Secondary acquired perineal hernia

Presacral hernia,
hernia diagnosis
and treatment options
A.ROSEN,
dep. Of surgery A
Is’hakov Arkady
MICHAEL MUGGIA
Surgery B’ department
Wolfson medical center
center.
A 63 years old patient was operated on
y 2011 for p
presacral Epidermoid
p
February
cyst measuring 1.4-6.8cm.
The patient had a TRANS
TRANS--SACRAL
EXCISION WITH COCCYGECTOMY (S4
(S4
and S5
S5).
Colonoscopy-was normal
ColonoscopyOn USUS-A CYSTIC LESION OF 1.4-6.2CM
:CT
CT
MRI
MRI
TRUS
HISTOLOGY:epidermoid cyst
10 cm
Ten months later she presented again, with
g in the scar region
g
which appeared
pp
a bulge
after surgery and increased slowly since.
She complained of pain while sitting,
obstructed defecation, flatus incontinence,
discomfort and skin irritation on the bulge
area.
Definition
Perineal hernia - protrusion into the
perineum of intraperitoneal or
extraperitoneal contents through a
congenital or acquired defect of the pelvic
diaphragm.
Historical background
1743 – De Garangeot – 1-st report of perineal hernia.
1916 – Moscowitz – 1-st perineal hernia repair.
1939 – Yeoman – 1-st report of postoperative perineal
hernia.
1990 – Lubal – 1-st diagnosis of posterior perineal hernia
byy CT scan.
Repair
R
i off a sacrall h
hernia
i after
ft sacrectomy
t
was
first described in 1988 by Chemyi et al. using a
primary suture technique
technique.
Santora et al. and Kaplan et al. introduced in
1998 a nonabstirbable polypropylene for the
repair of sacral hernia during resection of a
recurrent sacral tumor
tumor.
Furthermore, they suggested considering
prophylactic use of a mesh prosthesis when a
major sacrectomy is to be resected .
Classification and Incidence
Congenital perineal hernia – only 9 cases.
Primary acquired perineal hernias – 100 cases.
Secondary acquired (postoperative) perineal hernias
abdominoperineal resection
pelvic exenteration
coccygectomy or sacrectomy
Etiology
Congenital perineal hernia – failure of caudal regression
of peritoneal cul de sac
– defect in the fusion of two
layers of Denonvilliers
Denonvilliers'fascia
fascia.
Primary acquired perineal hernia – 4-th to 6-th decades
–♀>♂
– broader female pelvis
– attenuation of pelvic floor during pregnancy and
childbirth.
Secondary acquired perineal hernia – incisional hernia
after radical pelvic operations.
Contributory factors:
Congenital PH – general disturbance of connective tissue.
Primary acquired PH – ascites,
ascites
obesity,
chronic infections of pelvic floor,
high expression of relaxin receptors in
muscles of pelvic diaphragm,
urokinase deficiency.
f
Secondary acquired PH – surgical techniques of closure of perineal
wound,
insertion site of drains,
chemoradiation,
smoking,
wound
d iinfection.
f ti
Surgical anatomy
Anterior perineal hernia (♀
( ♀)
to superficial transverse perineal muscles
Posterior perineal hernia (♀
( ♀ ♂)
Symptoms:
discomfort and pain during sitting,
skin erosion over the herniated sac,
i t ti l obstruction,
intestinal
b t ti
difficulty in urination (herniation of urinary bladder).
Aim of surgical
g
repair
p
reduction of hernia contents,
isolation of fascial defect,
reconstruction of pelvic floor:
nylon sutures,
stainless steel,
steel
synthetic mesh,
autogenous
g
tissues (fascia
(
lata grafts
g
or muscle flaps).
p)
Repair
Indications
Congenital perineal hernia
Symptomatic acquired perineal hernia
Approach of repairs:
transabdominal
perineal
combined.
Transabdominal repair
(open or laparoscopic)
recurrent hernias
small bowel herniation
excluding tumor recurrence
secure suturing of mesh to bony
pelvis
pel is
Perineal repair
p
Advantage
- less morbidity
Disadvantage
- limited
li it d exposure
- difficult exclude tumor recurrence
- difficult mobilization of SB or repair
of injured viscera or vessels
- difficult fixation of mesh
Combined abdominoperineal approach
Advantage:
- best exposure
- safe mobilization and reduction
- reconstruction of pelvic floor above and below
Disadvantage:
- higher morbidity
Out of a total of 800 proctograms, 37
patients were found to have p
p
perineal
herniation. There was a male to female
g of the p
patients ranged
g
ratio of 1 to 3.1. Age
from 15 to 85 with a mean age of 49.9
y
years.
