Abdominal wall defects: pathogenesis,prevention and repair

‘Abdominal wall defects’ is a collective term used to describe two distinct pathologies: primary ventral hernias and incisional hernias. This article describes the pathogenesis, risk factors and the management of each.     

Groin hernias: features of recurrences

Summary In 2390 groin hernias operated on by the same surgeon there were 2327 inguinal hernias (97.4%) and 63 femoral (2.6%); 261 (11.2%) were recurrent hernias. The aim of this study was to define the different features of recurrences in a series of 206 recurrences operated on by an inguinal approach. The median time of recurrence was 3 years (< 1–58). It was < 1 year in 67 cases (40%) and 50% of all recurrences had occurred in 2.4 years. The time of recurrence after operation performed in childhood was 31 years (15–58). All recurrences were located in the area of the myo-pectineal and femoral orifices. There was only one site of recurrence in 125 cases (61%); the recurrence was direct in 73 cases (58%), indirect in 44 cases (35%) and femoral in 8 cases (7%). There were 2 sites of recurrence in 81 cases (39%), 76 mixed (94%) and 6 inguinal associated with a femoral hernia (6%). Altogether there were 288 sites of recurrence. There were 44 direct diverticular recurrences and 26 of these were located near the pubic tubercle. The rate of recurrence in current practice is much higher than that in specialized centers. The long delay of recurrence after simple resection of the sac in childhood constitutes an indirect argument for the Marcy procedure in adolescents and young men with type I or II hernias. The preeminence of direct recurrences and the existence of direct diverticular suprapubic recurrences are arguments for mesh procedures. The fact that all recurrences are located in the area of myo-pectineal and femoral orifices must be considered for the choice of a mesh procedure.     

Strangulated Small Bowel Obstruction Secondary to a Transmesosigmoid Hernia

Internal hernias are an infrequent cause of small bowel obstruction with transmesosigmoid herniation being very rare, especially in patients with no history of abdominal surgery or trauma. Early surgical intervention is important in acute presentation to reduce the high morbidity and mortality rates associated with this disease.     

Right paraduodenal hernia leading to bowel strangulation

Up to half of all internal hernias are caused by paraduodenal hernia, a rare congenital midgut malrotation that accounts for less than 1% of all intestinal obstructions. The diagnosis may arise from an incidental finding on abdominal imaging or the patient may present with abdominal pain, vomiting, and obstipation. Early recognition and management of this disease entity are keys because serious complications such as bowel ischemia and infarction may result from a delay in diagnosis. We present a case involving a 14-year-old boy with gangrenous small bowel secondary to right paraduodenal hernia.     

Retrocecal hernia preoperatively diagnosed by computed tomography: A case report

IntroductionRetrocecal hernia is a rare type of pericecal hernia. Because it is difficult to diagnose preoperatively, it is often treated with emergency operation.Case presentationAn 83-year-old male patient experienced sudden abdominal pain. Marked small bowel dilatation and intestinal obstruction were detected by abdominal computed tomography (CT). An enhanced CT scan also revealed a trapped cluster of small bowel loops behind the cecum and ascending colon. We preoperatively diagnosed small bowel ileus as a result of retrocecal hernia. After conservative therapy with a long intestinal tube, an emergency operation was performed. During the surgery, a portion of the ileum was found to be incarcerated in the retrocecal fossa. Intestinal resection was not necessary because the incarcerated ileum appeared viable, and the orifice to the hernia was opened. The patient was discharged without postoperative complications.DiscussionThe diagnosis of retrocecal hernia can often be confirmed intraoperatively. This disease is identified based on a minimal error in rotation with incarceration behind the cecum during the final phase of descent and fixation of the right colon or failure of cecal and retroperitoneal fixation. Early preoperative diagnosis is important to prevent intestinal ischemia, necrosis, and perforation and to reduce resection rates.ConclusionEarly preoperative diagnosis is important to avoid resection of the small intestine. CT scans are useful for preoperative diagnosis in case of retrocecal hernia.     

