Computerized Tomography Scan with a Valsalva Maneuver for the Diagnosis of Denervative Abdominal Wall Hernia

Abstract

Background: Flank or abdominal hernia after open renal surgery is rare. The mechanisms of this pathology involve wound dehiscence and/or the sub-costal nerve severing, and the latter still has room for emphases, especially for diagnosis establishment. Case Report: A 64-year-old woman presented with a ten years history of left abdominal pain and bulge after a left nephrectomy in 1998 because of her left renal stone disease. Following the procedure, she experienced a further left abdominal pain and developed a progressively enlarging left flank bulge. CT scan excluded the presence of an organic cause, such as intra-abdominal pathology, but showed a thinner layer of musculature on the left side without a definitive hernia orifice, which was distended during a Valsalva maneuver. A left flank denervative hernia was subsequently diagnosed. Surgical repair was employed with nonabsorbable synthetic mesh using a standard preperitoneal sublay fashion. Conclusion: This case raises our awareness of a hard sign of a denervative abdominal wall hernia in CT scan: abdominal wall bulge with attenuation of the abdominal wall musculature and without definitive hernia orifice at the affected side. If there is any doubt in the diagnosis (often there is in early stage), a CT scan with a Valsalva maneuver is suggested, which will make the sign more significant.