Eight of these patients complained of faecal
incontinence while the other 29
patients gave a history of chronic outlet
constipation.
Perineal Herniation
F. W. POON, J. C. LAUDER* and I. G. FINLAY'~1993
Beck
B
k ett al.
l reviewed
i
d eight
i ht patients
ti t who
h h
had
d perineal
i
l
hernia postabdominoperineal resection and pelvic
exenteration The repair involved a perineal and abdominal
exenteration.
approach. They concluded that using Marlex
(Davol Inc
(Davol.
Inc., Cranston
Cranston, RI) mesh through an abdominal
approach is the best way to repair a perineal hernia.
This allows attachment of the mesh to the lateral
musculature and posterior sacral periosteum under
direct vision.
Beck DE, Fazio VW, Jagelman DG, et al. Postoperative perineal
hemia. Dis Colon Rectum 1987:30:21-4.
A 42 years old lady, post traumatic
g
y, followed by
y hernia repaired
p
coxigectomy,
with gortex, continuous discharge due to
fistula formation
formation, disruption of meshmesh- repair
with gluteal flap.
Repair of a Long-Standing Coccygeal Hernia and Open Wound
Zook, Nicole L. M.D.; Zook, Elvin G. M.D.
Illinois University(1997)
Francisco Garcia reported a female patient who
required a second operation for posterior hernia
of the rectum after total coccygectomy.
On surgery,a circular area about 7 cm in diameter
was dissected.
dissected It had fibrous edges that could
not be brought together without tension.
An expanded olytetrafluoroethylene (ePTFE
(ePTFE, Gore
Tex1) mesh was inserted and secured with a
continuous double suture of the same material
to the edges of the defect.
Posterior Hernia of the Rectum after Coccygectomy
Francisco J. Garcı´a, Juan D. Franco, Rafael Ma´rquez, Jose´ A. Martı´nez and Jaime Medina spain 1998
Miles et al
al. reviewed 27 patients with sacral defects after
sacrectomy reconstructed with a variety of flaps,
including vertical rectus abdominis myocutaneous,
unilateral
il t l or bil
bilateral
t l gluteal
l t l advancement,
d
t and
d ffree
flaps.
Theyy concluded that in patients
p
with no p
preoperative
p
radiation therapy and intact gluteal vessels, the use of
bilateral gluteal advancement flaps should be
co s de ed
considered.
Miles WK. Chang DW, Koll SS, et al. Reconstruction of
large sacral defects following lotal sacrectomy. Plast Reconstr
Surg 2000:105:2387-94
.
Ong and
O
d Miller
Mill presented
t d a 72-year-old
72
ld gentleman
tl
presented with a large symptomatic perineal
hernia 12 months after his abdominoperineal
resection for a Dukes’ A, low rectal
adenocarcinoma.
The hernia was repaired via a perineal approach.
The pelvic floor defect was covered with an
acellular porcine dermal graft (PermacolTM)
(PermacolTM),
which was secured to the ischium using
orthopaedic Mitek suture anchor
A transperineal approach to perineal hernia repair using suture
anchors and acellular p
porcine dermal mesh
S. L. Ong • A. S. Miller(2005) Belgium
Use of bone anchors in perineal hernia repair:
a practical note
Frederik Berrevoet
Piet Pattyn
Diaz ett al.
Di
l reported
t d the
th use off gluteus
l t
maximus
i
and omental flap after mesh placement. Their
report included nine patients who underwent
gluteus maximus flap reconstruction and six who
had an omental flap
flap.
The authors’ experience suggests that this
combination of techniques is a reliable approach
for reconstruction of these extensive surgical
defects.
Diaz J. McDonald WS, Armstrong M. et al. Reconstruction
following extirpation of sacral malignancies, Ann Plast Surg 51:
126-^9.
Suggestions for repair:??????
repair:??????
1. Which approach
2.Use of mesh?
mesh?-- what kind
3.Method and place 0f anchorage