Posterior perineal hernia repair with perineal approach: a video vignette.

BACKGROUND
Perineal hernia (PH) is a well-known complication after abdominopelvic resection, but no consensus exists about the best technique for perineal hernia repair (Reference 1-3). We present the case of a man with a posterior perineal hernia after low anterior resection with subtotal inter-sphincter resection and colo-anal anastomosis.


CASE PRESENTATION
The patient is a 72-year-old man known to have an adenocarcinoma of the rectum treated with neoadjuvant radiochemotherapy (50 Gy and Xeloda) and low anterior resection with subtotal inter-sphincteric resection, colo-anal anastomosis and protective ileostomy in December 2015. In 2016, the patient presented with 3 episodes of recurrent prolapse of the colo-anal anastomosis requiring resection of the prolapse and a new colo-anal anastomosis with anterior and posterior levatroplasty during the last intervention. The protective ileostomy was finally closed in December 2016. In December 2019, the patient complained about a new perineal swelling without pain. A surgical management for perineal hernia was proposed, but refused by the patient. In January 2022, because of the inconvenience caused by the perineal hernia, the patient accepted a surgical intervention. A pelvic MRI was performed in January 2022 with evidence of a large perineal hernia with mesocolic content, no cancer recurrence. The repair was made through a perineal approach with a bioasbrobable monofilament polyester mesh with little tissue attachment (Symbotex, Covidien Product, Medtronic Parkway, Minneapolis, USA). The operation lasted 104 min, with minor bleeding (<20ml). The patient was discharged on postoperative day 10. At 7-month follow-up, he has no recurrence of the perineal hernia.


CONCLUSION
Perineal hernia is vey a rare complication following restorative rectal cancer surgery. As a result, management is poorly described in the literature. As the patient presented with 3 prolapses of the colo-anal anastomosis requiring surgical repair with absolutely no adhesions before the perineal hernia repair, we choose a mesh repair to strengthen the pelvic floor and a direct perineal approach to perform levatorplasty.