Primary and unusual abdominal wall hernias

Perforated appendicitis within a spigelian hernia

A woman in her 90s presented to the emergency department with new onset pain in a long standing right spigelian hernia. She was febrile and mildly hypotensive. CT scan demonstrated a hernia containing small and large bowel with significant fat stranding and thus proceeded to operative management via an open appendicectomy and suture repair of the hernia. There are few similar cases in the literature, with the predominance being suture repair, a roughly even split between open and laparoscopic approaches.

Incidentally found obturator hernias during totally extraperitoneal (TEP) inguinal hernia repair: a single-center experience

PURPOSE

This study aimed to determine the occurrence of incidental obturator hernia and clinical risk factors of their appearance in patients undergoing totally extraperitoneal (TEP) inguinal hernioplasty.

METHODS

Data were collected retrospectively from patients who underwent TEP inguinal hernioplasty between June 2020 and December 2022.

RESULTS

A total of 251 patients were included in the study. Obturator hernias were found in 21 patients (8.4%). At admission, no patient presented clinical signs of an obturator hernia. There was a significant predominance of women in the obturator hernia compared to the non-obturator hernia group (28.6% vs. 10.9%, respectively, p=0.018). There was no correlation between age (p=0.479) and BMI (p=0.771) and the occurrence of obturator hernia. Additional obturator hernia repair within the TEP inguinal hernioplasty procedure did not influence the overall length of the surgery (60.86 minutes) compared to the standard TEP inguinal hernioplasty (61.09 minutes, p=0.876).

CONCLUSIONS

The TEP inguinal hernioplasty allows the detection and repair of incidental obturator hernia. Through thorough inspection of the obturator canal, an asymptomatic obturator hernia can be detected and adequately treated within the same procedure, without the impact on the surgery duration, when performed by an experienced hernia surgeon.

The role of computed tomography in acute bowel obstruction due to a supravesical hernia: a case report from Nepal

Introduction and importance

Supravesical hernias are rare internal hernias but potential cause of small-bowel obstruction. The clinical features are often non-specific, preoperative diagnosis is very difficult and is often diagnosed intraoperatively. The exact pathogenesis is unclear with the major risk factors of prematurity, a positive family history, male sex, smoking habits leading to decreased collagen production, advancing age, and conditions characterized by defective collagen synthesis.

Case presentation

The authors are reporting a case of small-bowel obstruction secondary to a supravesical hernia, in a 78-year-old male presented with central abdominal pain, vomiting and obstipation. Ultrasonography of the abdomen and pelvis identified a marked dilation of the small-bowel loop with multiple loops of dilated jejunum and ileum in contrast-enhanced computed tomography (CT) scan of the abdomen and pelvis with lead point from the terminal ileum. Exploratory laparotomy was done with the diagnosis of left posterior a left posterior superior vesical hernia with small-bowel obstruction.

Clinical discussion

The case focuses supravesical hernia as a rare yet life-threatening etiology of small-bowel obstruction, emphasizing the importance of clinical suspicion when patients present with signs and symptoms of bowel obstruction. While diagnosis often occurs intraoperatively, the utilization of CT scans in emergency settings can provide valuable insights into the location, potential causes, and condition of the herniated bowel sac. The case highlights the pivotal role of CT scans in diagnosis and emphasizes the need for multidisciplinary cooperation among clinicians, radiologists, and surgeons.

Conclusion

Early intervention ensures better outcomes and prevents irreversible bowel damage, underscoring the importance of a comprehensive approach to patient care.

