first report with this technical approach that we could find in the English literature.     

Laparoscopic repair of a perineal hernia

Introduction

Perineal hernias are rare occurrences with statistics ranging from <1 to 3% incidence after open abdominoperineal resection (APR). The incidence of perineal hernia after laparoscopic APR is less certain due to the relatively recent advent of laparoscopic proctectomy. Here we discuss an occurrence of a perineal hernia after a laparoscopic APR and its subsequent laparoscopic repair with mesh.

Discussion

Repair of a perineal hernia can be technically challenging, with a variety of approaches each with its own risk of potential complications. Laparoscopic advancements have allowed a theoretically less invasive approach while having greater view of the necessary anatomical landmarks to achieve safe and tension-free repair of such hernias.

Conclusion

There are several case reports available to describe perineal repair but the numbers remain skewed due to the sparse reporting of complications post APR surgery. This may in fact be due to the asymptomatic aspect these hernias can have. Laparoscopic repair is a challenging yet viable approach to the correction of such occurrences.     

Laparoscopic repair of perineal hernia after abdominoperineal excision

Purpose

Perineal hernia is a challenging complication after abdominoperineal excision (APE) of the rectum. Surgical repair can be accomplished using challenging abdominal or transperineal approaches. A laparoscopic repair using a Proceed mesh might be an easy and effective alternative.

Methods

We describe a multi-center case-series of twelve patients with a symptomatic perineal hernia treated by laparoscopic mesh repair. A cone-shaped 10 × 15 cm Proceed Mesh was tacked to the promontory or sacrum and sutured to the pelvic sidewalls and the anterior peritoneum.

Results

Twelve patients underwent laparoscopic repair of their perineal hernia. Four men and eight women presented with a symptomatic perineal hernia after abdominoperineal excision between 2008 and 2013 and underwent a laparoscopic repair with a Proceed mesh. The median age at presentation was 53 years (range 39–68 years). The mean total theater time was 119 min (range 75–200 min). No conversion to an open procedure was needed. No early complications where seen. The mean hospital stay was 2.25 days (range 1–4 days). Three patients showed recurrence, of whom two had a defect in the middle of the proceed mesh, one had a defect anterior to the previous perineal hernia. All 3 patients underwent a redo-laparoscopic repair with mesh.

Conclusion

In this case series we present an alternative approach for the surgical repair of perineal hernias. Based on our experience, perineal hernia after APE can be repaired safely and effectively using the described laparoscopic 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.     

Recurrent perineal hernia repair: a novel approach

Purpose

Postoperative perineal hernias are rare complications from procedures, which compromise the pelvic floor, mainly abdominoperineal resection, proctocolectomy, and partial or total pelvic exenteration. Surgical repair can be accomplished through abdominal, laparoscopic, or transperineal approaches.

Methods

We present a case report of a 70-year-old man who underwent two prior operations for recurrent perineal hernia and was ultimately successfully treated with a third operation, a synthetic mesh redo procedure that utilized a synthetic mesh system marketed for women with pelvic organ prolapse.

Results

Although there is no "gold standard" for perineal hernia repair, our patient had multiple surgeries employing a variety of approaches. Final success was achieved using a mesh system with improved fixation to secure pelvic ligaments, using an exclusive perineal approach. Now, more than five years following the final surgery, the patient remains symptom free with no clinical evidence of perineal hernia recurrence.

Conclusions

To date, this is the only report of using this mesh system in a male. The advantages of using this mesh system are (1) exclusive perineal approach without the accompanying risks of abdominal or laparoscopic approach; (2) improved fixation of mesh to secure pelvic ligaments; and (3) lightweight, flexible, and large mesh shape that can easily be trimmed to allow versatility in procedures.     

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.     

How we do it: repair of large perineal hernia after abdominoperineal resection

Background

Symptomatic perineal hernia is a rare complication after abdominoperineal resection (APR). Management of these hernias is challenging. The recurrence rate after surgical repair is high because of the difficulty of prosthetic material fixation; there is no consensus regarding the best method of repair.

Methods

We introduced a novel combined laparoscopic-perineal dual fixation technique in the repair of perineal hernias after APR. This technique begins with a perineal approach under laparoscopic vision. After excision of the hernia sac, the mesh is introduced and fixed anteriorly to the urogenital diaphragm and laterally to the sacrotuberous ligament and the surrounding scar tissue. The perineal incision is then closed. Next, the mesh is fixed to the sacrum with ProTack^® and is fixed again to the sacrotuberous ligament via a laparoscopic approach.