Laparoscopic treatment of left paraduodenal hernia in two cases of children

IntroductionThe paraduodenal hernia is an internal hernia that might cause a small bowel obstruction. The laparoscopic repair of paraduodenal hernia is sporadically reported for its safety, convenience, and patient's satisfaction.Presentation of caseWe performed the laparoscopic treatment of the left paraduodenal hernia in two children, a 3-months old boy and 12-year old girl. The girl had a left upper quadrant pain for one month with postprandial nausea after eating. The 3-months boy presented with an intermittent severe irritability. Small bowel series and computed tomography showed the left paraduodenal hernia in two patients. We successfully did the laparoscopic paraduodenal hernia repair using 5 mm and 3 mm laparoscope. They discharged within 5 days, uneventfully.DiscussionDespite of technical difficulties in pediatrics such as small working space and less pneumoperitoneum, the laparoscopic repair for paraduodenal hernia leads to patient's earlier intake of diet and rapid recovery with cosmetic satisfaction. The 3 mm laparoscopic repair needs longer operation time, but it is feasible in infants.ConclusionLaparoscopic repair of paraduodenal hernia in children and infants is safe and feasible. We recommend the laparoscopic repair as the first surgical option for paraduodenal hernia.     

Do recurrences after paraesophageal hernia repair matter?

Background The recurrence rate for paraesophageal hernias (PEH) can be as high as 30% following laparoscopic repair. The aim of this study was to determine the severity of symptoms in patients with recurrences and the need for reoperation 10 years after surgery. Methods and Procedures Consecutive laparoscopic paraesophageal cases performed at a single institution between 1993 and 1996 were identified from the institution’s foregut database. Patients were asked about the presence and severity of symptoms (heartburn, chest pain, regurgitation, and dysphagia). Patients were also asked whether they had (1) been diagnosed with hernia recurrence or (2) undergone repeat surgical intervention. Results Complete follow-up was obtainable in 31 of the total of 52 patients (60%). The proportion of patients reporting moderate/severe symptoms was less at 10 years than preoperatively: heartburn 12% versus 54% (p < 0.001), chest pain 9% versus 36% (p = 0.01), regurgitation 6% versus 50% (p < 0.001), and dysphagia 3% versus 30% (p = 0.001). Two patients underwent repeat surgical intervention for symptomatic recurrences within the first postoperative year. Eight more patients have been diagnosed with hernia recurrences on either contrast esophagram or upper endoscopy but had not required reoperation. At ten years, more patients with hernia recurrence had heartburn than those who did not have recurrences (60% versus 14%; p < 0.05). Conclusions Despite a hiatal hernia recurrence rate of 32% 10 years after surgery, laparoscopic PEH was a successful procedure in the majority of patients; most remained symptomatically improved and required no further intervention 10 years after surgery.     

Spigelian hernia in a child: case report and review of the literature

Abstract. Spigelian hernias (SHs) are rarely observed among children. The diagnosis is not difficult to make once it has been considered. The condition requires a high index of suspicion because of its high potential for life-threatening complications. A 12-year-old boy underwent open appendectomy for presumed acute appendicitis. A normal appendix found at laparotomy suggested another etiology for the acute abdomen. Incarceration of the greater omentum in a spigelian hernia was found, and the hernia repaired. The repair of pediatric SH is straightforward and utilizes endogenous tissues. Patients should be followed up for as long as possible to develop data on the durability of the repair technique selected. Electronic Publication     

Classification of primary and incisional abdominal wall hernias

Purpose  A classification for primary and incisional abdominal wall hernias is needed to allow comparison of publications and future studies on these hernias. It is important to know whether the populations described in different studies are comparable. Methods  Several members of the EHS board and some invitees gathered for 2 days to discuss the development of an EHS classification for primary and incisional abdominal wall hernias. Results  To distinguish primary and incisional abdominal wall hernias, a separate classification based on localisation and size as the major risk factors was proposed. Further data are needed to define the optimal size variable for classification of incisional hernias in order to distinguish subgroups with differences in outcome. Conclusions  A classification for primary abdominal wall hernias and a division into subgroups for incisional abdominal wall hernias, concerning the localisation of the hernia, was formulated.

Lesser sac herniation through the greater omentum and gastro-pancreatic ligament: Report of a case

We report herein the case of a woman who developed a lesser sac hernia which was especially unusual in that the small bowel prolapsed through a defect in the greater omentum and was thereafter strangulated by a hole in the gastro-pancreatic ligament. The gastro-pancreatic ligament has never before been documented as causing an internal hernia. In our patient, a plain abdominal X-ray demonstrated as soft-tissue mass displacing the stomach to the left while abdominal computed tomography and ultrasonography showed a sac-like encapsulation of the small bowel loops between the liver and stomach. Careful evaluation of these radiographic findings allowed for the preoperative diagnosis of a lesser sac hernia to be made.     

