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Closed loop obstruction and adhesive intestinal obstruction in perineal hernia. Perineal hernia with bowel gangrene is uncommon but known complication of laparoscopic extralevator abdominoperineal excision (ELAPE). We present a rare case of closed loop small bowel obstruction with bowel gangrene secondary to an incarcerated perineal hernia that developed 7 years after an ELAPE. Intraoperatively, we found a definitive transition point due to adhesions in pelvis and a closed loop obstruction of the distal small bowel at different site with gangrenous intestine. She was managed successfully surgically with adhesiolysis and fixation of defect with biological mesh. Prevalence of perineal hernias will rise in future because of the increasing cases of ELAPE, in which no repair of pelvic floor is performed. The need of follow-up of these operations and more reporting of such cases are important in increasing awareness of these complications. Patients should be made aware of such complications and should seek urgent medical care.