Flank Hernia Research Articles

Combined open-robotic 'sandwich' repair for flank hernias: a case series of 10 patients.

Flank hernias represent a rare and technically challenging conundrum for abdominal wall surgeons. Various operative techniques have been attempted including open, laparoscopic, and robotic without an established gold standard. We present a novel technique utilizing a hybrid open-robotic "sandwich" technique for flank hernia repairs. Single center, retrospective case series of a single surgeon performing consecutive flank hernia patients via novel technique between 2017 and 2023. Demographic information, clinical hernia characteristics, operative technique, peri-operative complications, and long-term outcomes were collected. Ten patients underwent repair. Average age at repair was 67.6 (SD: 13.4), 70% males, mean BMI 29.6 (SD: 3.11), all ASA 3, and no current smokers. Average hernia defect measured 11.5cm (SD: 8.3) vertically and 8.1cm (SD: 3.7) horizontally. Mean operative time was 259.6min (SD: 85.1), estimated blood loss 30.5cc, and length of stay 1.6days (SD 1.6). There were no intra-operative complications. 30-day morbidity included one (10%) patient developing an ileus and one (10%) patient had a hematoma. At a mean follow up of 34months there was no chronic pain or hernia recurrences. This study outlines a novel approach to complex flank hernia repairs utilizing a combination of an open and robotic approach. There were no long-term surgery related complications, chronic pain, or recurrences in our cohort with a minimum follow up of 6months and mean of 34months. Further studies need to be completed in prospective fashion to elucidate the goal standard repair for flank hernias.

Outcomes of posterior sheath supplementation with Vicryl mesh in TAR-a single-center study.

In the Transversus Abdominis Release (TAR) procedure, ideally, the posterior sheath is completely reapproximated to establish an interface isolating the polypropylene mesh from visceral contents. When primary closure of the posterior sheath is unachievable, Vicryl mesh is commonly used to supplement the posterior sheath closure and an uncoated polypropylene mesh is placed superficial to the Vicryl mesh. The long-term implications of utilizing Vicryl mesh as an antiadhesive barrier are poorly understood. In this study, we aimed to assess our outcomes when utilizing Vicryl mesh to supplement the posterior sheath defects when placed underneath polypropylene mesh in patients undergoing posterior component separation. Adult patients who underwent VHR with concurrent TAR procedure with a permanent synthetic mesh and posterior sheath supplementation with Vicryl mesh in the Cleveland Clinic Center for Abdominal Core Health between January 2014 and December 2022 were queried retrospectively from a prospectively collected database in the Abdominal Core Health Quality Collaborative. We evaluated 30-day wound morbidity, perioperative complications, long-term mesh-related complications, and pragmatic hernia recurrence. 53 patients who underwent TAR procedure with posterior sheath supplementation using Vicryl mesh and had a minimum 12-month follow-up were identified. Of the53 patients, 94.3% presented with recurrent hernias, 73.6% had a midline hernia, 7.5% had a flank hernia, and 18.9% had concurrent parastomal hernia. The mean hernia width was 24.9 cm (± 8.8 cm). No Vicryl mesh-related operative complications were identified in our study, with no instances of mesh erosion, fistulas, or interventions for small bowel obstruction. Skin necrosis requiring reoperations was observed in three patients (5.7%), leading to permanent mesh excision in two cases (3.8%) without intraabdominal visceral involvement. Throughout the 12-month follow-up, 23 incidences (43.4%) of surgical site occurrences (SSOs) and surgical site occurrences requiring procedural intervention (SSOPI) were documented. Our findings suggest that posterior sheath supplementation with Vicryl mesh is a feasible approach to achieve posterior sheath closure in challenging abdominal wall reconstruction cases. Given the absence of notable mesh-related complications and a similar hernia recurrence rate to cases without posterior sheath supplementation, Vicryl mesh can be used to safely achieve posterior sheath closure in complex reconstructions with insufficient native tissue.

