Perineal Hernia Repair

1

Clinical Anatomy

• ▴

  Perineal hernias are caused by a defect in the pelvic floor and can be classified based on location and cause ( Fig. 14.1 ).

  

• ▴

  A perineal hernia defect is classified as either anterior or posterior in relationship to a line drawn between the ischial tuberosities of the hip bones ( Fig. 14.2 ).

  

• ▴

  An anterior perineal hernia is found in the urogenital triangle of the pelvic floor. This type of hernia occurs mainly in women.

• ▴

  A posterior perineal hernia is found in the anal triangle of the pelvic floor. This type of perineal hernia can occur in both men and women.

• ▴

  Perineal hernias may be either congenital or acquired.

• ▴

  Congenital perineal hernias develop in utero and are extremely rare.

• ▴

  Acquired perineal hernias are classified as either primary or secondary.

• ▴

  Primary acquired perineal hernias develop secondary to situations of extreme intra-abdominal pressure, such as pregnancy and childbirth, and are most common in women.

• ▴

  Secondary acquired perineal hernias develop secondary to prior pelvic procedures damaging the pelvic floor. This type of perineal hernia is found in both men and women.

• ▴

  The perineal membrane of the pelvic floor forms the hernia sac. Depending on the location of the defect, the bladder, uterus, small intestine, sigmoid colon, or rectum may be involved. Gastrointestinal or genitourinary complaints may occur as a result of these hernias.

2

Preoperative Considerations

• ▴

  Physical examination may be limited in the ability to identify anatomic relationships in perineal hernias.

• ▴

  Computed tomography with intravenous and oral contrast administration is beneficial in delineating key anatomic relationships, identifying contents within the hernia sac, and recognizing associated pathology such as obstruction ( Fig. 14.3 ).

  

• ▴

  Identification of concomitant pathology may have implications for the surgical approach.

• ▴

  As with any elective hernia repair, optimization of comorbid conditions is essential and should include education regarding smoking cessation, glycemic control, weight optimization, nutritional assessment, and assessment of general health. Patients with a prior history of methicillin-resistant Staphylococcus aureus infections are prescribed nasal mupirocin and chlorhexidine showers 5 days preoperatively for decolonization.

• ▴

  Mechanical and pharmacologic prophylaxis for deep vein thrombosis is accomplished.

• ▴

  Surgical antimicrobial prophylaxis for gram-positive organisms is performed with a cephalosporin. Preoperative antibiotics are adjusted in patients with a history of methicillin-resistant Staphylococcus aureus infections based on bacterial susceptibilities.

3

Operative Steps ( Video 14.1 )