Results

The dual fixation repair method is successful and without difficulties, with no recurrence at 13-month follow-up.

Conclusion

Our laparoscopic-perineal dual fixation method is a good alternative method for large perineal hernia repair after APR.

     

Polyester (Parietex) mesh for total extraperitoneal laparoscopic inguinal hernia repair

Polypropylene mesh is the most commonly used mesh for open and laparoscopic hernia repair in the United States. A variety of newly developed polyester mesh products have recently become available. This is the first U.S. multiinstitutional study evaluating the initial experience of polyester mesh use for total extraperitoneal (TEP) laparoscopic inguinal hernia repair. Between January 2000 and June 2001, 337 patients underwent 495 TEP laparoscopic inguinal hernia repairs using polyester mesh. There were 309 men and 28 women in the study, whose average age was 45 years (range, 17–80 years). The average operative time for all cases was 54.3 min (range, 18–157 min). There were no conversions to open repair and no mortality. Complications included 12 seromas/hematomas (six aspirated), chronic pain in three patients, urinary retention in two patients, and one incidence each of the following: epididimitis, prostatitis, hydrocele, and port-site cellulitis. Additionally, one patient had carbon dioxide (CO2) in the Foley bag at the end of the surgery, but a normal cystogram showed no identified bladder injury. There has been one recurrence (0.2%), occurring 4 months after surgery, which was repaired using a transabdominal laparoscopic approach. The mean follow-up period was 11 months (range, 2–22 months). There have been no documented infections of the mesh, and no mesh has been removed. This study documents a favorable initial experience with polyester mesh for TEP laparoscopic inguinal hernia repair. There were no complications related to the mesh. There may be technical and long-term advantages with the use of polyester mesh for laparoscopic inguinal hernia repair. Longer follow-up evaluation and additional studies are warranted to evaluate these potential advantages.     

Perineale Hernie

Background

Abdominoperineal excision of the rectum is a standard procedure in deep-lying rectal cancer if the sphincter muscle cannot be preserved. Besides common complications such as impotence, disorders of urinary tract function, and prolonged wound healing, perineal hernia is a rare long-term phenomenon. Surgical repair can be done either through a transabdominal approach or transperineally. Long-term results show that both methods are feasible in this situation. We report the third case of perineal hernia in German literature.

Case report

A 66-year-old man presented with a painful perineal tumor 2 years after abdominoperineal excision for rectal adenocarcinoma. Perineal hernia was confirmed by magnetic resonance imaging, and the patient underwent open mesh repair through a perineal approach.

Discussion

A number of surgical techniques have been described for the repair of perineal hernias. These include abdominal, perineal, and combined or laparoscopic approaches with or without mesh repair. The transabdominal route seems to have some advantages over the perineal approach. In cases of small hernias, the latter can however be the option of choice. In the presented case of an uncomplicated hernia, we decided on the perineal approach including mesh implantation to keep the trauma as small as possible.     

Feasibility and outcome after laparoscopic ventral hernia repair using Proceed mesh

Background  There are many different meshes available for laparoscopic repair of ventral hernias. A relatively new product is the Proceed mesh with a bioresorbable layer against the bowels and a polypropylene layer against the abdominal wall. There are, however, no human data available. The aim of this study was to evaluate the feasibility and outcome after laparoscopic ventral hernia repair using the Proceed mesh in humans. Methods  Patients presenting for laparoscopic ventral hernia repair in our department from September 2004 to October 2006 were included in the study. All patients had a standard laparoscopic ventral hernia repair using the Proceed mesh secured with tackers with a double crown technique. Patients were discharged according to standard discharge criteria, and follow-up was performed with a search in the national patient database and with manual search in the patients’ files. Results  Our study included 49 patients with a median age of 64 years (range 30–89) and body mass index of 27.8 (19.4–50.5). The dimensions of the mesh varied from 4 × 4 cm to 30 × 40 cm (median 15 × 15 cm). One patient developed an uncomplicated wound infection and none of the 49 patients developed mesh infections or postoperative seroma requiring surgical intervention. Thus, there were no mesh-related complications. During the follow-up period of 17 months (3–27), we have not seen any postoperative recurrences. The median length of stay was 1 day (range 0–63), and there was no mortality. Conclusion  Laparoscopic ventral hernia repair in humans using the Proceed mesh is feasible and has a low complication rate even in obese patients or those with pulmonary disease.     