Open repair of flank and lumbar hernias: 142 consecutive repairs at a high-volume hernia center

BackgroundFlank and lumbar hernias (FLH) are challenging to repair. This study aimed to establish a reproducible management strategy and analyze elective flank and lumbar repair (FLHR) outcomes from a single institution. MethodsA prospective analysis using a hernia-specific database was performed examining patients undergoing open FLHR between 2004 and 2021. Variables included patient demographics and operative characteristics. ResultsOf 142 patients, 106 presented with flank hernias, and 36 with lumbar hernias. Patients, primarily ASA Class 2 or 3, exhibited a mean age of 57.0 ​± ​13.4 years and BMI of 30.2 ​± ​5.7 ​kg/m2. Repairs predominantly utilized synthetic mesh in the preperitoneal space (95.1 ​%). After 29.9 ​± ​13.1 months follow-up, wound infections occurred in 8.3 ​%; hernia recurrence was 3.5 ​%. At 6 months postoperatively, 21.2 ​% of patients reported chronic pain with two-thirds of these individuals having preoperative pain. ConclusionsOpen preperitoneal FLHR provides a durable repair with low complication and hernia recurrence rates over 2.5 years of follow-up.

Robotic thoracoabdominal hernia repair: a novel approach.

Thoracoabdominal hernias remain a rare and poorly understood entity. Data remain sparse as terminology varies in the literature and case reports demonstrate wide variability in technique. We present a novel approach for repair of thoracoabdominal hernias using the robotic platform. Two patients underwent a robotic thoracoabdominal hernia repair in June 2022. They were followed for 1year with CT scans every 6months to exclude recurrence. Patient demographics and peri-operative details including defect size, closure technique, mesh size, length of stay, and complications were reported. Both patients successfully underwent a robotic repair of a thoracoabdominal hernia, addressing the intercostal hernia, diaphragmatic disruption, and flank hernia discretely during the operation. One patient had an uneventful recovery and discharged on post-operative day 3; the other developed a small bowel obstruction due to an early port site hernia which required surgical intervention. He eventually discharged on post-operative day 9. At one year, there is no clinical or radiographic evidence of recurrence for either patient. Robotic thoracoabdominal hernia repair is feasible and offers a minimally invasive repair option for these extremely complex hernias.

Challenging hernias: a case series of atypical hernias and review of literature

Atypical hernias encompass the categories of flank, lumbar, spigelian, suprapubic and subxiphoid hernias among other rarer variants. These are considered to be tribulation in terms of their diagnosis and management, in that they are in proximity to the bone, which makes defect delineation, adequate mesh overlap, and fixation very challenging. Here, we would like to highlight a selection of our institutional experience with such hernias and their management. Within the institution, 6 cases of such rare hernias repaired within the last 6 months were chosen that posed a therapeutic challenge to the operating team. The cases described are- an interparietal port site incisional hernia, true lumbar hernia, flank region incisional hernia, a traumatic flank hernia, traumatic obstructed interparietal flank hernia, and a traumatic diaphragmatic hernia. All of the above cases were successfully managed by our team by a combination of abdominal wall reconstruction and mesh repair and have not reported any post-operative complications in the follow up period. Literature regarding rare hernia repairs is becoming more exhaustive by the day. However, the likelihood that we encounter such cases in practice is still less. Hence, it is essential to further the knowledge about management of such complex hernias and make an informed decision tailored to the patient’s requirements.

Abdominal reconstruction in a patient with flank hernia after trauma, a case report and review of the literature

Abdominal reconstruction in a patient with flank hernia after trauma, a case report and review of the literature

