Lumbar Incisional Hernia Research Articles

LUMBAR INCISIONAL HERNIA REPAIR-PREPERITONEAL PLACING OF MESH-THE IMPORTANCE OF CT EVALUATION

Abstract Background Lumbar hernias can be congenital (primary) or aquired (postoperative and posttraumatic). The margins are well-known: the iliac crest, 12th rib, the erector spinae and the external oblique muscle. The most number of lumbar incisional hernias occur after nephrectomy. Objective To show the results in treatment of lumbar incisional hernias in district General hospital and to review the importance of CT evaluation before and after treatment of lumbar incisional hernias (specially for W3 = the width of hernia defect ≥ 10 cm ≈ large hernias). Methods This is retrospective case-study analysis from June 2005 till November 2021.The mean follow-up for all patients was 36 months. Results From 15 June 2005. to 15 November 2021 we operated 18 patients with diagnosis: Lumbar incisional hernia. 16 patients were operated due to principles of sublay-preperitoneal placing of MESH (all by the same surgeon). In our evaluation we divided the patients in 3 groups according to the width (size) of hernia defect – W1, W2 and W3. For the patients with “large hernias” (W3) – 5 patients, we perform CT of abdomen 3 times (before operation, a few months after operation and 2 or 3 years after operation). All other patients have CT of abdomen before operation-only certain proof for diagnosis. We do not have recurrences and none of our patients need analgetics more than two weeks after surgery. Laparoscopic incisional hernia surgery is not performed routine in our hospital yet. Conclusion Lumbar incisional hernias should be treated with sublay (preperitoneal placing of MESH) whenever is possible. CT evaluation before and after surgery is always usefull for large hernias, with big level of recommendence.

Incisional Hernia with Rare Finding of Liver as Content: A Case Report

Lumbar incisional hernia is an uncommon complication that affects the abdominal wall integrity, accounting for approximately 3.5% of all cases. It typically occurs following open nephrectomy or aortic aneurysm repair surgeries. Although rare, lumbar hernias can lead to discomfort, aesthetic issues, or even intestinal obstruction. In extremely rare cases, lumbar herniation of the liver can occur. Here, the authors present a case of a 60-year-old female patient with liver herniation through a lumbar incisional hernia and a history of pyelolithotomy for renal calculi. The authors performed an open hernia repair with meshplasty. Lumbar incisional hernias are rare and still difficult to manage. Computed tomography is the diagnostic method of choice in the evaluation of the parietal wall defect to choose the appropriate therapeutic management. Surgical management modalities are still poorly codified, with no precise recommendations, and this is probably due to the relative rarity of the cases.

Incisional lumbar hernias: Current role of laparoscopic approach with intraperitoneal onlay mesh procedure

Abstract PURPOSE: Lumbar incisional hernias are a defect of the posterolateral region on the abdominal wall that originated from previous surgical incisions in the area. A surgical approach is challenging due to low incidence and the lack of enough publications on the topic, which generates controversies among surgeons. The purpose of this paper is to show our laparoscopic approach experience using the intraperitoneal onlay mesh (IPOM) and IPOM Plus procedures for the treatment of lumbar incisional hernias. MATERIALS AND METHODS: This was a retrospective descriptive study, including 10 patients with lumbar/posterolateral incisional hernias, diagnosed by computerized tomography scan and surgically treated with the IPOM laparoscopic technique in one case and IPOM Plus in nine cases from 2014 to 2021. Demographic data and baseline characteristics of enrolled patients were assessed, as well as perioperative data, surgical time, length of hospital stay, and recurrence during an average 38.6-month follow-up. RESULTS: In the series assessed, the defect size ranged between 24 and 72 cm2, with mean longitudinal and transversal diameters of 7.9 and 5.8 cm, respectively. The surgery lasted 120–180 min. There were no cases of conversion or intraoperative visceral lesions. Nine patients were discharged on an average of 37.8 ± 8.9 h after admission, and one patient stayed for 64 h due to extra analgesic demand. Postoperative morbidity was a case of hematoma. There was one case of recurrence. CONCLUSION: The results of our experience have shown the benefits of the laparoscopic approach with the IPOM Plus method for the treatment of lumbar incisional hernias, including short hospital stays and low incidence of postoperative complications. Accordingly, this mainstream technique, which has shown good outcomes both in the short and the long term, appears to be a simple and safe procedure.

