Eventración perineal y paraostomal luego de cirugía de Miles: abordaje quirúrgico secuencial

Abdominoperineal amputation (APA), or Miles’ procedure, is the treatment of choice for anal or low rectal cancer that invades the sphincter or is not amenable to organ-preserving approaches. Although the surgery is intended to be curative, it is associated with significant morbidity. Incisional hernias are common complications of abdominal surgery, but perineal and parastomal hernias following a Miles’ procedure are particularly complex and challenging. Perineal hernia is an uncommon but likely underdiagnosed complication, with a reported incidence ranging widely from 0.6% to 26% depending on the series [1], most frequently observed in patients undergoing extra-levator resections and those who received neoadjuvant treatment. Risk factors include female sex (due to pelvic morphology), obesity, smoking, surgical site infection, and prior hysterectomy. Clinically, it may present as anything from asymptomatic perineal asymmetry to chronic pain, skin ulceration, bowel obstruction, or—as in this case—severe limitation in ambulation and sitting position [2]. There is no consensus on the optimal repair technique for perineal hernia. Options include abdominal (open or laparoscopic), perineal, or combined approaches [3,4]. The laparoscopic approach offers the advantages of minimally invasive surgery and excellent visualization of the deep pelvis, but may be insufficient to ensure distal closure in large defects, where the perineal approach allows stronger anchoring and muscular reconstruction. Parastomal hernia, on the other hand, is the most frequent complication of permanent stomas, with long-term rates exceeding 50% [5]. Its repair is equally complex due to high recurrence rates and the risk of contamination. We present a highly complex case in a patient with both types of defects, managed with a sequential and combined strategy.