OC-077 OPEN REPAIR OF FLANK AND LUMBAR HERNIAS (FLH): 145 CONSECUTIVE REPAIRS AT A HIGH-VOLUME, TERTIARY HERNIA CENTER

Abstract Aim FLH present a surgical challenge due to their anatomic location, proximity to boney structures, and lack of elasticity of the surrounding muscle. With less than 1,000 cases reported, there is no uniform operative management. This is the largest study to date evaluating FLH repair (FLHR). Materials & Methods A prospective, single-center, hernia specific database was queried for patients who underwent open flank or lumbar hernia repair from 2004–2021. Demographics, operative characteristics, and outcomes were evaluated. Standard statistical methods were used. Results 145 patients included 109 flank hernias and 36 lumbar hernias. The hernias resulted from prior surgery (73.3%), blunt trauma (19.7%), or primary defects (7.0%). The mean defect size was 125.7±166.8cm2, 46.9% were recurrent, and 11.0% of patients visited a pain specialist preoperatively. Mesh was commonly synthetic (92.4%), a mean of 755.9±373.4 cm2, and placed in the preperitoneal space (92.7%). Component separation technique was utilized in 16.8% of cases and pelvic bone anchor fixation in 13.8%. Preoperative chronic pain was present in 75% of patients receiving bone anchors and only 6.6% postoperatively. Complete defect closure occurred in each case. Wound infection (8.1%) and mesh infection (1.4%) were uncommon. Prolonged, postoperative discomfort was reported in 22%, half of which had chronic pain preoperatively (p<0.01). Hernia recurrence was 3.4% at 29.3±13.2 months follow-up. Recurrences occurred posteriorly in 3 and in 2 mesh infections requiring explantation. Conclusions Open preperitoneal repair of FLHs with synthetic mesh results in low rates of postoperative complications and hernia recurrence. Postoperative pain correlated closely with preoperative pain.

ID:16060 Dorsal Root Ganglion Stimulation to Treat Focal and Diffuse Pain After Minimally Invasive Spine Surgery

Dorsal root ganglion stimulation (DRG-S) is an accepted neuromodulatory technique for the treatment of focal and dermatomal pain syndromes, and emerging evidence is demonstrating its efficacy in non-dermatomal syndromes such as failed back surgery syndrome (FBSS). Chronic pain patients often present with more than one source of pain1 and patients that experience a surgical complication are more likely to experience a second complication2. Here we present a patient who lost efficacy with SCS, leading to an extreme lateral interbody fusion (XLIF), which was complicated by flank hernia and severe focal neuropathic pain post-surgical repair. A year after XLIF, she was diagnosed with FBSS. DRG-S was successfully used to treat both conditions.

A novel hybrid approach to the repair of flank hernias

A novel hybrid approach to the repair of flank hernias

Ultrasound Guided Percutaneous Nephrolithotomy in Mesh-Repaired Incisional Hernia.

Objectives To describe our technique of percutaneous nephrolithotomy (PNL) in patients with mesh-repaired flank incisional hernia. Polypropylene mesh which is used for fascia strengthening in hernia repair elicits intense inflammatory reaction and the consequent fibrosis alters the characteristics of abdominal wall. Thus, prior history of flank hernia repair with mesh may result in percutaneous nephrolithotomy failure. Materials and Methods Demographic data, renal stones characteristics, and any complication during surgery and follow-up of patients who were treated by PNL during 2011 to 2020 and had mesh in their flank region were collected. Results Percutaneous nephrolithotomy was performed without any problem in 8 patients with guide of ultrasonography. Conclusion Based on our experience, ultrasound-guided PNL is feasible and hypothetically superior to fluoroscopy in such circumstances.

OV18 ENDOSCOPIC RETRO-MUSCULAR REPAIR OF PARASTOMAL HERNIA - A TANTALIZING NEW TECHNIQUE

Abstract Development of retro muscular space with transversus abdominis release has reached maturity in endoscopic surgery. Next-level reconstruction is adaptation to parastomal hernia repair alone or in conjunction with another abdominal wall hernia repair. We aim to present this extraperitoneal modified mesh technique based on the Sugarbaker principle with video demonstration and share clinical data and results from twenty-four patients operated with this technique within two years from the spring of 2019 to the spring of 2021. 77% patients had para-colostomy hernia and 41% of the patients had accessory repairs for midline or opposite flank hernia. 18% had prophylactic mesh at index operation, 27% were recurrent parastomal hernia and ostomies were formed median 32 months prior to parastomal hernia repair. 72% of the patients were operated robotically and 28% laparoscopically. Median follow up at time for presentation will be 17 months.