V-026 LAPAROSCOPIC TAPP REPAIR: IS IT REALLY FEASIBLE IN A RE-RECURRENT HERNIA?

Abstract Aim Describe a step by step laparoscopic transabdominal preperitoneal (TAPP) repair of a re-recurrent incisional lumbar hernia. Material & Methods This is the case of a 72-year-old man who had a previous traumatic right lumbar hernia initially approached by laparoscopic intra-peritoneal onlay mesh repair (IPOM) and its recurrence approached by open onlay mesh repair. CT-scan revealed a lumbar hernia on the right with a neck size of 40 mm. The hernia sac measured 65 mm and contained part of the right colon inside, without signs of incarceration nor dilated intestinal loops. According to the European Hernia Society classification for incisional abdominal wall hernias, the patient had a lateral hernia (L4 W2). Results Lateral incisional hernias are limited by the inguinal region inferiorly, the costal margin superiorly, the lateral margin of the rectal sheath medially and the lumbar region laterally. Due to their low incidence and the resulting lack of expertise in the treatment of this abdominal wall defect, surgical treatment poses a challenge- Conclusion The repair of a recurrent hernia is a daunting task, even more so of a re-recurrent one. By choosing to perform a TAPP repair, we were able to prove a laparoscopic re-do repair is feasible even faced with weakened tissues and distorted anatomy.

P-127 E-TEP ASSISTED REVERSE-TAR FOR THE TREATMENT OF LARGE LUMBAR INCISIONAL HERNIAS ASSOCIATED TO MIDLINE DEFECTS

Abstract Aim To describe a new hybrid surgical approach of large lumbar incisional hernias (IH) associated to synchronic midline defects. Material and Methods Prospective multicentric study including patients with large lumbar hernias (L4W3) associated to midline abdominal wall defects. Surgical intervention starts with a bilateral retrorectus dissection performed through a minimally invasive extraperitoneal endoscopic approach (eTEP). Once this space has been dissected, the lumbar IH is treated with an overextended centrifugal preperitoneal open approach through the previous lumbar incision. Afterwards the dissected spaces are communicated performing a reverse transversus abdominis release (TAR) from lateral to medial. A prosthetic preperitoneal repair is performed with an absorbable and permantent meshes that cover the space dissected. Results Five patients were included in the study. All patients had lumbar hernias L4W3 associated to primary or incisional midline hernias M1–5 W1–2. Eighty percent of the patients were women, with a mean age of 62 years. Mean BMI was 32 (range 30–34), with a 60% of diabetic patients, and 80% of recurrent lumbar hernias (between 1 and 3 previous repair attempts). Mean surgical time was 198 minutes (range 160–250). Mean hospital stay was 5 days (range 4–8 days). Two lumbar hematomas which didn't required any interventional procedure took place as the only surgical site occurrences, without any systemic complications. No recurrence has taken place after 5 months mean follow up (range 2–9 months) Conclusion Hybrid eTEP and open approach of large lumbar hernias associated with small midline defects seem to be an efficient and safe approach.

