Perineal Hernia: A Perineal Genu Pectoral Approach With Flap and Non-Absorbable Mesh Repair Technique

Background A perineal hernia is a protrusion of an organ or an intra-peritoneal tissue through a defect of the pelvic floor, which occurs after extended perineal surgeries. The incidence of perineal hernia is poorly documented. To date, there is no gold-standard technique. Numerous surgical approaches are described: abdominal (laparotomy or laparoscopy), perineal and combined approach, using flap, mesh or both for perineal hernia repair. We hereby describe a perineal approach with flap and non-absorbable mesh repair technique. Method The patient is lying in genu pectoral position. A gluteal Y-like incision is performed with subcutaneous dissection of the hernia sac with anterior bladder dissection and dorsal dissection to the coccyx, which allows a reduction of the hernia contents. Then a dissection of subcutaneous flaps from the gluteus maximus muscle (GMM) is performed. Peritoneal closure is performed with exclusion of the perineal cavity. Detachment of the lower third of the GMM from the sacrum and release of the pedicled gluteus flap is made. The mesh covering the perineal defect extensively is fixed with a 2 cm overlap to the pubis, then to the coccyx, and laterally the mesh on the sacral-tuberosity ligament, the ischium, the coccygeal muscle and the ischio-pub branch. Gluteal flaps are fixed to the coccyx and pubis for mesh adequate coverage. A preventive negative pressure wound therapy is placed over the skin closure. The patient shows no evidence of recurrence after 2 years follow-up.