Techniques of perineal hernia repair: A systematic review and meta-analysis

BackgroundPerineal hernias are rare, underreported and poorly studied complications of extensive pelvic surgeries. Their management is challenging, with currently no treatment algorithm available.MethodMEDLINE, EMBASE, Cochrane Library, and Web of Science databases were searched. Studies comprising at least 3 patients who underwent surgical perineal hernia repair were included. The primary outcome was perineal hernia recurrence. The secondary outcomes were overall complications and surgical site occurrences.ResultsTwenty-nine studies were included, comprising 325 patients undergoing 347 repairs. Overall complications were 33% (95% confidence interval 24%–43%) in the entire cohort, 31% (19%–44%) after perineal repair, 39% (14%–67%) after abdominal repair, and 36% (19%–53%) after mesh repair (20% with biological, 46% with synthetic mesh). The surgical site occurrence rate was 18% (8%–29%). The overall recurrence rate was 22% (15%–29%). Recurrence after perineal repair was 19% (10%–29%): 20% with mesh (25% with biological, 19% with synthetic), 24% with primary repair, and 39% with flap repair. Recurrence after an abdominal repair was 18% (11%–26%): 16% with laparoscopic, 12% with open, 16% with mesh (24% with biological, 16% with synthetic), 30% with primary, and 25% with flap repair. No significant differences could be found in the meta-analysis regarding overall complications and recurrence.ConclusionSynthetic mesh repair seems to be associated with a lower recurrence rate than other techniques, especially after an abdominal approach. The perineal and abdominal approaches appear to be safe, with similar recurrence rates. The combined approach seems promising, but more evidence is needed.     

Perineal hernia as a rare complication after laparoscopic abdominoperineal resection: Report of a case

We report what seems to be the second documented case of perineal hernia after laparoscopic abdominoperineal resection (APR) and describe its successful repair with transperineal intraperitoneal mesh. An 89-year-old woman complained of a large, painful perineal swelling 4 months after APR for rectal cancer. Computed tomography (CT) showed small intestine protruding through the pelvic floor into the perineal area. However, opening of the hernia sac revealed no intra-abdominal adhesions. An oval, 8 × 12 cm Bard Composix Kugel Patch (Davol, Cranston, RI, USA) was inserted into the intraperitoneal space and secured over the defect in the pelvic floor; then firmly attached to the pelvic wall with 16 interrupted nonabsorbable sutures. There has been no sign of hernia recurrence in 10 months of follow-up. We speculate that because laparoscopic surgery is minimally invasive, fewer postoperative adhesions in the abdominal cavity can result in the small bowel sliding more readily into the perineal area. Based on our experience, perineal hernia after laparoscopic APR can be repaired easily and effectively with a Composix Kugel Patch.     

Laparoscopic ventral hernia repair with the Goretex Dualmesh: long-term results and review of the literature

Since 1993 laparoscopy has become a popular technique of repair of ventral hernias. The authors review the long-term results of a systematic laparoscopic repair of ventral hernias and discuss the current problems compared to open repair. Between 1997 and 2003, 146 patients had a laparoscopic ventral hernia repair using an intraperitoneal Goretex Dualmesh with a 3–5-cm mesh overlap secured with a combination of nonabsorbable sutures and staples. A total of 155 attempts of laparoscopic repair was performed with four conversions. The 151 laparoscopic operations were completed in 105.8 min with a mesh implant being of 341 cm². There were two postoperative deaths and two patients had to be reoperated on. Mesh infection was diagnosed in two cases. Mean length of stay was 4.9 days. During a follow- up of 26.6 months eight patients (5.8%) developed a recurrence. Laparoscopic ventral hernia repair is a reproducible technique. Most of the comparative studies have shown an overall lower rate of complications after laparoscopic repair compared to open but with a 2–4% risk of bowel injury. The two other benefits of the laparoscopy are reduced postoperative pain and shorter hospital stay. The recurrence rate is usually between 2 and 7% but no difference has been found compared to open repair. Laparoscopic ventral hernia repair using the Goretex Dualmesh is a reliable operation with a low rate of conversion to open. Despite the risk of serious bowel injury, laparoscopy achieves as good results as the mesh open repair on the long term with the benefit of a decreased complication rate and a shorter hospital stay.     

