Perineal hernia

This video demonstrates the anatomy and surgical repair of perineal hernia. This is a rare hernia and it requires careful dissection of the hernia sac from adjoining structures including the bladder and the vagina. The hernia defect in the pelvic floor is repaired primarily and reinforced with a piece of mesh. The peritoneum is closed over the mesh.

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Perineal   hernia

Authors
J Leroy
Abstract
This video demonstrates the anatomy and surgical repair of perineal hernia. This is a rare hernia and it requires careful dissection of the hernia sac from adjoining structures including the bladder and the vagina. The hernia defect in the pelvic floor is repaired primarily and reinforced with a piece of mesh. The peritoneum is closed over the mesh.

Catégorie
complex cases
Mots-clés
laparoscopic,hernia repair,perineum
Type de vidéo
Durée
08'00''
Publication
2004-09
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1164e.htm

Perineal   hernia

1. Case presentation 00'17''
The patient is a 58-year-old female who presents for elective repair of hernia. She has a sciatica-like pain that radiates to the right middle thigh due to the hernia. In the past, she has had an ectopic pregnancy requiring an exploration by Pfannenstiel, an exploratory laparotomy for small bowel occlusion 6 months prior to the current surgery. At that time, they found incarcerated bowel in the pelvic floor but were unable to repair the hernia. The physical exam was unremarkable except for a fullness of the right buttock, an MRI revealed a hernia sac with bowel contents at the level of the right pelvic floor. Here we see a schematic view of the external area of the hernia in the perineum. We can see that it exits lateral to the vagina and into the right buttock area. Here we see the normal anatomy as it is viewed from interior to exterior. The vagina is in the midline and in front of that, we see the bladder. Laterally we have the area where the hernia comes down as the perineum extends through the levator ani and the deep transverse peritoneal muscle. We will attempt to fix the hernia as we pull back this hernia sac and will place a mesh in this area. Here we see the placement of the ports with the surgeon and his assistant standing to the left of the patient. The umbilicus is where we place the endoscope and the other ports are working ports. We do an exploration first of the hernia area itself, as you can see this transversus is down towards the pelvic floor. At this time, we have pulled back the bowel and we are making sure that the colon and no other bowel contents have been incarcerated in the hernia sac itself. We easily see the uterus, the round ligament, Fallopian tubes. We will first start by opening the peritoneum in the lateral area and come towards the medial. It is important during this dissection to use a minimal amount of cautery and stay very close to the peritoneum itself to avoid any unnecessary bleeding. We continue the dissection down pulling tissues off of the peritoneum. With the previous surgical history, we see that these are stuck to each layer. We progressively continue down towards the pelvic floor using sharp and blunt dissection as we see here. As we continue to make our way down towards the pelvic floor, we can see a better definition of the urinary bladder as it is being pulled down into the hernia itself. We retract the contents medially and continue the dissection. We begin to see the muscles of the pelvic floor are becoming defined here. We have the bladder, which has been pulled medially and we are progressively using the Harmonic scalpel here to dissect the tissues off the bladder to return the bladder to its normal position. We stay close to the bladder wall attempting to find the best plane between that and the hernia sac. As you can see here progressively, the sac is being worked off of the bladder, which is continuously pulled medially. The use of the Harmonic scalpel minimizes the amount of bleeding. We continue to work down towards the pelvic floor in the area where the hernia sac traverses the levator ani muscle. Also medial to this image is the vagina. Continuing a careful dissection, we see here the vagina is medial, the bladder is pulled up towards us and we see clearly now the hernia sac as it traverses the pelvic floor. Here we have placed the sound into the vagina to better distinguish the structures and to avoid any injury to the vagina. Here we are dissecting free the hernia sac. We can clearly see how it’s traversed through the pelvic floor muscles. We place the sound in the vagina to determine its location and we can see that it is intact in this image here, and here you can see the depth of the hernia as it traverses through the pelvic wall into the right buttock area. We are now going to close the hernia orifice primarily using absorbable suture. In this instance, we will try to take tissue from the inside wall as well as across the levator ani muscle layer. Individual sutures are used with intra- and extra-corporeal knots. Once this pelvic floor has been re-approximated, we see that the hernia orifice has been closed. We will now place a polypropylene non-woven mesh with a size of approximately 15 by 10cm introduced through the endoscope trocar. We attach it laterally to the side wall around Cooper’s ligament using staples and also we will attach it medially to the vagina to prevent the vagina from falling down again into the previous hernia area. This helps to reinforce our previously made closure of the hernia. Once we feel that the mesh is adequately in place, keeping the vagina and the bladder from slipping again into the same area, we will close the peritoneum again with staples as you see here, complete closure of the hernia orifice with repair of the peritoneum.