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PubMed This is a summary of 21 peer-reviewed journal articles Updated
General Surgery

Surgical Repair Options for Perineocele

At a Glance

Perineocele surgery is individualized: surgeons choose a perineal, abdominal, or combined approach based on hernia size, scarring, prior radiation, tissue quality, and symptoms. Mesh, and sometimes a tissue flap, may reinforce the pelvic floor, but the hernia can return.

Deciding to repair a perineocele (perineal hernia) is a collaborative process between you and your surgical team. Because these hernias are rare and the anatomy of the pelvic floor is complex, there is no single “best” way to fix them [1]. Instead, your surgeon will tailor the approach based on your symptoms, your prior surgeries, and the quality of your tissue [2].

When is Surgery Necessary?

Elective surgery is an individualized decision. It may be considered if the hernia is causing significant pain, making it difficult to sit, or interfering with your bowel or bladder function [3][4]. The natural history of these hernias is not well established, but surgery may be considered if symptoms progress, or if there is skin breakdown or high risk of incarceration (where the bowel becomes trapped) [5][3].

Surgical Approaches

There are three main ways surgeons can access and repair a perineocele:

  1. The Perineal Approach: The surgeon makes an incision directly over the bulge in the perineum [6].
    • Pros: It is often a shorter operation with a faster recovery time (median hospital stay of about 4 days) [7].
    • Cons: It can be difficult for the surgeon to see and safely move the bowel if it is stuck to the hernia sac (adhesions) [8].
  2. The Abdominal Approach (Laparoscopic or Robotic): The surgeon works from inside the abdomen, often using small “keyhole” incisions and a camera [9].
    • Pros: This allows for a clear view of the entire pelvic floor and makes it easier to pull the trapped organs back into the abdomen safely [9][10].
    • Cons: Recovery may take slightly longer (median hospital stay of about 8 days) [7].
  3. The Combined Approach: This uses both an abdominal and a perineal incision. It is often reserved for very large or complex hernias where the surgeon needs to work from both sides to ensure the repair is secure [11][4].
    (Note that median stays vary by study and your own stay will depend on your specific condition and complications).

The Role of Mesh

In most cases, the hole in the pelvic floor is too large to simply stitch closed. Instead, surgeons use a “patch” called mesh to bridge the gap [9].

  • Synthetic Mesh: Made of durable medical-grade plastics (like polypropylene). It provides a strong, permanent reinforcement [12]. Research across various studies suggests a recurrence rate of approximately 29% when synthetic mesh is used for these hernias [13].
  • Biologic Mesh: Made from processed human or animal tissue. Your body eventually replaces this mesh with its own living tissue, though it is not guaranteed to be completely replaced [14]. It is often used if there is a higher risk of infection or if you have had prior radiation [15]. Recurrence rates for biologic mesh in this area have been reported at around 39% [13]. (Note: These figures are from observational studies, not individualized predictions).

Using Tissue Flaps

In complex cases—especially if you have had radiation or extensive cancer surgery (like an APR)—the surgeon may use a tissue flap. This involves moving healthy muscle and skin from another part of your body to fill the “empty space” in the pelvis and provide extra cushioning for the repair [16][17].

  • VRAM Flap: Uses muscle and skin from your abdomen [18].
  • Gracilis Flap: Uses a slender muscle from your inner thigh [19].
  • Gluteus Flap: Uses muscle from your buttock [20].

Adding a tissue flap to a mesh repair may help lower the risk of the hernia coming back. One study found that only 14% of patients had a recurrence when a flap was added, compared to 34% for mesh alone, though more research is needed to confirm this as this study had limited statistical power and selection bias [21].

Choosing the Right Approach

Your surgeon will weigh several factors to decide on the best plan for you:

If you have… The surgeon may prefer…
A small, simple hernia Perineal approach [6]
Significant internal scarring (adhesions) Abdominal approach (Laparoscopic/Robotic) [9]
History of pelvic radiation Biologic mesh or a tissue flap [15][16]
A very large, complex defect Combined approach with mesh and a flap [4][21]

(Note: These are not strict rules; the team also weighs ostomy location, contamination, operative risks, and surgeon experience).

