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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 2  |  Page : 58-60

Deadly if missed: Acase of recurrent perineal hernia mimicking as perineal cellulitis following abdominoperineal resection


1 Department of Colorectal Surgery, Box Hill Hospital, Melbourne, Australia
2 Department of Medicine, University of Melbourne, Melbourne, Australia
3 Department of Colorectal Surgery, Box Hill Hospital; Department of General Surgery, Royal Melbourne Hospital, Melbourne; Department of Surgery, Eastern Clinical School, Monash University, Clayton, Australia

Date of Web Publication27-Jun-2019

Correspondence Address:
Dr. Himeesh Kumar
Department of Colorectal Surgery, Box Hill Hospital, 8 Arnold Street, Box Hill, Victoria
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/WJCS.WJCS_7_19

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  Abstract 


Perineal hernia is a rare condition most commonly described following abdominoperineal resection(APR). We report the case of a 71-year-old woman who presented with a third episode of strangulated perineal hernia mimicking perineal cellulitis following APR surgery. She underwent an emergency laparotomy, small bowel resection, and biological mesh repair. We further discuss the pros and cons of different surgical options available to surgeons when faced with this problem.

Keywords: Abdominoperineal resection, biological mesh, perineal hernia, small bowel ischemia


How to cite this article:
Kumar H, Ng SC, Chua JY, Chandra R. Deadly if missed: Acase of recurrent perineal hernia mimicking as perineal cellulitis following abdominoperineal resection. World J Colorectal Surg 2019;8:58-60

How to cite this URL:
Kumar H, Ng SC, Chua JY, Chandra R. Deadly if missed: Acase of recurrent perineal hernia mimicking as perineal cellulitis following abdominoperineal resection. World J Colorectal Surg [serial online] 2019 [cited 2019 Aug 18];8:58-60. Available from: http://www.wjcs.us.com/text.asp?2019/8/2/58/261549




  Introduction Top


Perineal hernias are rare, with less than a hundred being described in the literature. It involves herniation of intra-abdominal or pelvic organs through the pelvic floor. It may be congenital; however, majority of patients develop these hernias following abdominoperineal resection(APR). There seems to be a higher risk in women due to wider pelvises. Other predisposing factors include smoking, excision of the levators, treatment with neoadjuvant chemoradiation, and postoperative wound infection.[1],[2],[3] The incidence of postoperative perineal herniation varies greatly between studies, ranging from 0.6% to 7%.[3]

The rarity of this condition renders decision-making on the establishment of guidelines for the management of perineal hernias very challenging. This case study describes an atypical presentation of recurrent perineal hernia and discusses the different surgical options available.


  Case Report Top


A71-year-old woman presented with a 2-day history of severe abdominal pain and vomiting, preceded by a “popping” sensation in her perineum. On examination, her abdomen was soft but mildly tender centrally. There was a tender swollen area of red purple discoloration in her perineum suggestive of perineal cellulitis or deep tissue infection. It was not associated with any cough impulse [Figure1].{Figure1}

This is on a background of hypertension and previously treated recurrent perineal hernia that was sustained from an APR performed 12years ago for rectal cancer. She had two attempts of mesh repairs, the last of which was 5years prior to her current presentation.

This atypical presentation of perineal infection had prompted further investigations with computed tomography(CT), which demonstrated small bowel obstruction secondary to strangulation through a defect within her pelvic floor[Figure2].{Figure2}

A small defect in her pelvic floor was identified during an emergency laparotomy, through which 25-cm loop of small bowel had herniated and became infarcted [Figure3]. Small bowel resection was performed with primary anastomosis. The defect was suture repaired with a porcine Biodesign® mesh (Cook Medical, Bloomington Indiana, USA) using 2-0 reinforced with a pedicled omental flap. Recovery was uncomplicated, and she was discharged a week later with outpatient follow-up.{Figure3}


  Discussion Top


Perineal hernias may present with a wide range of symptoms. Some common symptoms include perineal pain, discomfort when standing or sitting, urinary symptoms(e.g., dysuria and stress incontinence), bowel obstruction, and breakdown of perineal skin.[3] Classic signs may include perineal bulge with cough impulse, wound dehiscence, or evisceration. However, more often than not, patients tend to present with nonspecific signs and symptoms, making diagnosis difficult. For this reason, it is always important to be mindful of the diagnosis and consider it when patients have underlying predisposing factors.

