Background: Hidradenitis Suppurativa (HS) is a chronic condition affecting apocrine glands of the axilla, perineum and inguinal regions. The presentation of inflammatory nodules and sinus tracts can be extensive with sequelae of contractures and open wounds resulting in both a physical and psychological burden. Lifestyle modifications and medications are first-line treatment, however can have dissatisfactory outcomes particularly for patients with advanced disease. Surgical intervention ranges from draining acute abscess to deroofing sinus tracts while extensive disease is excised enbloc with reconstruction of the defect. Reconstruction of perineal disease is often fraught with wound healing complications secondary to contamination of the wound bed. Herein, we describe a novel multidisciplinary approach to the surgical management of advanced perineal HS. Case summary: A 53-year-old male presented with progressive Hurley stage III perineal HS despite treatment with adalimumab. On examination, the perineum, inguinal and gluteal cleft regions were all involved with disease extending up to the anal verge. A combined colorectal and plastic team were assembled for staged surgical intervention. A diverting loop ileostomy was performed following a colonoscopy confirming nil tracts extending to the anal canal. Resection of disease was performed 2 months post once the stoma had matured. The wound bed was reconstructed with a dermal matrix and subsequently skin grafted. Ileostomy reversal was performed following complete wound healing. Conclusion: Management of advanced HS which are refractory to medical treatment requires a multidisciplinary surgical approach. A diverting ileostomy should be considered for severe cases of perineal HS to optimise the reconstructive effort.