Successful Reconstruction of Recurrent Perineal Hernia After APR Using a Vertical Rectus Abdominis Myocutaneous Flap: A Salvage Option for a Refractory Case.

Abstract

<h4>Background/aim</h4>Perineal hernia (PerH) is a rare but challenging complication following abdominoperineal resection (APR). While primary repairs using mesh are commonly performed, recurrent or intractable cases often require more robust reconstructive options. Among these, myocutaneous flap techniques have emerged as promising alternatives, particularly in anatomically complex or previously treated patients. However, there remains no standardized surgical approach, and the choice of procedure must be individualized according to the patient's background, prior interventions, and anticipated risk of recurrence.<h4>Case report</h4>A 76-year-old man developed a perineal hernia two months after undergoing APR for rectal cancer. The hernia recurred despite two separate laparoscopic mesh repairs, indicating the limitations of conventional approaches in this setting. Imaging revealed a significant perineal bulge containing the small intestine and bladder, without evidence of malignancy or local tumor recurrence. Considering the failure of previous mesh repairs and the likelihood of severe pelvic adhesions, a salvage procedure was performed using a vertical rectus abdominis myocutaneous (VRAM) flap <i>via</i> a combined abdominal and perineal approach. The flap, based on the deep inferior epigastric vessels, was transposed to fill the pelvic floor defect and reinforce the weakened perineal region. Postoperative recovery was uneventful, and the patient has remained free of recurrence for 38 months. This durable outcome underscores the utility of flap-based reconstruction for complex pelvic defects.<h4>Conclusion</h4>This case demonstrates that VRAM flap reconstruction can provide durable and safe repair for recurrent perineal hernia after APR. It should be considered a valuable salvage option when conventional mesh repairs fail.