European Hernia Society has defined ventral hernias larger than 10 cm as giant ventral hernias. Lumbar hernias are one among the rare hernias and account for <1.5% of all abdominal hernias. Only a few cases of giant lumbar hernias are reported in the literature.
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.
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.
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.
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. 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. Another method to achieve tension-reduced abdominal closure is posterior component separation of the abdominal wall, 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.
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Conflicts of interest
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