Giant spigelian hernia in a middle-aged female: The importance of intraoperative ultrasonography for hernia localization-Case report

Spigelian hernia is a rare type of abdominal wall hernia that accounts for only 0.12% of all abdominal hernias. A Spigelian hernia, also known as a spontaneous lateral ventral hernia or a hernia of the semilunar line, occurs when a part of the abdominal contents protrudes through the Spigelian fascia. Due to its anatomical location, Spigelian hernia can be difficult to diagnose through physical examination alone. Here we report a case of a 40-year-old female who experienced right abdominal pain and swelling, where ultrasonography imaging was crucial in the intraoperative diagnosis of Spigelian hernia. The patient underwent laparotomy mesh repair to address the condition. The lack of consistent physical findings and the rarity of the disease require a high level of clinical suspicion in the diagnosis of a Spigelian hernia. Its associated abdominal complaints are often vague and nonspecific, making it even more challenging. This case emphasizes the importance of utilizing imaging techniques to aid in the diagnosis of a Spigelian hernia and prompt surgical intervention to prevent complications associated with the hernia.

Awareness of Hernias and Their Risk Factors Among Adults in the Western Region of Saudi Arabia

Objective To assess the awareness of hernia and its risk factors among adults in the western region of Saudi Arabia. Our hypothesis was that the studied population was in need of education regarding this matter.  Methods This cross-sectional study was conducted in the western region of Saudi Arabia from November to December 2022, using a Google form. The generated questionnaire consisting of two parts was distributed electronically through social media platforms. The targeted population included adults from the western region of Saudi Arabia. The data were obtained using Microsoft Excel and analyzed using Statistical Package for Social Sciences (SPSS) v. 26 software (IBM Corp., Armonk, NY). Results A total of 1570 adults from the western region of Saudi Arabia were included in our study. We found that 13% of the participants had good overall knowledge about hernia, 31% had poor knowledge, and 56% had moderate knowledge. Alarmingly, 55% of the participants had a poor attitude, and 27% were evaluated as having poor practice. In addition, we found a significant association between people's level of knowledge and multiple factors, including age (p-value < 0.001), marital status (p-value< 0.001), and occupation (p-value< 0.001).  Conclusion Based on our research, more than half of our population had a moderate level of knowledge regarding hernias including their risk factors and complications, with alarming levels of poor attitudes toward the disease. Healthcare workers were our participants' leading source of medical information, which directs us towards fully equipping them with the knowledge to educate the public effectively.

A Comparative Study of Retrorectus Mesh Placement Versus Properitoneal Mesh Placement in Open Repairs of Ventral Hernias

Background Ventral hernias affect millions of patients each year. Surgery is the main line of management and various techniques have been advocated; however, mesh repair has become the norm and different approaches have been described regarding the plane of mesh fixation, but none of them are standardized. Open repair is commonly practiced, and the two most commonly performed methods are retrorectus and properitoneal mesh placement. Objectives To compare the postoperative outcomes between the retrorectus plane and the properitoneal plane of fixation of mesh in open ventral hernia repair. Methods Between September 2018 and August 2020, 56 patients with midline ventral hernia admitted to Ramaiah Hospital, Bengaluru were chosen for this prospective comparative study. Group A had 28 patients who underwent open retrorectus mesh repair and 28 patients in Group B underwent open properitoneal mesh repair. The postoperative outcomes were studied in terms of operating time, postoperative complications, and early recurrence at the end of six months and 24 months post-surgery. Results The operative time for retrorectus mesh placement was significantly lower than properitoneal mesh placement. The latter had a higher complication rate overall with an incidence of 18%, with seroma being the most common complication; however, the difference in complication rates was not statistically significant. Skin necrosis was identical in both groups and 0% of cases in both groups had SSI or mesh infection. Three patients (10.71%) in the retrorectus group and two patients (7.10%) in the properitoneal group developed recurrence at 24 months follow-up. Conclusion Retrorectus mesh repair and properitoneal mesh repair in open ventral abdominal hernias have equally good postoperative outcomes.

Obturator hernia (the little old lady's hernia) diagnosed via computed tomography: a case report

Obturator hernia is an infrequent clinical entity of abdominal wall hernia, accounting for an incidence rate ranging from 0.073 to 2.2% of all hernias and being responsible for 0.2-1.6% of all cases of mechanical intestinal obstruction. The computed tomography (CT) scan, as an imaging modality, is critical in improving the diagnostic rate of obturator hernia.

