EP875 - Strangulated Perineal Hernia In The APR Patient:​ A Case Report ​

Purpose/Background: Perineal hernia is a rare hernia type, typically occurring between the levator ani and coccygeus muscles​. Perineal hernias can present as primary or secondary hernias. Secondary hernias may occur after abdominoperineal resection (APR) or other abdominal perineal procedures, occurring in 1-27% of patients​. A majority of these patients present for elective repair, typically utilizing a mesh repair. However, cases of incarcerated and strangulated perineal hernia are significantly more rare​. There is no consensus on the surgical approach in cases of incarceration and strangulation. Few case reports exist in this setting and all vary in their approaches​. We report on a case of small bowel strangulation in a patient with a secondary perineal hernia after APR requiring operative intervention and temporizing repair via an omental flap.

A 75 year old female with history of laparoscopic hand-assisted APR with end colostomy in 2022 for rectal cancer at an outside institution presented with severe perineal pain and skin changes, nausea and vomiting, and no ostomy output for five days​. The patient has a known perineal hernia and had been seen in the outpatient setting for consideration of elective repair​. The patient noted that her hernia normally reduced spontaneously when lying flat but noted that recently, it has not been reducing.​ Imaging showed an incarcerated loop of small bowel with upstream dilation and concern for strangulation​. Given these findings, the patient was leveled for immediate operative intervention via exploratory laparotomy.

Methods/Interventions: The abdomen entered via midline laparotomy incision. Adhesions were noted throughout the abdomen​. A 20cm loop of small bowel was noted to be descending into the pelvis which appeared grossly necrotic and foul smelling but without perforation​. Further adhesiolysis allowed for evisceration of the strangulated loop which was excised and a side-to-side anastomosis was created.​ An omental flap was created by dividing the greater omentum off of the transverse colon from hepatic flexure to mid transverse colon​. The omental flap was secured anteriorly to the uterus and broad ligament via 3-0 vicryl suture​. A 19Fr Blake Drain was left in place under the omental flap.​

Results/Outcomes: Post-operatively, the patient gradually had resolution of symptoms and was discharged one week later​. At five months post-op, the patient noted a new reducible bulge of her perineum. CT imaging confirmed perineal hernia recurrence. The patient is currently following with a pelvic floor hernia specialist for future repair of her perineal hernia​.

Conclusion/Discussion: In conclusion, Perineal hernia is a known but uncommon complication following APR​. Emergent presentations of perineal hernias are even more infrequent and are only described sporadically in the literature. Some case reports mention the use of biologic mesh in repairing incarcerated perineal hernias and one other study noted the use of an omental flap in the setting of a primary incarcerated perineal hernia​. Our method of repair utilized an omental flap in the setting of a strangulated secondary perineal hernia​. While this repair was not definitive, it can be an adequate temporizing measure that can bridge the patient to a more definitive repair in the future.

Perineal Hernia
Physical exam findings of discoloration at the site of the perineal hernia.
CT of small bowel incarceration/strangulation
CT image demonstrating incarceration/strangulation of the small bowel within the perineal hernia.