Laparoscopic repair of complicated umbilical hernia with Strattice Laparoscopic™ reconstructive tissue matrix

INTRODUCTION

Complex hernias continue to present a challenge. Surgical techniques for repair are carefully considered to reduce risk for complications. Laparoscopic repairs improve postoperative infection rates, and placement of biologic mesh decreases mesh infection rates. However, laparoscopic repairs using biologic mesh is generally challenging due to difficulty with maneuverability.

PRESENTATION OF CASE

We present a case of a complex ventral hernia that was laparoscopically repaired using a new FDA cleared laparoscopic biologic graft. The patient had multiple comorbidities, including obesity, hepatitis C, endocarditis secondary to IV drug use, tobacco smoking, bilateral inguinal hernia, and recurrent umbilical hernia. The recurrent hernia was larger, irreducible, and discolored compared to original defect. The patient underwent laparoscopic repair with primary closure and reinforcement with Strattice™ Tissue Matrix Laparoscopic (LifeCell Corporation, Branchburg, NJ). At nine months postoperative, the patient had no evidence of recurrence, infection, or chronic pain, demonstrating early success from the surgical management.

DISCUSSION

Presence of multiple comorbidities and incarcerated recurrent hernia increase risk for complications during and/or after hernia repair. Considering these factors, laparoscopic repair with Strattice Laparoscopic and defect closure was a reasonable technique for repair.

CONCLUSION

Laparoscopic suture repair reinforced with biologic dermal tissue matrix was successfully performed during a complex hernia repair.     

Laparoscopic repair of a right paraduodenal hernia

Background: Laparoscopic repair of a right paraduodenal hernia has never been described in the literature. A 24-year-old woman was admitted after 2 weeks of intermittent abdominal pain associated with nausea and vomiting. Physical examination was normal. Laboratory studies and upper endoscopy were normal. Computed tomography revealed that the small bowel was on the right side of the abdomen and the colon on the left, suspicious for malrotation. Subsequent upper gastrointestinal series with small bowel follow-through revealed the ligament of Treitz on the right with the small bowel encased within a probable hernia sac. A presumptive diagnosis of a right paraduodenal hernia was made.Methods and Results: Initial access was obtained with a 10-mm infraumbilical port followed by placement of 5-mm ports in the right and left upper and lower quadrants. The duodenum was identified and the small bowel was found encased within a hernia sac, which was opened widely from the duodenum to the pelvis. The hernia sac was opened laterally to avoid injury to the superior mesenteric vessels. The small bowel was then released from the sac into the peritoneal cavity. The entire bowel was inspected and no other abnormalities were noted. The patient had resolution of her abdominal pain and her postoperative course was uncomplicated. She was discharged home on postoperative day 3 and has since done exceptionally well.Conclusions: Paraduodenal hernia, a rare cause of small bowel obstruction, can present a diagnostic challenge. However, when the diagnosis is made preoperatively, a laparoscopic repair is a feasible and practical option. Poster presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Los Angeles, CA, USA, 12–15 March 2003 This article contains the opinions of the authors only and does not represent the opinions of the U. S. Department of Defense or the U. S. Army.     

Incarcerated Vesico-Inguinal Hernia: a Case Report

In this paper we report a rare case of an incarcerated inguinoscrotal hernia of the urinary bladder in a 64-year-old male patient. He presented with a giant inguinal hernia and pollakisuria. The bladder was surgically repositioned intra-abdominally and resection of part of the bladder fundus was performed through laparotomy. Closure of the inguinal defect was performed through an inguinal approach. The patient’s further recovery was uneventful. Herniation of the bladder is a very infrequent finding in inguinal hernias. We searched the literature and only found a few case reports describing this rare pathology. The literature and treatment options are discussed.     

A Grynfeltt hernia: Report of a case

Superior lumbar hernia (Grynfeltt hernia) is an uncommon variety of abdominal wall defect. There are three types of lumbar hernia: congenital, acquired, and incisional hernias. Diagnosis depends largely on the capacity for clinical suspicion, and confirmation is based on imaging tests. We report a case of an acquired lumbar hernia diagnosed by computed tomography (CT), which was treated successfully at our institution.     

Allograft AlloDerm® tissue for laparoscopic transabdominal preperitoneal groin hernia repair: A case report

INTRODUCTION

Synthetic mesh is the prosthetic material used for most inguinal hernioplasties. However, when left in contact with intra-abdominal viscera, it often becomes associated with infection and migration, particularly in irradiated tissues, contaminated fields, immunosuppressed individuals, and patients with intestinal obstruction or fistula. AlloDerm^® Regenerative Tissue Matrix (LifeCell Corporation, Branchburg, NJ) is derived from human cadaver skin and may be associated with fewer visceral adhesions and more durability in infected fields than synthetic mesh.