V-022 HYBRID APPROACH E-TEP AND OPEN FOR COMBINED LUMBAR AND MIDLINE HERNIAS

Abstract Aim To present the case of a 61-year-old woman with a recurrent lumbar incisional hernia L4W3R (EHS Classification) associated with a primary midline hernia, as well as a proposed treatment by combined e-TEP and open approach. Material and Methods This is a 61-year-old woman with a personal history of obesity, with an open right nephrectomy and later onlay hernia repair. She had a large lumbar eventration with an 11 cm defect (L4W3) associated with a primary midline hernia with rectus diasasis. We performed a hybrid e-TEP approach for the midline hernia associated with lumbar open approach to perform a complete repair by reverse-TAR technique. Results The treatment of combined lateral and midline hernias remains controversial. In patients in whom the lateral hernia is the primary hernia, one of the proposed approaches would be to perform a posterior component separation from the lateral defect. This involves performing a reverse transverse abdominis release (reverse-TAR), opening the rectus sheath from the lateral preperitoneal plane. In obese patients and with large defects, performing this step can be highly complicated due to the difficulty for correct visualization of the area. Conclusions We propose this combined approach, performing a minimally invasive surgery for the dissection of the midline defect, which allows us to perform in a simpler way later the approach from the side, as well as a better exposure and visualization of the area; thus allowing, despite the technical difficulty, the correct placement of a large mesh, which widely covers all the defects.

Minimally invasive transabdominal preperitoneal repair of incisional lumbar hernia

Introduction: A lumbar hernia is a rare type of abdominal wall defect by anatomic location. It can be primary in origin over the lumbar triangles that can be categorized into superior (Grynfeltt) and inferior (Petit), or secondary as a result of trauma or surgery. Lumbar abdominal wall hernia in which clinical presentations may vary from an asymptomatic bulge in the lumbar area to a symptomatic lumbar mass with back pain. Anatomical location makes challenging diagnosis and repair. Individual approach for every patient is a key for successful surgical treatment. In this paper, we present a minimally invasive approach to the treatment of incisional lumbar hernia. Case presentation: A 75-year-old patient from Pazardzhik town, admitted to our unit at the Military Medical Academy for swelling in the left lumbar region at the site of an old surgical scar from a previous nephrectomy (2020) caused by nephropathy. The swelling has a one-year history and causes periodic local pain and discomfort during physical exercise. CT-scan show us incisional left site lumbar hernia, 10cm defect diameter with descending colon and spleen as a hernia contents. We conducted preoperative preparation and consultations with an anesthesiologist, cardiologist and nephrologist. The patient underwent minimally invasive transabdominal preperitoneal lumbar hernia repair with a prosthesis. The postoperative period went smoothly and the patient was discharged on the fourth day. Three months later, he feels well and there is no evidence of recurrence. Conclusions: Preoperative CT-scan of the abdomen with contrast in lumbar hernia patients is a mandatory requirement for proper diagnosis and selection of an appropriate surgical approach. Minimally invasive transabdominal preperitoneal incisional lumbar hernia repair provides optimal view in operative field, minimal tissue trauma, fast recovery and good cosmetic results. This is a new method, but a feasible, useful and safe alternative to conventional surgical techniques for incisional lumbar hernia repair. Keywords: Incisional lumbar hernia, Preperitoneal repair, Hernia with rare location

An Extremely Rare Case Report of a Retroperitoneal Hernia Following Spinal Surgery

Introduction: Retroperitoneal hernias are extremely rare lumbar wall defects. Secondary hernias can occur after previous flank surgeries, infection or trauma. There is a paucity of literature regarding lumbar incisional hernias, most of them related to lateral approaches to the spine. Research Question: The objective of this article is to report a rare case of a retroperitoneal hernia following spinal surgery. Material and Methods: We review a rare presentation of a symptomatic acquired retroperitoneal hernia following several posterior lumbar spine approaches. An extensive literature review regarding retroperitoneal hernia and its relation to spinal surgery was performed. Results: A successful hernia repair suturing the transversalis fascia to the middle layer of the thoracolumbar fascia using a biological mesh was performed, with resolution of the hernia symptoms. Discussion and Conclusion: Although retroperitoneal hernias are extremely rare, we must emphasize the importance of an adequate surgical exposure in order to preserve the retroperitoneal and thoracolumbar fasciae as biological barriers during surgical approaches to the spine.

