Introduction

Herein is reported a rare case of perineal hernia in a male patient, one year after Abdominal Perineal Resection (APR) for treatment of low rectal adenocarcinoma.

Case presentation

We present the case of a 65-year-old man with a history of hypertension, dyslipidemia and smoking, who underwent APR due to invasive adenocarcinoma of the distal rectum pT4b N2, following neoadjuvant chemoradiotherapy.

Four months after surgery, during a follow-up consultation, a perineal hernia was identified. A CT scan revealed no tumour recurrences; however, there seemed to be an eventration and a significant prolapse of digestive loops at the level of the posterior pelvic floor (Figure 1).

He underwent surgical correction according to Martijnse technique. Intraoperatively, a perineal hernia with approximately 5 cm in diameter was observed, with small bowel loops inside it (Figure 2). A polypropylene mesh was used and fixed to the coccyx and aponeurosis of the gluteal muscles (Figure 3). A drain was placed and removed on 3rd post-operative day. The immediate postoperative period was uneventful and the patient was discharged on the 4th postoperative day.

Surgery was decided in the casa because, although asymptomatic, the patient’s preference was to be submitted to surgery.

Discussion

Perineal hernia is a rare complication after major pelvic surgery, more common in women, and typically occurs within the first year after surgery. It is defined as the herniation of intra-abdominal contents (usually small bowel loops) through the perineum [1,2].

Figure 1: CT-scan (sagittal) revealing a perineal hernia at the level of the posterior pelvic floor.

Figure 2: Intra-operative image showing loops herniation through the perineum.

Figure 3: Intra-operative image after mesh placement.

There are several risk factors, including female sex, preoperative chemoradiotherapy and smoking [2].

Patients are generally asymptomatic but may report symptoms such as perineal swelling and pain during the Valsalva manoeuvre and changes in bowel habits. Symptoms worsen with standing and sitting positions [1].

Surgical indications include the presence of symptoms associated with the hernia, skin erosion/trophic lesions, bowel obstruction, urinary dysfunction and ultimately, patient´s desire [1].

References

1. Moraru D, Scripcariu D, Ferariu D, et al. Perineal eventration after abdominoperineal resection for rectal cancer: Anatomical, surgical and clinic-pathological landmarks. Romanian Journal od Morphology & Embryology. 2020; 61(4): 1111-1119. 10.47162/ RJME.61.4.13.
2. Soback H, Lahav L, Franko R, Avital S. A three layered repair of a large perineal hernia: case report and review of the literature. Surgical Case Reports. 2023; 9: 58. 10.1186/s40792-023-01363-5.