Laparoscopic vs open inguinal hernia repair

Background: The role of laparoscopic inguinal hernia repair is controversial. The aim of this study was to find out whether it is justified to switch from the predominantly modified Bassini repair which the authors had been using to laparoscopic repair. Methods: Randomized controlled trial in 120 eligible patients admitted for elective hernia repair in a university hospital. Results: Sixty patients underwent laparoscopic transabdominal preperitoneal mesh repair; the other 60 patients had an open repair, mostly with the modified Bassini technique. Operative time for laparoscopic repair was significantly longer, mean (s.d.) 95 (28) min vs 67 (27) min (p < 0.001). The mean analogue pain score during the first 24 h after surgery was 36.2 (20.2) in the laparoscopic group and 49.3 (24.9) in the open group (p= 0.006). The requirement for narcotic injections and postoperative disability in walking 10 m and getting out of bed were also significantly less following laparoscopic repair. The postoperative hospital stay was not significantly different, mean 2.6 (1.2) days for laparoscopic repair and 3.0 (1.5) days for open repair (p= 0.1). Patients were able to perform light activities without pain or discomfort sooner after laparoscopic repair, median interquartile range 8 (5–14) days vs 14 (8–19) days (p= 0.013). Patients also resumed heavy activities sooner, but not significantly, after laparoscopic repair, median 28 (17–60) days vs 35 (20–56) days (p= 0.25). The return to work was not significantly different, median 14 (8–25) days after laparoscopic repair and 15 (11–21) days after open repair (p= 0.14). After a mean follow-up of 32 months one patient developed a recurrent hernia 3 months after a laparoscopic repair. Laparoscopic repair was more costly than open repair by approximately $400. Conclusions. Laparoscopic inguinal hernia repair was associated with less early postoperative pain and disability and earlier return to full activities than open repair, but there were no benefits regarding postoperative hospital stay and return to work; laparoscopic repair was also more costly. Received: 23 May 1997/Accepted: 1 August 1997     

Laparoscopic incisional hernia repair: a review of the literature

Incisional hernia is a common long-term complication of abdominal surgery. Historically the open repair with or without mesh was the mainstay of treatment. However, many recently published laparoscopic repair studies have challenged surgeons to re-evaluate which technique provides the best short and long-term outcomes. A Medline search of all English-language literature was performed using the keywords ‘incisional’, ‘ventral’, ‘hernia’, ‘laparoscopic’, and ‘open’. Further references were obtained by cross-referencing the bibliography in each paper. Current evidence suggests that the laparoscopic incisional hernia repair is the optimal surgical treatment. A laparoscopic repair appears to shorten hospital stay, decrease perioperative complication rates, and decrease recurrence rates. However, there is no randomized trial utilizing a standardized complication grading system making it difficult to draw a definitive conclusion as to which repair is best.     

Laparoscopic Transabdominal Preperitoneal Repair of Ventral Hernia: A Step Towards Physiological Repair

The laparoscopic ventral hernia repair with preperitoneal placement of mesh minimizes the complications related to the intraperitoneal position of mesh and fixating devices. It allows safe use of conventional and less expensive polypropylene mesh. The prospectively collected data of 68 patients who underwent laparoscopic transabdominal preperitoneal mesh hernioplasty, for different types of ventral hernias between January 2005 and December 2009 was retrospectively reviewed. The study included 68 patients, 16 males and 52 females with a mean age 51.1 ± 11.1 years (range 23–74 years). Most of the hernias (67.6%) were in the midline position. The mean size of the defect was 30.8 ± 24.4 cm2 (range, 4–144 cm2) and the mean mesh size was 237.8 ± 66.8 cm2 (range, 144–484 cm2). The mean operating time was 96.7 ± 16.7 min (range 70–150 min). All repairs were done with polypropylene mesh. The mean postoperative hospital stay was 1.5 ± 0.6 days (range, 1–4 days). Nineteen patients (27.9%) suffered from postoperative complications. Four patients (5.8%) were detected to have seroma formation. There were two recurrences (2.9%). The mean follow up was 22.7 ± 13.4 months (range, 6–48 months). The laparoscopic preperitoneal ventral hernia repair with polypropylene mesh is cheaper and has acceptable postoperative outcomes. Peritoneal coverage of the mesh not only acts as a barrier between mesh and bowel and thereby prevents adhesions, it also provides an additional security of fixation. This is a safe and feasible option of ventral hernia repair in expert hands. However, for proper validation of these conclusions a long term prospective clinical trial is required.     