Bilateral congenital flank hernias due to complete lateral abdominal wall muscular agenesis

We report a case of a 4-week-old female presenting with congenital bilateral flank hernias. The patient was born at term and was found to have large bilateral flank bulges. Although her hernias were asymptomatic, bilateral lower extremity jerking movements prompted further workup which revealed thoracolumbar spinal cord dysraphism. No other congenital anomalies were identified. Given the low risk of incarceration, repair was delayed until 9 months of age. At operation, complete bilateral agenesis of the oblique and transversus abdominus musculature was found. Open repair was performed with bilateral latissimus dorsi rotational muscle flaps and biological mesh. Congenital flank hernias are extremely rare with few cases reported in the literature. While they can appear externally similar to the more widely reported congenital lumbar hernia, the herniation through the absent oblique and transversus musculature makes this case anatomically distinct. The exact etiology of congenital flank hernias is unclear, although given the presence of associated congenital anomalies, migrational failure during embryogenesis represents a likely culprit. Surgeons approaching this pathology should understand the importance of a thorough multidisciplinary evaluation for associated anomalies prior to operation and be familiar with complex hernia repair techniques such as rotational flaps.

Management of blunt traumatic abdominal wall hernias: A Western Trauma Association multicenter study.

Blunt traumatic abdominal wall hernias (TAWH) occur in approximately 15,000 patients per year. Limited data are available to guide the timing of surgical intervention or the feasibility of nonoperative management. A retrospective study of patients presenting with blunt TAWH from January 2012 through December 2018 was conducted. Patient demographic, surgical, and outcomes data were collected from 20 institutions through the Western Trauma Association Multicenter Trials Committee. Two hundred and eighty-one patients with TAWH were identified. One hundred and seventy-six (62.6%) patients underwent operative hernia repair, and 105 (37.4%) patients underwent nonoperative management. Of those undergoing surgical intervention, 157 (89.3%) were repaired during the index hospitalization, and 19 (10.7%) underwent delayed repair. Bowel injury was identified in 95 (33.8%) patients with the majority occurring with rectus and flank hernias (82.1%) as compared with lumbar hernias (15.8%). Overall hernia recurrence rate was 12.0% (n = 21). Nonoperative patients had a higher Injury Severity Score (24.4 vs. 19.4, p = 0.010), head Abbreviated Injury Scale score (1.1 vs. 0.6, p = 0.006), and mortality rate (11.4% vs. 4.0%, p = 0.031). Patients who underwent late repair had lower rates of primary fascial repair (46.4% vs. 77.1%, p = 0.012) and higher rates of mesh use (78.9% vs. 32.5%, p < 0.001). Recurrence rate was not statistically different between the late and early repair groups (15.8% vs. 11.5%, p = 0.869). This report is the largest series and first multicenter study to investigate TAWHs. Bowel injury was identified in over 30% of TAWH cases indicating a significant need for immediate laparotomy. In other cases, operative management may be deferred in specific patients with other life-threatening injuries, or in stable patients with concern for bowel injury. Hernia recurrence was not different between the late and early repair groups. Therapeutic/care management, Level IV.

Flank incisional hernia after lateral approach spine operations: presentation and outcomes after repair.

The flank approach to lumbar spine surgery is considered a new minimally invasive alternative to the anterior abdominal approach. Flank incisional hernia is one complication, but it has been poorly studied. Retrospective review of patients referred for evaluation of abdominal bulging after Lateral Interbody Fusion (LIF), 2013-2020. Seventeen patients were evaluated for abdominal bulging after LIF: 14 were diagnosed with incisional hernias. Three with denervation injury without hernia defect were excluded. This is the largest study addressing incisional flank hernias after LIF, an under-represented complication in the spine literature. We show that the patients present early, within months of their operation, and yet most hernias are not diagnosed for over a year. Although LIF is considered a minimally invasive procedure, the morbidity from hernia complications cannot be overlooked. These flank hernias are difficult to repair with suboptimal outcomes. We prefer robotic approach with primary closure of the defect and extraperitoneal sublay mesh, whenever possible. Prevention is key. To help reduce risk of hernia, we recommend closure of all muscle layers with slowly absorbable suture; this is different than was originally described in the spine literature.

