perineal hernias following abdomino - perineal excision of rectum ( aper ) , requiring repair , have been reported to occur in < 1% [ 1 , 2 ] of people .
patients may exhibit some perineal bulging following an increase in intra - abdominal pressure , but are rarely symptomatic and , therefore , do not require operative intervention . the literature to date has reported that perineal hernias occur primarily following aper ; however , there is very little data with regard to incidence and the management of perineal hernias .
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 . given 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 .
repair 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 .
a 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 . 
figure  1:(a and b ) coronal and transverse magnetic resonance imaging scans demonstrating perineal hernia extending into the left thigh .
( demonstrated by white arrows . ) ( a and b ) coronal and transverse magnetic resonance imaging scans demonstrating perineal hernia extending into the left thigh .
given the recurrent nature of the hernia , a rectus flap repair was performed and after 15 months he remains hernia free .
although the majority of patients after aper will demonstrate an element of perineal herniation , they do not exhibit any symptoms and , therefore , do not require operative repair .
commonly reported symptoms secondary to perineal hernias include perineal discomfort , a dragging sensation , skin breakdown , urinary dysfunction , bowel obstruction and evisceration of pelvic contents [ 14 ] .
given the paucity of available literature , it is difficult to identify definitive predisposing factors ; however , reported factors include smoking , chemoradiotherapy , sacrectomy / coccygectomy , excessive length of small bowel , lack of peritoneal closure and excision of the levators [ 1 , 2 , 4 ] .
with conventional aper , involvement of circumferential resection margins ( crm ) has been identified to occur most commonly at the floor of the pelvis .
the aim of elape is to reduce this crm positivity , along with rates of intra - operative perforation .
tissue morphometry of elape specimens showed that this reduction in crm positivity occurs as a result of removing more tissue from around the tumour than standard aper , and thus improving rates of local recurrence and overall survival . despite these superior oncological outcomes ,
elape has also been associated with an increase in perineal wound complications , which may be attributed to the increased size of the perineal defect
. there has been an increase in the uptake of laparoscopic aper in recent years , which may be attributed to an increase in the incidence of perineal hernias ; however , actual figures have not been reported .
a possible reason is that a laparoscopic technique may result in fewer adhesions and thus less restriction of small bowel herniation .
our patient had undergone both neo - adjuvant and adjuvant therapy , along with a laparoscopic elape .
's systematic review on the outcome of primary perineal reconstruction following elape demonstrated lower rates of perineal complications compared with primary closure . there has been debate surrounding reconstructive technique , but no significant differences in perineal complication rates have been demonstrated between biological mesh and myocutanous flap reconstruction .
primary reconstruction using biological mesh may be preferable due to shorter operating times , absence of donor site morbidity and the option of operating independent of a plastic surgeon .
however , the tendency for biological mesh to thin with time , leading to possible recurrence and the risk of infection , may make some opt for myocutanous flap reconstruction .
cost benefits have been suggested when using a biological mesh over a rectus abdominis flap due to their association with a reduced length of post - operative stay . due to
the variety of flap reconstructions reported and due to relatively low numbers in each study , preference is still yet to be determined .
the use of a transabdominal technique allows of better visualisation of the defect and allows identification of tumour recurrence , while a transperineal approach minimises the potential risks associated with entering the peritoneal cavity .
laparoscopic repair has been shown to have results comparable with those of open repair , but is dependent on patient selection ( body habitus , comorbidities , intraperitoneal adhesions ) .
perineal hernia repair can be a challenging procedure , with a recurrence rate of up to 30% ; foster et al .   demonstrated that primary reconstruction at the time of elape may be preferable to potentially prevent perineal hernias .
presently , it is thought that a high - quality prospective trial is needed to help answer the many questions that arise between surgeons when discussing the management options for perineal hernias .
repair after elape poses a significant challenge ; hence , further research is needed to determine the best method of managing and preventing this difficult complication .
however , we advocate that management of the perineal defect at the time of initial surgery should be discussed and carried out with the input of the plastic surgeons .
 symptomatic perineal hernias following abdomino - perineal excision of rectum have been reported to occur uncommonly . 
 we present the case of a 79-year - old gentleman who developed a perineal hernia after laparoscopic - assisted extralevator abdomino - perineal excision ( elape ) of the rectum . despite initial myocutaneous flap repair 
 , there was further symptomatic recurrence . 
 magnetic resonance imaging demonstrated non - compromised bowel extending beneath the gracilis flap with extension into the adductor compartment of the left thigh . given the recurrent nature , a rectus flap repair was performed and after 15 months , he remains hernia free . 
 there is currently no consensus as to the optimal operative technique in the prevention and management of these hernias ; however , primary reconstruction at the time of elape may be preferable . 
 symptomatic perineal hernias can be severely debilitating and require operative repair . 
 we suggest that surgical options should be discussed and carried out with the input of a plastic surgeon . 
INTRODUCTION
CASE REPORT
DISCUSSION