VP028 TAPP REPAIR FOR INCISIONAL LUMBAR HERNIA

Abstract Aim “Incisional hernias are very common and can present even after minimally invasive surgery for other pathologies. Laparoscopic ventral hernia repair first described by LeBlanc in 1992, gained great popularity, because of its known advantages over the open techniques. In the last decade because of increasing concerns about the future risks of using an intra-peritoneal mesh, several minimally invasive techniques using a mesh outside abdominal cavity have been described. We report the use of a TAPP technique.” Material and Methods “48 yo female patient, that underwent a laparoscopic right adrenalectomy, for myelolipoma, in 2015, with subsequent incisional lumbar hernia (L4W1) in the extraction incision.” Results “The patient was submitted to a laparoscopic TAPP repair in ambulatory surgery with extended recovery. The hernia defect was closed with a barbed suture and it was used a 15x15cm medium weight polypropylene mesh without traumatic fixation. For pain control it was done a TAP block guided by laparoscopy. The duration of surgery was 90 minutes. The patient had no complications. No recurrence on follow-up (4 months).” Conclusions “New minimally invasive procedures for the repair of incisional hernias avoid the intraperitoneal mesh position and maintain all the advantages of the minimally invasive approach. Some of these techniques may be complex and have a long learning curve. TAPP seems reproducible and a good option if a good extra-peritoneal dissection is possible. Larger series are needed, to accurately compare these new techniques with IPOM, open sublay and to select the best technique for each patient.”

Incisional Lumbodorsal Hernias Following Retroperitoneal Robotic Partial Nephrectomies for Small Renal Masses at a High-Volume Tertiary Referral Center.

Introduction: Herein we evaluate the incidence of incisional lumbodorsal hernia (ILDH) after retroperitoneal robotic partial nephrectomy (RRPN) and associated patient-specific and tumor-specific risk factors. Furthermore, we aim to evaluate the role of routine lumbodorsal fascial closure for the prevention of ILDH. Methodology: This is a retrospective review of our robotic partial nephrectomy database of all RRPNs performed at Washington University School of Medicine from 2000 to 2020. Postoperative imaging was reviewed for evidence of ILDH. A clinically significant hernia was defined as the protrusion of visceral organ(s) through the lumbodorsal fascia. Patient and tumor characteristics, and fascial closure techniques were analyzed to determine predictors of ILDH. Results: In total, 150 patients underwent RRPN between 2007 and 2020 with an average follow-up of 4.9 (1-37) months. Twelve (8%) ILDHs were identified. Ten (6.7%) patients had herniated retroperitoneal fat whereas 2 (1.3%) patients had herniated colon. All were asymptomatic and managed conservatively. On matched cohort comparison, patients with ILDH had larger tumors than patients without an incisional hernia (3.9 cm vs 2.8 cm, p = 0.029). In general, patient factors were no different between patients with and without ILDH. However, coronary artery disease (CAD) was more prevalent in patients with ILDH (33.3% vs 10.9%, p = 0.028). Patients with ILDH were more likely to have a port site extended for specimen extraction (66.7% vs 38.2%, p = 0.069). Lumbodorsal fascial closure and type of suture material were not associated with prevention of ILDH (p = 0.545, p = 0.637). Conclusion: The radiographic incidence of lumbar incisional hernias after RRPN without routine fascial closure of the extraction incision was 8%. All were asymptomatic and did not require surgical repair. Larger tumor size and CAD were associated with ILDH.

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.

Lumbar Incisional Hernia Repair: Complete Reconstruction of the Deficient Myofascial Component Using Christmas Tree Bone Anchors