ROBOTIC TRANS-ABDOMINAL PREPERITONEAL APPROACH (TAPP) APPROACH FOR LATERAL INCISIONAL HERNIAS.

ABSTRACT Background: Lateral incisional hernias arise between the linea alba and the posterior paraspinal muscles. Anatomical boundaries contain various topographic variations, such as multiple nearby bony structures and paucity of aponeurotic tissue that make it particularly challenging to repair. Aim: To describe a robotic assisted surgical technique for incisional lumbar hernia repair. Methods: Retrospective data was collected from four patients who underwent robotic-assisted repair of their lumbar hernias after open nephrectomies. Results:Age ranged from 41-53 y. Two patients had right sided flank hernias while the other two on the left. One patient had a recurrent hernia on the left side. The patients were placed in lateral decubitus position contralateral to the hernia defect side. A trans-abdominal preperitoneal approach was used in all cases. Each case was accomplished with two 8 mm robotic ports, a 12 mm periumbilical port, and a 5 mm assistance port that allowed docking on the ipsilateral hernia side. The hernias were identified, a preperitoneal plane was created, and the hernia sac completely dissected allowing for complete visualization of the defect. All defects were primarily closed. Polypropylene or ProGripTM mesh was applied with at least 5 cm overlap and secured using either #0 Vicryl® transfacial sutures, Evicel® or a combination of both. The peritoneal space was closed with running suture and the ports were removed and closed. The average surgical length was 4 hr. The post-operative length of stay ranged from 0-2 days. Conclusion: The robotics platform may provide unique advantages in the repair of lateral incisional hernias and represents a safe, feasible and effective minimally invasive approach for the correction of lateral incisional hernias.

The Effects of Preoperative Botulinum Toxin A Injection on Abdominal Wall Reconstruction

BackgroundFascial closure significantly reduces postoperative complications and hernia recurrence after abdominal wall reconstruction (AWR), but can be challenging in massive ventral hernias. MethodsA prospective single-institution cohort study was performed to examine the effects of preoperative injection of botulinum toxin A (BTA) in patients undergoing AWR for midline or flank hernias. ResultsA total of 108 patients underwent BTA injection with average 243 units, mean 32.5 days before AWR, without complications. Comorbidities included diabetes (31%), history of smoking (27%), and obesity (mean body mass index 30.5 ± 7.7). Hernias were recurrent in 57%, massive (mean defect width 15.3 ± 5.5 cm; hernia sac volume 2154 ± 3251 cm3) and had significant loss of domain (mean 46% visceral volume outside abdominal cavity). Contamination was present in 38% of patients. Fascial closure was achieved in 91%, with 57% requiring component separation techniques (CSTs). Subxiphoidal hernias needed a form of CST in 88% compared with 50% for hernia not extending subxiphoidal (P < 0.001). Mesh augmentation was used in 98%. Postoperative complications occurred in 40%: 19% surgical site occurrences, 12% surgical site infections, and 7% respiratory failure requiring intubation, 2% mesh infection and no fascial dehiscence. Recurrence was identified in seven patients after mean 14 months of follow-up. Patients undergoing AWR with CST had more surgical site occurrences (29 versus 7%, p0.003) and respiratory failures (18 versus 0%, P = 0.002) than patients who did not require CST. ConclusionsIn patients with massive ventral hernias, the use of preoperative BTA injections for AWR is safe and is associated with high fascial closure rates and excellent recurrence rates.

