EP342 - Robotic Approach to Perineal Hernia Repair: a Case Report

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Purpose/Background: Perineal hernias are rare complications following abdominoperineal resection for treatment of rectal cancer. Repair can be performed via a perineal approach, transabdominal approach, or combination of the two. The following is a case report of a patient who underwent robotic assisted laparoscopic perineal hernia repair for a symptomatic hernia.

Methods/Interventions: The patient is a 67-year-old female with history diabetes, prior hysterectomy, and T1N1bM0 rectal adenocarcinoma status post robotic abdominoperineal resection with subsequent chemoradiation. She presented to the office seven months after her index operation with complaints of a bulge of her perineum that had been progressively enlarging. She was self-conscious about her appearance due to this protrusion visible when wearing pants. She had no evidence of obstructive symptoms and had continued colostomy output. An MRI pelvis was completed without evidence of hernia, although limited as patient was lying flat. On examination, there was evidence of a reducible perineal hernia thus decision was made to proceed with operative intervention.

Results/Outcomes: Patient was taken to the operating room where she initially underwent cystoscopy with ureteral stent placement by Urology. After abdominal entry, a ten-centimeter perineal defect was identified, reapproximated with polydioxanone suture, and a piece of coated composite mesh was placed in an intraperitoneal onlay fashion. The mesh was secured with absorbable suture and a drain was placed in the pelvis. Patient had an uneventful postoperative course and was discharged home on postoperative day three.

Conclusion/Discussion: Perineal hernias are defined as protrusion of intra or extraperitoneal contents through a congenital or acquired defect of the pelvic diaphragm. They can occur primarily, such as with factors associated with increased intra-abdominal pressure. Often, perineal hernias occur secondarily, often following pelvic operations with a wide variety in incidence from 1-26%. Risk factors that can lead to it are preoperative chemoradiation, smoking, or a more extensive resection. Diagnosis is made using computed tomography, MRI, or ultrasound. Surgical indication including symptomatology including pain, bowel obstruction, skin erosion leading to evisceration, and difficulty voiding. The defect itself is closed primarily or by using mesh, with data reporting up to 22% recurrence overall across all repair types. In this case, imaging modalities were unrevealing for the hernia, and it was found ultimately on physical examination. The patient underwent uneventful robotic repair with mesh placement and has done well postoperatively. Her course will be followed for evaluation of recurrence.