PRESENTATION OF CASE

We report the first case in which AlloDerm was used in a laparoscopic transabdominal preperitoneal repair of a multiple recurrent right inguinal hernia, a left femoral hernia, and an umbilical hernia in the same patient. Use of AlloDerm greatly enhanced the maneuverability during laparoscopic hernia repair due to its pliability and strength and eliminated the need to cover the prosthetic with peritoneum.

DISCUSSION

Previous pelvic radiation and multiple previous groin repairs can render the peritoneum friable, resulting in obstacles to successful closure. AlloDerm is a reasonable choice for groin hernia repairs when such factors are present.

CONCLUSION

The long-term durability of AlloDerm for laparoscopic groin hernia repairs is yet to be determined, but based on current data it seems prudent to use this technique in laparoscopic repair of complex groin hernias where infection is suspected or inadequate prosthetic coverage with peritoneum is anticipated.     

Congenital Intra-Mesosigmoid Hernia- A Case Report of a Rare Sigmoid Mesocolon Hernia

Internal hernia is the protrusion of the viscera through normal or abnormal peritoneal or mesenteric apertures within the confines of peritoneal cavities.     

Hernioscopy: a useful technique for the evaluation of incarcerated hernias that retract under anaesthesia

Introduction The diagnosis of strangulation within an incarcerated abdominal-wall hernia is not always possible preoperatively. In approximately 1% of cases of incarcerated hernias, a strangulated viscus will reduce spontaneously following administration of muscle relaxants during induction of anaesthesia, and the surgeon has to perform an exploratory laparotomy. The aim of this study was to report the use of hernioscopy to inspect intra-abdominal contents and thus prevent unnecessary laparotomy. Patients and methods The case notes of all patients undergoing hernioscopy for incarcerated hernias that reduced spontaneously during induction of anaesthesia, skin incision, or prior to evaluation of sac contents were reviewed. Hernioscopy is performed following insertion of a 10-mm port through the hernia sac. Standard insufflation with carbon dioxide is performed, maintaining an intra-abdominal pressure of 10–12 mmHg following which the laparoscope is inserted and a diagnostic examination performed. Following completion of hernioscopy, the laparoscope is withdrawn, the pneumoperitoneum released, and the hernia repaired in a conventional manner using a tension-free technique. Results Five patients underwent hernioscopy for the evaluation of incarcerated hernias that had reduced spontaneously prior to inspection of sac contents. There were four men with indirect inguinal hernias and one woman with an incarcerated femoral hernia. The hernioscopy of the four men was unremarkable and they went home the following day. The female patient had blood within the peritoneal cavity arising from the upper abdomen and underwent laparotomy and splenectomy. She made an unremarkable recovery and was discharged on postoperative day 7. Conclusion Hernioscopy is a simple and useful technique that can be performed by surgeons familiar with laparoscopic procedures such as appendicectomy and cholecystectomy.     

Laparoscopic repair of recurrent groin hernia: results of a prospective study

Background  Recurrences continue to be seen after repair of inguinal hernias. The repair of these recurrent hernias is a more complex and demanding procedure, with a high re-recurrence rate. Definite advantage has been demonstrated with endoscopic repair of these hernias. Methods  The results for this prospective study from January 2003 to December 2006 were evaluated after laparoscopic repair of 65 recurrent hernias in 61 patients. The patients were followed up for 1 year. Longer follow-up evaluation was performed for the patients who underwent surgery in the initial 3 years. Results  In this study, 37 recurrent hernias were managed using the transabdominal preperitoneal technique (TAPP) technique and 28 using the totally extraperitoneal (TEP) technique. There was no conversion and no cases of postoperative wound infection. Of the 12 metachronous hernias repaired simultaneously, 3 were occult. Seroma developed in five patients. At a follow-up assessment after 1 year, one patient had groin pain, and there was one re-recurrence. A longer follow-up period with a mean of 35.11 months failed to show any new re-recurrence. Conclusions  Laparoscopic repair of recurrent inguinal hernia is safe and effective. The morbidity and recurrence rates for the procedure are as low as for laparoscopic repair of primary hernias. Laparoscopic repair should be the gold standard for these hernias.