Ultrasound-Guided Chemical Component Separation with Botulinum Toxin A prior to Surgical Hernia Repair

US-guided chemical component separation (CCS) of the abdominal musculature using botulinum toxin A can facilitate the surgical repair of large or complex hernias. Eight patients (2 women and 6 men with median age of 54 years [range, 34–78 years]) underwent preoperative US-guided CCS with hydrodissection before planned surgical repair of large or complex ventral (n = 4), inguinal (n = 2), and flank (n = 2) hernias by 2 interventional radiologists. Technical success rate of US-guided CCS procedures was 100%, and all patients achieved surgical closure a mean 34.1 days (range, 14–48 days) after US-guided CCS.

Hybrid laparoscopic and open repair of post-nephrectomy flank hernia

Surgical repair of flank hernia is not routinely performed, due to perceived technical difficulties with the surgery and risk of recurrence, or the misconception that flank hernia is solely due to a denervation injury. Due to the rareness of flank hernia in the literature, there is no general consensus on the best method of surgical repair. We present the case of a patient with a symptomatic large flank hernia following open nephrectomy, in which a hybrid technique of open and laparoscopic flank hernia repair with sublay mesh and bone anchor fixation was successfully performed with good outcome. This case highlights the benefits of the hybrid approach, which allowed a laparoscopic assessment of the defect and adhesiolysis, followed by the open repair which enabled adequate mesh overlap, fixation to surrounding tissues and bone anchor fixation.

Robotic assisted treatment of flank hernias: case series

BackgroundFlank hernias are uncommon, surgical treatment is challenging and the minimally-invasive approach not always feasible. The aim of this study was to report the safety and feasibility of the robotic-assisted repair.MethodsThe study was approved by the local ethic committee (2019–01132 CE3495). A retrospective search on a prospectively collected dataset including demographic and clinical records on robotic surgery at our institution was performed to identify patients treated for a flank hernia. Patients were followed-up 6 months.ResultsFrom January 2018 to December 2019, out of 190 patients who underwent robotic-assisted hernia surgery, seven with incisional flank hernia were included. Median age was 69.0 years (IQR 63.2–78.0), BMI was 27.3 kg/m2 (IQR 25.8–32.3) and two patients were male (29%). All patients were referred to surgery because of pain, whereas one of them described recurrent episodes of small bowel obstruction.The median hernia defect measured 25 mm ((IQR 21–40), median mesh diameter was 10 cm (IQR 10–12.5) and median operative time was 137 min (IQR 133–174). No intraoperative complication occurred.Postoperatively, one patient developed a pneumonia, which required antibiotics. Length of hospital stay was 4.0 days (IQR 3.0–7.7). Six months after surgery, neither recurrence nor chronic pain were recorded.ConclusionsRobotics in abdominal wall hernia surgery remains a matter of debate, despite a growing interest from the surgical community. In our reported experience with flank hernias, we found the robotic-assisted approach to be safe and feasible for the treatment of this uncommon clinical entity.

Simplified Repair of Traumatic Iliac Crest Flank Hernias with Mesh Strips.

Background:Traumatic abdominal wall hernias are rare injuries resulting from blunt abdominal trauma. Traditional approaches have included both open and laparoscopic approaches, with placement of large meshes with giant overlaps. Perhaps the most technically difficult aspect of these repairs is fixating the abdominal wall to the iliac crest. The senior author has developed a method of repair using 2-cm strips of mesh. In this article, we present a description of 4 patients treated with this technique.Methods:We included 4 adult patients who underwent traumatic flank hernia repairs by the senior author. We excluded incisional hernias and patients who received a planar sheet of mesh. Demographics and outcomes collected included length of stay, follow-up time, and complications.Results:The average age was 38.5 years. Three hernias were due to motor vehicle collision injuries, and 1 was a crush injury at work. No planar meshes or bone anchors were used. No patients required component separation. There were no instances of surgical site infection, hematoma, or wound breakdown. All repairs were intact at the time of last follow-up (average, 24.3 months; range, 4–48.7 months).Conclusions:Traumatic flank hernias are rare injuries that can be difficult to address. Here, we describe a technique of primary repair with mesh strips that distribute the forces of repair across a greater surface area than can be achieved with sutures. Placing drill holes through the iliac crest avoids the cost and complexity of suture anchors.