Case presentation

The authors herein report an 87-year-old thin male patient with a known history of chronic obstructive pulmonary disease who presenting with complaints of abdominal pain for 3 days and constipation for 2 days, as well as one episode of vomiting without any features of peritoneal irritation, which was diagnosed early as a right-sided obturator hernia via CT and managed with exploratory laparotomy with hernia reduction and polypropylene mesh repair.

Discussion

Obturator hernia is a rare surgical phenomenon with a varied clinical spectrum, ranging from asymptomatic to presenting as intestinal obstruction. The CT scan plays a critical role in the detection of obturator hernias, which ameliorates the possible significant postoperative morbidity and mortality.

Conclusion

This report demonstrates that a high index of suspicion combined with CT imaging aids in early diagnosis and management, thus overcoming the reluctant morbidity.

Incarcerated Epigastric Hernia

An epigastric hernia is a form of ventral hernia. Most of these contain preperitoneal fat or the omentum. Herniation of intra-abdominal organs, a rare form of rectus sheath midline herniations, is seldom seen, and incarcerations in these cases are rare. A 56-year-old male presented with complaints of irreducible epigastric swelling. Thorough clinical examination and imaging studies revealed that the patient had an epigastric hernia. An intraoperative image showed that the small bowel had herniated through the epigastric defect and was obstructed; however, the small bowel was viable. The contents were reduced after enlarging the constricting ring, and anatomical repair with mesh reinforcement was done. Postoperatively, the patient had an uneventful recovery and was discharged.

Pre- and postsurgical imaging findings of abdominal wall hernias based on the European Hernia Society (EHS) classification

Abdominal wall hernias are common and can present as technical challenges to surgeons. When large, hernias diminish quality of life. Various classifications of incisional hernias have been proposed; however, there are many terms, sometimes causing confusion (1). Radiologists must know the normal anatomy of the abdominal wall, the CT protocol, and what if any maneuvers can be performed to better identify an abdominal wall defect. The description of the radiological approach for primary and incisional wall hernias is based on the 2007 European Hernia Society classification, with particular emphasis on presurgical and postsurgical imaging findings. This classification provides a simple and reproducible method to describe hernias to offer proper surgical management. We highlight this classification so that radiologists and surgeons can have a unified language.

A delayed diagnosis of obturator hernia hoodwinked by previous laparoscopic inguinal hernia repair

Obturator hernia is a rare and diagnostically challenging type of pelvic hernia with associated high morbidity and mortality. It is frequently seen in frail, elderly female multiparous patients with non-specific symptoms and signs that may be clouded by multiple gastrointestinal or musculoskeletal comorbidities. This report discusses the case of an 84-year-old woman with refractory groin pain and previous laparoscopic inguinal hernia repair that was misdiagnosed leading to a delayed diagnosis and mortality. Previous laparoscopic repair was a misleading factor that hoodwinked clinicians and surgeons until computed tomography (CT) imaging proved otherwise. In emaciated, elderly female patients presenting with non-specific abdominal or hip pain, early CT imaging can assist in diagnosis when signs or symptoms are unclear. Clinical vigilance and serial examination are important in elderly patients who are often under the care of geriatricians allowing early discovery and treatment of this hernia.

Closed loop obstruction and adhesive intestinal obstruction in perineal hernia

Perineal hernia with bowel gangrene is uncommon but known complication of laparoscopic extralevator abdominoperineal excision (ELAPE). We present a rare case of closed loop small bowel obstruction with bowel gangrene secondary to an incarcerated perineal hernia that developed 7 years after an ELAPE. Intraoperatively, we found a definitive transition point due to adhesions in pelvis and a closed loop obstruction of the distal small bowel at different site with gangrenous intestine. She was managed successfully surgically with adhesiolysis and fixation of defect with biological mesh. Prevalence of perineal hernias will rise in future because of the increasing cases of ELAPE, in which no repair of pelvic floor is performed. The need of follow-up of these operations and more reporting of such cases are important in increasing awareness of these complications. Patients should be made aware of such complications and should seek urgent medical care.

