Management of a complex recurrent perineal hernia
A 79-year-old gentleman who initially underwent a laparoscopic assisted extralevator abdomino-perineal excision (ELAPE) of the rectum for extensive circumferential low rectal cancer after neo-adjuvant long course chemoradiotherapy developed a symptomatic perineal hernia. Initial closure of the perineal wound was performed using a double layer of interrupted mattress sutures with a 2/0 absorbable braided suture. The patient's only co-morbidity was intermittent asthma, for which he was prescribed a Salbutamol inhaler.\nGiven the nature of the disease, it was felt that he would benefit from adjuvant chemotherapy. Subsequent radiological surveillance did not show any evidence of recurrence and CEA levels remained low. However, magnetic resonance imaging (MRI) carried out at 19 months demonstrated that the small bowel had herniated through the levator sling and the patient had started to experience severe discomfort in the perineal region.\nRepair of the defect was carried out in conjunction with the Plastic surgery team, using a pedicled gracilis flap. Again, despite an uneventful recovery, 5 months later the patient experienced lower abdominal pain and nausea and noted a distinct swelling of his left upper thigh.\nA repeat MRI confirmed a further recurrence of the perineal hernia in the form of uncompromised bowel, which extended beneath the gracilis flap, which then continued into the adductor compartment of the left thigh (Fig. a and b).\nGiven the recurrent nature of the hernia, a rectus flap repair was performed and after 15 months he remains hernia free.