title: Laparoscopic repair of postoperative perineal hernia using a two-mesh technique.
abstract: OBJECTIVE
  Perineal herniation following abdomino-perineal excision of the rectum (APER) can be debilitating. Repair options include a transabdominal (laparoscopic or open), perineal or a combined approach, but there is no consensus on the optimal technique. We describe a novel laparoscopic two-mesh technique and short- to medium-term outcomes.
  
  
  METHODS
  Six patients underwent this operation between 2008 and 2014. Patients were positioned in a modified Lloyd-Davies position, allowing perineal access, and steep Trendelenburg to aid displacement of small bowel from the pelvis. A polypropylene mesh was shaped, placed over the hernial defect, tacked postero-laterally and sutured antero-laterally to reconstitute the pelvic diaphragm. A second larger mesh (composite) was placed over the first supporting mesh and secured with tacks and sutures, overlapping the hernial defect, preventing small bowel contact with the mesh.
  
  
  RESULTS
  The median time from the index operation to presentation of the hernia was 5 months. One patient with dense small bowel adhesions from the primary repair had a combined laparoscopic and perineal approach. The median operating time was 141 min and median length of stay was 3 days. There were no intra-operative complications and no recurrences over a follow-up of 1-76 months.
  
  
  CONCLUSIONS
  We describe a novel laparoscopic technique for perineal hernia repair following APER with a low recurrence rate in the intermediate term.
authors.affiliation: Department of Colorectal Surgery, Royal Surrey County Hospital, Guildford, UK.
authors.forename: S K
authors.initials: SK
authors.lastname: Allen
authors.forename: K
authors.initials: K
authors.lastname: Schwab
authors.forename: A
authors.initials: A
authors.lastname: Day
authors.forename: D
authors.initials: D
authors.lastname: Singh-Ranger
authors.forename: T A
authors.initials: TA
authors.lastname: Rockall
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D059685:Herniorrhaphy / Q000379:methods*; D006801:Humans; D000069290:Incisional Hernia / Q000209:etiology / Q000601:surgery*; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D010502:Perineum / Q000601:surgery*; D011183:Postoperative Complications / Q000601:surgery; D013526:Surgical Mesh
keywords: Hernia; laparoscopic; perineal