EHS and AHS guidelines for treatment of primary ventral hernias in rare locations or special circumstances

Background

Rare locations of hernias, as well as primary ventral hernias under certain circumstances (cirrhosis, dialysis, rectus diastasis, subsequent pregnancy), might be technically challenging. The aim was to identify situations where the treatment strategy might deviate from routine management.

Methods

The guideline group consisted of surgeons from the European and Americas Hernia Societies. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used in formulating the recommendations. The Scottish Intercollegiate Guidelines Network (SIGN) critical appraisal checklists were used to evaluate the quality of full‐text papers. A systematic literature search was performed on 1 May 2018 and updated 1 February 2019. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was followed.

Results

Literature was limited in quantity and quality. A majority of the recommendations were graded as weak, based on low quality of evidence. In patients with cirrhosis or on dialysis, a preperitoneal mesh repair is suggested. Subsequent pregnancy is a risk factor for recurrence. Repair should be postponed until after the last pregnancy. For patients with a concomitant rectus diastasis or those with a Spigelian or lumbar hernia, no recommendation could be made for treatment strategy owing to lack of evidence.

Conclusion

This is the first European and American guideline on the treatment of umbilical and epigastric hernias in patients with special conditions, including Spigelian and lumbar hernias. All recommendations were weak owing to a lack of evidence. Further studies are needed on patients with rectus diastasis, Spigelian and lumbar hernias.

Hernia supravesical como causa de obstrucción intestinal: reporte de un caso

Las hernias abdominales internas son una causa poco frecuente de obstrucción intestinal, que se presentan por el deslizamiento de los órganos intraabdominales, en especial el intestino delgado, a través de defectos congénitos o adquiridos en el mesenterio o en los espacios intraperitoneales. La hernia supravesical interna es una de las presentaciones menos frecuentes de esta entidad y su diagnóstico es intraoperatorio en la mayoría de los casos. Se presenta el caso de un paciente de sexo masculino que consultó con manifestaciones de obstrucción intestinal, y fue sometido a cirugía de urgencias, con el hallazgo de una hernia supravesical interna.

Giant Spigelian Hernia presenting as small bowel obstruction: Case report and review of literature

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Spigelian Hernia is a rare abdominal wall hernia.

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Urgent presentation with small bowel obstruction is uncommon.

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Laparoscopy could be an option in elective surgery but in emergent setting laparotomy is required.

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Mesh repair is mandatory to avoid recurrence.

Introduction

Spigelian Hernia is an uncommon pathology of abdominal wall (0.12–2.4%), usually small sized and with vague symptoms. It rarely presents as Small Bowel Obstruction or reaches dimensions that becomes clinically remarkable.

Presentation of case

84-year-old woman entered our Surgical Department for Small Bowel Obstruction due to a giant (8 × 7 cm) abdominal wall hernia, which was intraoperatively identified as Spigelian Hernia. We performed a minilaparotomy with reduction of viable small bowel and preperitoneal positioning of polypropilene mesh. Postoperative course was uneventfull.

Discussion

Due to its small dimensions and infrequence, the diagnosis could be challenging even if the patient undergoes a CT scan. The presentation with clear signs of small bowel obstruction associated with a large abdominal hernia is rare and suggests a urgent surgical approach with mesh repair to avoid recurrences.

Conclusion

Even if rarely symptomatic, the Spigelian Hernia is an entity to consider in the differential diagnosis of small bowel obstruction in a virgin abdomen. Preoperative diagnosis, when available, is mandatory to guide a correct surgical approach.

Voluminous paraumbilical hernia containing the pancreas - An unusual cause of acute pancreatitis: A case report

Introduction

The paraumbilical hernia sac often contains the omentum, the small bowel, and less commonly the colon. The herniation of the pancreas through a paraumbilical hernia is extremely rare and has been reported only by two cases in the literature; moreover, acute pancreatitis secondary to this condition is a particularly unusual event.

Case report

We present a very unusual case of a 67-year-old female patient with a voluminous paraumbilical hernia containing the pancreas, complicated by acute pancreatitis. Laboratory data revealed an elevation of the pancreatic enzymes. An intravenous contrast-enhanced computed tomography (CT) scan of the abdomen demonstrated a large hernia sac containing multiple viscera, including the pancreas. The patient underwent emergency laparotomy with a diagnosis of intestinal obstruction.