Lumbar incisional hernias are difficult to repair because one of the hernia margins is bone, namely, the iliac crest. Previous studies have described the use of orthopedic bone anchors that fix a mesh onto the iliac crest. We present a novel technique for open repair of large lumbar incisional hernias using a double-mesh technique in combination with suture-loaded bone anchors to reattach the abdominal wall musculature onto the iliac crest. The surgical technique involves creating a preperitoneal plane behind the transversus abdominus and above the iliac crest and iliacus, below the iliac crest, with application of a Prolene mesh in this layer. This is followed by the drilling of suture-loaded Christmas Tree bone anchors™ along the rim of the iliac crest. The preloaded sutures are used to attach the myofascial component on the iliac crest, followed by the placement of a second Prolene mesh in an on-lay fashion. Drains are left in the preperitoneal and subcutaneous spaces. Unlike other reported techniques in the literature which only fix mesh onto the iliac crest, our technique with the use of Christmas Tree bone anchors™ allows for complete reconstruction of the lumbar abdominal wall defect and its myofascial components.

Open retromuscular large mesh reconstruction of lumbar incisional hernias including the atrophic muscular area.

Lumbar incisional hernias (LIH) are a rare wall defect, whose surgical management is challenging because no recommendation exists. Moreover, LIH are frequently associated with flank bulging which should be taken into account during LIH surgical repair. We aimed to describe a cohort of patients operated on for LIH using a homogeneous surgical technique and to report surgical outcomes. The records of all consecutive patients operated on in a specialized surgical center between January 2009 and January 2015 were retrospectively reviewed. The same open technique was performed, i.e., using a mesh into the retroperitoneal space posteriorly, placed with the largest overlap inferiorly and posteriorly, and fixed through the controlateral abdominal wall muscles under strong tension to correct the flank bulging. The cohort included 31 patients, of median age 62, who presented two or more comorbidities in 68% of cases. LIH was recurrent in 45% of patients, and was related to nephrectomy in 61% of patients. The mesh was totally extraperitoneal in 65% of patients. The postoperative mortality rate was null. The rate of specific surgical complications was 32.3%, and the rate of overall postoperative morbidity (Clavien-Dindo classification) was 38.7%. After a median follow-up of 27.5months, the recurrence rate was 6.5% and 9.7% reported chronic pain. The open approach for LIH repair was safe and enabled treating flank bulging simultaneously in all patients. Due to the paucity of adequate scientific studies, this reproducible open method could help moving toward a standardization of LIH surgical management.

Éventrations lombaires symptomatiques après néphrectomies par lombotomie : quels sont les facteurs de risque ?

Lumbar incisional hernias after open nephrectomy are rare but can lead to aesthetic disorder, discomfort or intestinal obstruction. The aim of the study is to highlight their risk factors. The characteristics of patients who suffered from symptomatic and surgically treated lumbar incisionnal hernia after open nephrectomy (study group "GE") were compared to those of patients who underwent open nephrectomy without postoperative incisional hernia (control group "GT") using the Student's t test and Mann-Whitney test (statistical significance P value<0.05). GT patients were randomly selected with a 1/4 ratio (1 lumbar incisionnal hernia vs 4 controls). From 2004 to 2014, 417 open nephrectomies were performed in one university hospital. Forty-five patients were included: 9 in GE and 36 in GT. There was no statistically significant difference between GT and GE for weight, height, body mass index (BMI), emergency, partial nephrectomy, laterality, rib resection, laparoscopic conversion to open surgery, postoperative complications, smoking, diabetes mellitus, cardiovascular history, obesity and sex, but there was a statistically significant difference for age, operative time, chronic obstructive pulmonary disease (COPD) and severe obesity (BMI>35) with, respectively, P=0.05, P=0.02, P=0.04 and P=0.02. Risk factors for lumbar incisional hernia after open nephrectomy are age, operative time, severe obesity and COPD. 5.

Fatal outcome of a lumbar incisional hernia originating at the surgical site of hip arthroplasty: An exceptionally rare case

This article discusses an uncommon case of complicated incisional lumbar hernia secondary to total hip arthroplasty. A female patient with a history of bilateral total hip arthroplasty at another institution was hospitalized for acute oedematous pancreatitis and was treated conservatively. An initial abdominal computerized tomography showed the incidental finding of a left lumbar hernia in close relationship with a hip prosthesis. During the 30th day of hospital stay, the incisional hernia became incarcerated, and the intestinal contents strangulated. The severity of this complication finally led to the death of the patient. Despite their rarity, these hernias should be included within the differential diagnosis of flank masses and late hip arthroplasty symptomatic complications.