Éventrations périnéales après exérèse rectale ou pelvienne. Prise en charge actuelle et prévention

Perineal hernias are a rare complication of major pelvic excisions. Their incidence (approximately 1% after abdominoperineal excision and 3% after pelvic exenteration) is probably underestimated, asymptomatic cases being unreported. Many repair procedures are presently used to solve this difficult problem. Abdominal (including laparoscopic) approach, perineal approach or both have been reported, with or without the implantation of prosthetic mesh or muscular flaps. Indications are based on the assessment of symptomatic burden, and the local and general conditions. Recurrence following repair is not rare, illustrating the difficulty to solve efficiently this condition. Prevention of perineal hernias is mandatory especially in patients at risk of impaired healing following extensive perineal excision. A primary closure of the perineal wound is recommended with addition of muscular flaps as soon as local or general risk of defective healing process is suspected.     

Critical evaluation of a novel DualMesh repair for large hiatal hernias

Background  The use of mesh for laparoscopic repair of large hiatal hernias may reduce recurrence rates in comparison to primary suture repair. However, there is a potential risk of mesh-related oesophageal complications due to prosthesis erosion. The aim of this study was to critically evaluate a novel mesh (DualMesh) repair of hiatal hernias with particular reference to intraluminal erosion. Method  Medical records of 19 patients who underwent laparoscopic hiatal hernia repair with DualMesh reinforcement of the crural closure were reviewed from a prospectively collected database. Quality of life and symptom analysis was performed using quality of life in reflux and dyspepsia (QOLRAD) questionnaires pre- and postoperatively after 6 weeks, 6 months, 1 year and 2 years. Barium studies were performed on patients pre-operatively and two years postoperatively to assess hernia recurrence. After 2 years, oesophagogastric endoscopy was performed to assess signs of erosion. Results  Mean patient age was 70.5 years (range 49–85 years). Two years after hiatal hernia repair, there was significant improvement in quality-of-life scores (QOLRAD: p < 0.001). Follow-up barium studies performed at 31.3 months (range 29–40 months) after surgery showed moderate recurrent hernias (>4 cm) in 1/14 patients (7%). Endoscopies performed at 34.4 months (range 28–41 months) after surgery did not show any signs of prosthetic erosion. Conclusion  Laparoscopic reinforcement of primary hiatal closure with DualMesh leads to a durable repair in patients with large hiatal hernias. Long-term endoscopic follow-up did not show any signs of mesh erosion after prosthetic reinforcement of the crural repair.     

Comparison of laparoscopic and open repair of incisional and primary ventral hernia: results of a prospective randomized study

Background Incisional hernia is an important complication of abdominal surgery. Its repair has progressed from a primary suture repair to various mesh repairs and laparoscopic repair. Laparoscopic mesh repair is a promising alternative, and in the absence of consensus, needs prospective randomized controlled trials. Methods Between April 2003 and April 2005, 66 patients with incisional, primary ventral and recurrent hernias were randomized to receive either open retrorectus mesh repair or laparoscopic mesh repair. These patients were followed up at 1-, 3-, and 6-month intervals thereafter for a mean of 12.17 months (open repair group) and 13.73 months (laparoscopic repair group). Results Lower abdominal hernias after gynecologic operations constituted the majority of the hernias (∼50%) in both groups. There was no significant injury to viscera or vessel in either group and no conversions. The defect size was 42.12 cm² in the open (group 1) and 65.66 cm² in the laparoscopic group (group 2), and the prosthesis sizes were, respectively, 152.67 cm² and 203.83 cm². The hospital stay was 3.43 days in open group and 1.47 days in laparoscopic group (p = 0.007). There was no significant difference in the pain scores between the two groups. More wound-related infectious complications occurred in the open group (33%) than in the laparoscopic group (6%) (p = 0.013). There was one recurrence in the open repair group (3%) and two recurrences in laparoscopic group (6%) (p = 0.55). Conclusions Laparoscopic repair of incisional and ventral hernias is superior to open mesh repair in terms of significantly less blood loss, fewer complications, shorter hospital stay, and excellent cosmetic outcome.