Before deciding on surgery, you must discuss the risks with your team. Repairing a perineal hernia carries significant risks, including bleeding, bowel/bladder/ureter injury, wound breakdown, mesh exposure or erosion, thromboembolism (blood clots), and flap donor-site complications. While success rates are generally high, the overall risk of a perineocele returning after surgery is estimated at roughly 18–22% [2]. Your care team will focus on finding the most durable solution for your specific anatomy [1].

Common questions in this guide

When is surgery recommended for a perineocele?
Repair may be considered when a perineocele causes significant pain, makes sitting difficult, or interferes with bowel or bladder function. Surgeons may also discuss surgery if symptoms worsen, the skin breaks down, or there is a risk that bowel could become trapped.
How do surgeons choose a perineocele repair approach?
The choice depends on the hernia’s size and complexity, previous operations, internal scar tissue, tissue quality, and the surgeon’s experience. A perineal approach may suit a small, simple hernia, an abdominal laparoscopic or robotic approach may help when internal scar tissue is present, and a combined approach may be used for a large or complex defect.
What type of mesh is used to repair a perineocele?
Mesh is often used to reinforce the pelvic-floor opening because it may be too large to close with stitches alone. Synthetic mesh provides permanent reinforcement, while biologic mesh may be considered when infection risk is higher or tissues have been affected by radiation; the best option depends on your surgical situation.
Why might a tissue flap be added to perineocele repair?
A tissue flap moves healthy muscle and skin from the abdomen, inner thigh, or buttock to fill pelvic space and add cushioning and support. It may be considered for a large or complex defect, especially after radiation or extensive cancer surgery, but it also has risks at the donor site.
How likely is a perineocele to come back after surgery?
Recurrence remains possible even after a successful repair, and published estimates for perineal hernia repair are roughly 18% to 22% overall. Rates vary with the patient’s anatomy, prior treatment, repair method, and follow-up, so study percentages cannot predict an individual result.

Get notified when new evidence is published on perineocele.

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References

References (21)
  1. 1

    A 25 year experience of perineal hernia repair.

    McKenna NP, Habermann EB, Larson DW, et al.

    Hernia : the journal of hernias and abdominal wall surgery 2020; (24(2)):273-278 doi:10.1007/s10029-019-01958-0.

    PMID: 31049717
  2. 2

    Techniques of perineal hernia repair: A systematic review and meta-analysis.

    Maspero M, Heilman J, Otero Piñeiro A, et al.

    Surgery 2023; (173(2)):312-321 doi:10.1016/j.surg.2022.10.022.

    PMID: 36404179
  3. 3

    Perineal hernia after abdominoperineal resection - a systematic review.

    Salati SA, Arkoubi AY

    Polski przeglad chirurgiczny 2022; (94(6)):61-70 doi:10.5604/01.3001.0015.7677.

    PMID: 36468514
  4. 4

    Rare case of strangulated primary acquired perineal hernia causing small bowel obstruction requiring emergency operative repair.

    Jamsari G, Kwik C, King J, Pathma-Nathan N

    Journal of surgical case reports 2024; (2024(3)):rjae164 doi:10.1093/jscr/rjae164.

    PMID: 38505337
  5. 5

    Ileal strangulation by a secondary perineal hernia after laparoscopic abdominoperineal rectal resection: A case report.

    Tomohiro K, Tsurita G, Yazawa K, Shinozaki M

    International journal of surgery case reports 2017; (33()):107-111 doi:10.1016/j.ijscr.2017.02.005.

    PMID: 28292663
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    Anterior Perineal Hernia following Robot-Assisted Radical Cystectomy in a Male Patient: A Case of Transperineal Mesh Repair.

    Sato Y, Kinoshita T, Komori K, et al.

    Surgical case reports 2026; (12(1)) doi:10.70352/scrj.cr.26-0310.

    PMID: 42359365
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    Surgical Repair of Postoperative Perineal Hernia: A Case for the Perineal Approach.

    Hung LY, Abbass MA, Sapci I, et al.

    Diseases of the colon and rectum 2022; (65(5)):727-734 doi:10.1097/DCR.0000000000002374.

    PMID: 34907986
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    Case report of perineal hernia after laparoscopic abdominoperineal resection.

    Honjo K, Sakamoto K, Motegi S, et al.

    Asian journal of endoscopic surgery 2018; (11(2)):173-176 doi:10.1111/ases.12420.