Perineal cellulitis has not been described in the literature as a presentation for strangulated perineal hernia. It is a condition most commonly present in the initial postoperative phase. It is unusual to see spontaneous perineal cellulitis in the absence of recent surgery or immunosuppression. The absence of predisposing factors for perineal cellulitis should alert clinicians to the potential of a more sinister underlying pathology such as in this case where it was masking an advance stage of ischemic bowel. Careful history taking and examination are critical to reach the correct diagnosis. In cases of recurrence, a negative cough impulse should not dismiss perineal hernia as a diagnosis, as it may be masked by previous repair. Timely diagnosis of a strangulated perineal hernia is crucial as delays can lead to bowel ischemia, peritonitis, and death.

Surgical repair of perineal hernias is only indicated in the presence of complications, significant symptoms, or failure of conservative management. Consensus for repair of perineal hernia has not been reached to date. Surgical approaches include transabdominal, perineal, and combined transabdomino-perineal approach with single-or dual-layer mesh reinforcement,[1],[2],[3],[4],[5],[6] which should be selected based on the clinical setting. The key steps of repair involve hernial sac reduction and careful identification of the muscular and fascial anatomy of the pelvic floor for reconstitution.[4]

Although the perineal approach is the simplest and is particularly attractive as the abdomen is not entered, this simplicity comes at a price of exposure, with it being more difficult for bowel mobilization.[7] The transabdominal approach is favored in this emergency setting, given the findings on the preoperative CT, as it allows easier bowel adhesiolysis and resection. The use of bioprosthetic mesh was predicated based on the fact that there was minimal contamination in the pelvis and that a tension-free closure of the perineal defect could not be otherwise achieved. Its advantage in this setting includes its relatively bacteria-resistant property and its ability to allow tissue remodeling.[3]

The combined transabdominal and perineal approach nonetheless has been shown to provide the best exposure for the surgeon. This advantage, however, comes at the price of increased morbidity; thus it should only be used with caution in difficult or unique cases.[8] Although we have closed the abdominal wound primarily and repaired the hernia with a mesh in the case presented, it is still important to realize and consider the potential of concurrent necrotizing fasciitis, especially in more severe cases or immunocompromised patients. In this circumstance, the combined approach would be ideal as it would allow more aggressive debridement of the perineum and vacuum-assisted closure(VAC) dressing for temporary closure of the perineum with subsequent relook, debridement, and staged closure.


  Conclusion Top


Perineal hernias are rare and can present with relatively nonspecific signs and symptoms. The index of suspicion should remain high if predisposing factors are evident. Clinicians should not dismiss the diagnosis of perineal hernia in the absence of a cough impulse. Caution should be taken with the diagnosis of perineal cellulitis years after APR surgery as this occurrence often underlies a more sinister disease process such as that of ischemic bowel.

We recommend the transabdominal approach for emergency bowel resection and hernial repairs. Finally, the decision to use mesh should be made on a case-by-case basis at the discretion of the operating surgeon taking into account the patient's history, comorbidities, amount of contamination, and anatomy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
PatelRK, SayersAE, GunnJ. Management of a complex recurrent perineal hernia. JSurg Case Rep 2013;2013. pii: rjt056.  Back to cited text no. 1
    
2.
RayhanabadJ, SassaniP, AbbasMA. Laparoscopic repair of perineal hernia. JSLS 2009;13:237-41.  Back to cited text no. 2
    
3.
MartijnseIS, HolmanF, NieuwenhuijzenGA, RuttenHJ, NienhuijsSW. Perineal hernia repair after abdominoperineal rectal excision. Dis Colon Rectum 2012;55:90-5.  Back to cited text no. 3
    
4.
PreissA, HerbigB, Dörner A. Primary perineal hernia: Acase report and review of the literature. Hernia 2006;10:430-3.  Back to cited text no. 4
    
5.
AllenSK, SchwabK, DayA, Singh-RangerD, RockallTA. Laparoscopic repair of postoperative perineal hernia using a two-mesh technique. Colorectal Dis 2015;17:O70-3.  Back to cited text no. 5
    
6.
VeenhofAA, van der PeetDL, CuestaMA. Perineal hernia after laparoscopic abdominoperineal resection for rectal cancer: Report of two cases. Dis Colon Rectum 2007;50:1271-4.  Back to cited text no. 6
    
7.
SoJB, PalmerMT, ShellitoPC. Postoperative perineal hernia. Dis Colon Rectum 1997;40:954-7.  Back to cited text no. 7
    
8.
BeckDE, FazioVW, JagelmanDG, LaveryIC, McGonagleBA. Postoperative perineal hernia. Dis Colon Rectum 1987;30:21-4.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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