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Giant lumbar incisional hernia with loss of domain


 Department of Minimal Invasive Hernia Surgery, GEM Hospital and Research Centre, Chennai, Tamil Nadu, India

Date of Submission29-Aug-2021
Date of Acceptance23-Nov-2021
Date of Web Publication10-Mar-2022

Correspondence Address:
Umang Bharat Mamaniya,
Department of Minimal Invasive Hernia Surgery, GEM Hospital and Research Centre, Thiruvengadam Nagar, MGR Road, Perungudi, Chennai - 600 096, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.jmas_274_21

  Abstract 


Giant lumbar hernia, with loss of domain, is a complex scenario to treat. Abdominal compartment syndrome is a dreaded post-operative complication. This can gravely impair the patient's respiratory function and also cause insufficient perfusion of the viscera. Pre-operative progressive pneumoperitoneum can facilitate bowel repositioning and can reduce impairment of the post-surgery lung function, essential for a favourable post-operative outcome. Here, we describe the treatment of a case of giant lumbar incisional hernia by the creation of progressive pneumoperitoneum and hybrid repair of incisional hernia with left posterior component separation and placement of giant prosthetic reinforcement of the defect.


Keywords: Giant lumbar hernia, progressive pneumoperitoneum, transverse abdominus release



How to cite this URL:
Mamaniya UB, Dasgupta P, Senthilnathan P, Chinnusamy P. Giant lumbar incisional hernia with loss of domain. J Min Access Surg [Epub ahead of print] [cited 2022 May 28]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=339344





  Introduction Top


European Hernia Society has defined ventral hernias larger than 10 cm as giant ventral hernias.[1] Lumbar hernias are one among the rare hernias and account for <1.5% of all abdominal hernias.[2] Only a few cases of giant lumbar hernias are reported in the literature.


  Case Report Top


A 50-year-old gentleman, known diabetic, presented with a left flank giant incisional hernia [Figure 1], gradually increasing in size for 10 years, with no features of obstruction. He had undergone left pyelolithotomy 11 years back and right PCNL 9 years back. Computed tomography revealed the following: hernial contents were small bowel and part of transverse colon, defect width was 13.8 cm and hernial volume was 2174 cc. Botox was not used because of financial constraints of the patient.
Figure 1: Pre- and post-operative

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Creating pneumoperitoneum (in operation theatre)

Veress needle was passed in the right subcostal region in mid-clavicular line under ultrasound guidance. A 7 Fr. central venous catheter was inserted using Seldinger technique. 1800 cc of air was filled. Insufflation was stopped when the patient had interscapular discomfort. Six more sessions of insufflation were done on an outpatient basis every alternate day (average 1000 cc per session). The hernia sac was supported with a tight elastic adhesive bandage to prevent air from being insufflated within the sac. The patient was kept on low-molecular weight heparin. After getting anaesthetic fitness, he underwent hybrid repair of incisional hernia with left posterior component separation and placement of giant prosthetic reinforcement of the hernial defect.

  • Position: Right lateral, 15° right-sided raised, table break
  • Steps: [Figure 2] Retrorectus space was entered just to the left of umbilicus using 11 mm-OptiView trocar. Working ports (5 mm) were placed above and below the camera port. Retrorectus space was developed. Transverse abdominus release (TAR) was initiated on the left side. Circumferential dissection of the sac was done by doing TAR above and below the sac. Incision of TAR was extended into subdiaphragmatic space medially to allow diaphragmatic fibres to go above and peritoneum to fall below. The dissection was extended into space of Retzius and space of Bogros on the left. To remove the excess skin and scar tissue, an open elliptical incision was given around the scar. Further dissection of the hernia sac beyond the psoas muscle was done. The dissected fascioperitoneal flap was closed with 2.0 polyglactin suture to re-establish the neo-peritoneum. A 30 cm × 30 cm macroporous polypropylene mesh was placed in the left retro-muscular space extending from the sub-diaphragmatic space above to the inguinal space below and stitched to the psoas muscle. Negative suction drains were placed in pre-peritoneal and sub-cutaneous region. Muscular repair was done using 1.0 polypropylene suture. Skin was closed with 3.0 polyamide suture.
Figure 2: Intra-operative photographs

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Post-operatively, the patient was shifted to the intensive care unit (ICU). He was started on liquids on the 1st post-operative day and soft diet on the 2nd day. He was shifted to the ward on the 3rd day and discharged on the 6th day [Figure 1] On 6 months of follow-up, the patient was asymptomatic.


  Discussion Top


In a giant hernia, repositioning the hernial content into the abdominal cavity may cause a post-operative increase of intra-abdominal pressure. Intra-thoracic pressure is raised as a result of cephalic displacement of the diaphragm. This can gravely impair the patient's respiratory function and also cause insufficient perfusion of the viscera.[3] Enlargement of the abdominal capacity by progressive pneumoperitoneum can facilitate bowel repositioning by lengthening the abdominal muscles and facilitating minimal tension closure. Further, it can condition the lungs before surgery and thus reduce the impairment of lung vital capacity after surgery.[4] Another method to achieve tension-reduced abdominal closure is posterior component separation of the abdominal wall,[5] which involves dividing the transverses abdominus muscle allowing the extension of retromuscular space up to the flank.

In the present case, the reintroduction of the contents from the sac to the abdominal cavity, closing the skin flaps of the abdominal wall and dissection of the retromuscular plane for the placement of the prosthesis were made easier. Post-operatively, adequate tolerance for reintroduction of viscera into the abdominal cavity was observed, without any ventilatory complications. Thus, pre-operative progressive pneumoperitoneum and hybrid component separation technique allowing placement of giant prosthesis can be used in the treatment of such complex cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, et al. Classification of primary and incisional abdominal wall hernias. Hernia 2009;13:407-14.  Back to cited text no. 1
    
2.
Kalyanasundar S, Bhatnagar A, Tiwari M, Pandey R, Shalja. Giant lumbar hernia and review of literature. Indian J Public Health Res Dev 2016;7:249-52.  Back to cited text no. 2
    
3.
Trakarnsagna A, Chinswangwatanakul V, Methasate A, Swangsri J, Phalanusitthepha C, Parakonthun T, et al. Giant inguinal hernia: Report of a case and reviews of surgical techniques. Int J Surg Case Rep 2014;5:868-72.  Back to cited text no. 3
    
4.
Sabbagh C, Dumont F, Fuks D, Yzet T, Verhaeghe P, Regimbeau JM. Progressive preoperative pneumoperitoneum preparation (the Goni Moreno protocol) prior to large incisional hernia surgery: Volumetric, respiratory and clinical impacts. Prospective study. Hernia 2012;16:33-40.  Back to cited text no. 4
    
5.
Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall defects: An anatomic and clinical study. Plast Reconstr Surg 1990;86:519-26.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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2004 Journal of Minimal Access Surgery
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Online since 15th August '04