Doble lesión de pared abdominal: hernia incisional lumbar izquierda y seudohernia por denervación y atrofia muscular derecha. Manejo laparoscópico conjunto

IntroductionIncisional defects of the posterolateral abdominal wall are a challenge for any surgeon. No standard surgical treatment has been set for these patients. ObjectiveThe aim of this study is present the unusual case of a patient with 2 incisional lesions, a left lumbar hernia and a giant right-sided pseudohernia, and to develop their surgical treatment at the same time using double laparoscopy. Clinical caseA 65-year-old woman, who after a car accident needed 4 spinal surgeries, and another 4 for right renal lithiasis. A tomography confirmed the existence of a left lumbar incisional hernia and a pseudohernia with intense lateral muscular atrophy. A single laparoscopic approach is set out: transabdominal retroperitoneal hernioplasty (left), and intra-abdominal hernioplasty of the left hemiabdominal wall (right) with fixation to the osseous margins (12th rib and the iliac crest). Follow-up over one year shows no recurrence of the lumbar hernia but no clear improvement of the pseudohernia, which had a similar abdominal perimeter and costoiliac axis. DiscussionLaparoscopic surgery for the treatment of posterolateral abdominal wall defects is still a controversial choice as it does not reproduce the open technique. Laparoscopic repair seems to be the most beneficial choice for the patient with lumbar hernia, but for incisional pseudohernias the documentation available is limited. ConclusionLumbar hernias and pseudohernias are frequent complications after previous surgery. Laparoscopic approach is an effective treatment for the lumbar hernia, but ineffective for the pseudohernia.

Lateral Incisional Hernia Repair by the Retromuscular Approach with Polyester Standard Mesh: Topographic Considerations and Long‐term Follow‐up of 61 Consecutive Patients

Because of the lack of published data and the relative rarity of lateral incisional hernia (LIH), their repair remains a major challenge for surgeons. The aim of the present study was to evaluate the outcome of LIH treated by the retromuscular approach (RMA) with a polyester standard mesh. Sixty-one patients were treated between June 2000 and November 2007 in an academic tertiary referral center using one standardized surgical technique and one type of mesh. Lumbar incisional hernia was excluded. All data were prospectively culled. The early complications and recurrence rates were evaluated. There were 14 (23%) subcostal, 12 (19.6%) flank, and 35 (57.4%) iliac fossa LIH. The mean patient age was 57 years, and 60% were male. The average width of the defect was 7.6 cm and the overall defect size averaged 56 cm². Seventeen patients (28%) had had previous LIH repair. Ten patients had double hernia locations (midline and lateral) repaired simultaneously. The average operative time and hospital stay were 136 min and 7 days, respectively. The early complications rate was 18%. Four patients required reoperation. There were no mesh infections. The median follow-up was 47 months (range: 1-125 months). Recurrence was observed in three patients (4.9%). LIH repair by RMA with a polyester heavyweight mesh proves to be a safe treatment with a moderate complication rate and a low infection rate, even in the treatment of large or multifocal parietal defects.

Single incision endoscopic surgery for lumbar hernia

Single Incision Endoscopic Surgery (SIES) has emerged as a less invasive surgery among laparoscopic surgeries, and this approach for incisional hernia was reported recently. This is the first report of SIES for an incisional lumbar hernia. A 66-year-old Japanese woman was referred to our institution because of a left flank hernia that developed after left iliac crest bone harvesting. A 20-mm incision was created on the left side of the umbilicus and all three trocars (12, 5, and 5 mm) were inserted into the incision. The hernial defect was 14 × 9 cm and was repaired with intraperitoneal onlay mesh and a prosthetic graft. The postoperative course was uneventful. SIES for lumbar hernia offers a safe and effective outcome equivalent compared to laparoscopic surgery. In addition, SIES is less invasive and has a cosmetic benefit.

