Further insights into the treatment of perineal hernia based on a the experience of a single tertiary centre

Abstract

Aim There is little evidence concerning the optimal surgical technique for the repair of perineal hernia. This study aimed to report on the evolution of a technique for repair of perineal hernia by analysing the experience in a tertiary referral centre. Method This was a retrospective review of consecutive patients who underwent perineal hernia repair after abdominoperineal excision in a tertiary referral centre. The main study end‐points were rate of recurrent perineal hernia, perineal wound complications and related re‐intervention. Results Thirty‐four patients were included: in 18 patients a biological mesh was used followed by 16 patients who underwent synthetic mesh repair. Postoperative perineal wound infection occurred in two patients (11%) after biological mesh repair compared with four (25%) after synthetic mesh repair (P = 0.387). None of the meshes were explanted. Recurrent perineal hernia following biological mesh was found in 7 of 18 patients (39%) after a median of 33 months. The recurrence rate with a synthetic mesh was 5 of 16 patients (31%) after a median of 17 months (P = 0.642). Re‐repair was performed in four (22%) and two patients (13%), respectively (P = 0.660). Eight patients required a transposition flap reconstruction to close the perineum over the mesh, and no recurrent hernias were observed in this subgroup (P = 0.030). No mesh‐related small bowel complications occurred. Conclusion Recurrence rates after perineal hernia repair following abdominoperineal excision were high, and did not seem to be related to the type of mesh. If a transposition flap was added to the mesh repair no recurrences were observed, but this finding needs confirmation in larger studies.

Getting to the ‘bottom’ of perineal hernias

“…The study also builds on an earlier study published in 2016 which reported the institution’s experience with biological meshes in perineal hernias [6]. The high recurrence rates with biological meshes led to a practice change, replacing biological meshes with its synthetic counterpart [5]. With the benefit of hindsight, the high recurrence rate is probably to be expected.…”

“…In this issue of the journal, Blok et al . [5] report a single centre experience with perineal hernia over a 10‐year period. Although the study only comprises 34 patients, it is one of the larger studies on perineal hernias.…”

Review of Postoperative Perineal Hernia and Available Reconstruction Techniques

“…However, the choice of treatment depends on the symptoms and how they affect the day to day life of the patient. Patients who are fit for surgery, have no recurrency, and are bothered or have severe symptoms (perineal swelling, perineal skin necrosis, urinary problems and/or intestinal obstruction) are offered surgical treatment [4,14,17,19].…”

“…The aim of surgical repair is to exclude recurrency, closure of the pelvic defect with reconstruction of a new pelvic floor and reduction of hernial sac content and/or excision of hernial sac [4,16,17,19,23]. Imaging with MRI and endoscopy may help exclude recurrency [17].…”

“…The cause of postoperative PerH is not known, however, wide extent of dissection, wound infection, Neoadjuvant radiotherapy, length of small bowel and wider female pelvis, have been identified as risk factors for development of postoperative PerH [14,16,17,19]. Technically, PerH is an incisional hernia because it occurs following surgery and but PerH does not frequently develop in patients with strong risk factors for incisional hernia such as obesity, diabetes mellitus, collagen disorders and wound infection [16].…”