Biological mesh repair of a strangulated perineal hernia following abdominoperineal resection
An 81-year-old lady presented to the on call general surgeons with abdominal pain and vomiting for 24 hr. Two years previously she had undergone a laparoscopic abdominoperineal resection for carcinoma of the rectum at another centre. She had not previously received radiotherapy and was a non-smoker. History, examination and abdominal X-ray suggested small bowel obstruction. On admission, there were no signs of peritonism, observations were normal and markers of inflammation were not significantly raised.\nAlthough not known to have a hernia, she described discomfort and swelling in her perineum over the previous year that sometimes made it difficult to sit down. Direct examination of the perineum confirmed the presence of an irreducible but non-tender hernia (Fig. ). Conservative treatment with nasogastric drainage and intravenous fluids produced no clinical improvement. The following morning a CT of the abdomen and pelvis was performed which confirmed small bowel obstruction and revealed a cut off at the neck of a perineal hernia.\nAt operation, small bowel obstruction was found with volvulus of a loop of ileum around an adhesion at the neck of the perineal hernia (Fig. ). Around 80 cm of gangrenous mid-ileum was resected and a primary end-to-end anastamosis performed. After thorough washout of the abdomen and pelvis, the wide pelvic floor defect was bridged with Strattice™ Tissue Matrix, secured in place with 2.0 prolene sutures (Fig. ). An omental pedicle graft was used to cover the mesh and fill the pelvis. One abdominal tube drain and two perineal suction drains were inserted and removed over the course of the next 7 days.\nThe patient made an uncomplicated recovery and was discharged home. At 6 months follow-up, she remained well with no reported problems other than a slight increase in stoma activity. There was resolution of her previous perineal symptoms and no clinical recurrence of the hernia.