Laparoscopic incisional lumbar hernia repair

Incisional lumbar hernia is an uncommon hernia type. Open surgical procedures have significant postoperative morbidity and patient dissatisfaction, therefore, for the repair of seven incisional lumbar hernias, we attempted using an intraperitoneal laparoscopic technique that was described to have good short-term results and decreased morbidity. We applied a laparoscopic technique using polypropylene meshes in five patients and composite meshes in two patients to cover the defect, then placed prolene sutures and hernia staples to secure the mesh intraperitoneally. The technique was successful in all patients, and they tolerated the procedure well. All did well after surgery, ambulating and eating a regular diet on postoperative day 1. No postoperative complications developed. At a mean follow-up of 34.1 months (range 17-43 months) none of them had pain, mass, or evidence of recurrence, and furthermore, cosmesis was excellent. We believe that the laparoscopic approach is feasible, safe, and the least invasive choice for repairing difficult hernias such as incisional lumbar hernias.

Laparoscopic repair of large flank hernia staged with laparoscopic sleeve gastrectomy in the morbidly obese

Laparoscopy is the preferred operative approach for the repair of abdominal wall hernias. The large amount of intra-abdominal fat that accompanies morbid obesity obscures the anatomy, making flank hernia repairs in this population technically challenging, more so in the presence of previous flank surgery and multiple intra-abdominal adhesions. Laparoscopic repair of flank and lumbar hernias with mesh have also become standard practice [ 1 Palanivelu C. Rangarajan M. John S.J. Laparoscopic transperitoneal repair of lumbar incisional hernias: a combined suture and “double-mesh” technique. Hernia. 2008; 12: 27-31 Crossref PubMed Scopus (18) Google Scholar , 2 Iannitti D.A. Biffl W.L. Laparoscopic repair of traumatic lumbar hernia. Hernia. 2007; 11: 537-540 Crossref PubMed Scopus (12) Google Scholar , 3 Madan A.K. Ternovits C.A. Speck K.E. Laparoscopic lumbar hernia repair. Am Surg. 2006; 72: 318-321 PubMed Google Scholar ]. Compared with open hernia repair approaches, laparoscopy typically offers fewer complications, a decreased length of hospital stay, less pain, and overall improved outcomes. However, incisional hernia recurrence rates are still high in the morbidly obese [ 4 Raftopoulos I. Courcoulas A.P. Outcome of laparoscopic ventral hernia repair in morbidly obese patients with a body mass index exceeding 35 kg/m2. Surg Endosc. 2007; 21: 2293-2297 Crossref PubMed Scopus (56) Google Scholar , 5 Tsereteli Z. Pryor B.A. Heniford B.T. et al. Laparoscopic ventral hernia repair (LVHR) in morbidly obese patients. Hernia. 2008; 12: 233-238 Crossref PubMed Scopus (71) Google Scholar , 6 Novitsky Y.W. Cobb W.S. Kercher K.W. et al. Laparoscopic ventral hernia repair in obese patients: a new standard of care. Arch Surg. 2006; 141: 57-61 Crossref PubMed Scopus (92) Google Scholar ]. It is thus essential to identify methods to decrease the recurrence rates and minimize morbidity during operative repair. Surgically induced weight loss before flank hernia repair appears to be a sound alternative to decrease recurrences and the associated morbidity. Laparoscopic sleeve gastrectomy has shown optimal short-term outcomes and is technically suited for the morbidly obese with large flank hernias and intra-abdominal adhesions. The weight loss provided by the sleeve gastrectomy as a first stage might facilitate flank hernia repair during a second procedure, by decreasing the amount of intra-abdominal fat, reducing the operative morbidity and intra-abdominal pressure and resulting in minimization of hernia recurrence. The case and operative technique of a laparoscopic flank hernia repair preceded by laparoscopic sleeve gastrectomy is described in a morbidly obese patient.