    PMID: 28880495
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    Perineal hernia repair after abdominoperineal resection (APR) with the laparoscopic-peritoneal dual fixation technique.

    Li J, Shao X, Cheng T

    Hernia : the journal of hernias and abdominal wall surgery 2022; (26(5)):1307-1314 doi:10.1007/s10029-022-02632-8.

    PMID: 35652965
  10. 10

    Robotic repair of perineal hernias: a video vignette and review of the literature.

    Watanaskul S, Schwab ME, Colley A, et al.

    Surgical endoscopy 2023; (37(3)):2290-2294 doi:10.1007/s00464-022-09521-2.

    PMID: 35982283
  11. 11

    Postoperative perineal hernia repair: what is the evidence?

    Li J, Wu L, Shao X, Cheng T

    Surgery today 2023; (53(10)):1105-1115 doi:10.1007/s00595-023-02654-4.

    PMID: 36720743
  12. 12

    Meta-analysis of controlled studies comparing biologic and synthetic unabsorbable mesh in contaminated fields.

    Carvalho AC, Santos FAV, De Carvalho Garcia DP

    Surgical endoscopy 2025; (39(7)):4094-4101 doi:10.1007/s00464-025-11811-4.

    PMID: 40473948
  13. 13

    Mesh, flap or combined repair of perineal hernia after abdominoperineal resection - A systematic review and meta-analysis.

    Sharabiany S, Brouwer TPA, Kreisel SI, et al.

    Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2022; (24(11)):1285-1294 doi:10.1111/codi.16224.

    PMID: 35712806
  14. 14

    Cumulative 5-year Results of a Randomized Controlled Trial Comparing Biological Mesh With Primary Perineal Wound Closure After Extralevator Abdominoperineal Resection (BIOPEX-study).

    Blok RD, Sharabiany S, Stoker J, et al.

    Annals of surgery 2022; (275(1)):e37-e44 doi:10.1097/SLA.0000000000004763.

    PMID: 33534231
  15. 15

    Is there a place for a biological mesh in perineal hernia repair?

    Musters GD, Lapid O, Stoker J, et al.

    Hernia : the journal of hernias and abdominal wall surgery 2016; (20(5)):747-54 doi:10.1007/s10029-016-1504-8.

    PMID: 27240846
  16. 16

    The "Pelvic Bowl" Framework: An Objective-centered Approach to Perineal Reconstruction After Extirpative Pelvic Surgery.

    Ernstrom CJ, Korenblit M, Kiel L, et al.

    Annals of plastic surgery 2026; doi:10.1097/SAP.0000000000004871.

    PMID: 42663550
  17. 17

    Primary flap closure of perineal defects to avoid empty pelvis syndrome after pelvic exenteration in gynecologic malignancies: An old question to explore a new answer.

    Arcieri M, Restaino S, Rosati A, et al.

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    PMID: 38134482
  18. 18

    [Plastic surgery of extended defects after exenteration of the pelvis].

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  19. 19

    Single centre experience of bilateral gracilis flap perineal reconstruction following extra-levator abdominoperineal excision.

    Coelho JAJ, McDermott FD, Cameron O, et al.

    Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2019; (21(8)):910-916 doi:10.1111/codi.14654.

    PMID: 31017735
  20. 20

    [Pelvic floor reconstruction with gluteus maximus myocutaneous flap in the treatment of perineal wound healing failure after pelvic exenteration].

    Tao Y, Wang YL, Zhu L, et al.

    Zhonghua wei chang wai ke za zhi = Chinese journal of gastrointestinal surgery 2025; (28(1)):81-85 doi:10.3760/cma.j.cn441530-20231117-00176.

    PMID: 39971555
  21. 21

    Perineal hernia repair: Multicentre comparative analysis of mesh-only versus mesh combined with tissue flap.

    Kreisel SI, de Jong DLC, Hompes R, et al.

    Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2025; (27(7)):e70159 doi:10.1111/codi.70159.

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This page is for informational purposes only and does not constitute medical advice. Discuss the choice of approach, mesh or tissue flap, and expected risks and recovery with your surgical team.

Guide contents perineocele
Research & Literature
03 Diagnosis and Imaging for Perineocele 05 Recovery, Complications, and Recurrence