Conclusion

The clinicians should consider this rare condition in the differential diagnosis of patients presenting with large paraumbilical hernias associated with classical symptoms of acute pancreatitis, particularly in the absence of typical risk factors for pancreatitis. An intravenous contrast-enhanced abdominal CT scan should be performed immediately in these patients. We recommend the patients and the surgeons to consider prompt surgical repair for paraumbilical hernias to avoid further complications and the higher incidence of morbidity and mortality associated with emergency surgeries.

Anterior perineal hernia after anterior exenteration

Perineal hernia is a rare complication of anterior exenteration. We reported this complication after an anterior exenteration for bladder cancer with bleeding complication requiring packing and second-look laparotomy. Perineal approach is a simple and effective method for repair of perineal hernia.

Rare Enterorectal Pelvic Floor Hernia-A Cadaveric Study

We present a cadaveric case study of an 88-year-old woman with an unusual posterior perineal hernia containing small bowel, rectum, and mesentery. Dissection revealed several loops of the small bowel occupying the presacral space and displacement of the rectum into a large perineal evagination. The intestinal mucosa appeared to have been healthy at the time of death, and we did not find any indication of rectal prolapse. There was also no evidence of past surgery, suggestive of a primary hernia. We conclude this patient had a posterior enterorectal perineal hernia. Suggestions for surgical repair are described.

[Primary posterior perineal hernia associated with dolichocolon]

BACKGROUND

Primary posterior perineal hernias in men are rare. We report a case of this type of hernia associated with dolichocolon, a condition which, to our knowledge, has not been reported previously.

CLINICAL CASE

A 71-year old male presenting with a perineal tumour of 40 years evolution. He had no history of perineal surgery or trauma. On physical examination, a lump of 4×3cm was observed in the right para-anal region, which increased in volume during the Valsalva manoeuvre. Computed tomography showed a defect in the pelvic floor, which was reconstructed using a roll of polypropylene mesh in the hernia defect.

DISCUSSION

The case described is of interest, not only because a perineal hernia is a rare clinical entity, but also because repair using a roll of mesh has not been reported associated with a dolichocolon, which can be considered a factor risk for development.

CONCLUSIONS

The surgical approach and repair technique of the pelvic floor for perineal hernias should be individualised. The use of mesh for reconstruction should always be considered. The presence of dolichocolon can contribute to the gradual development of a perineal hernia.

Current options in umbilical hernia repair in adult patients

Umbilical hernia is a rather common surgical problem. Elective repair after diagnosis is advised. Suture repairs have high recurrence rates; therefore, mesh reinforcement is recommended. Mesh can be placed through either an open or laparoscopic approach with good clinical results. Standard polypropylene mesh is suitable for the open onlay technique; however, composite meshes are required for laparoscopic repairs. Large seromas and surgical site infection are rather common complications that may result in recurrence. Obesity, ascites, and excessive weight gain following repair are obviously potential risk factors. Moreover, smoking may create a risk for recurrence.

An atypical lateral hernia and concomitant inguinal and umbilical hernias in a patient with polycystic kidney disease and an intracranial aneurysm - a combined approach of clinical and radiological investigation, endoscopic hernia repair, and anatomical cadaver model documentation and a systematic review of the literature

Atypical hernias are difficult to diagnose due to their rarity and often unspecific symptoms. In the literature there exist hints to peri-inguinal hernias, i.e. direct lateral hernia, but most of them are forms of Spigelian hernias. Since the majority were described during the first half of the past century or even earlier, only very few cases have been documented using modern diagnostic techniques. We report a unique case of a 51 year old patient presenting with an atypical inguinal hernia with concomitant inguinal and umbilical hernias in combination with cystic kidney disease and intracranial aneurysm. The atypical position of the hernia was assumed from clinical inspection, ultrasound and CT scan and verified during pre-peritoneoscopy. Using an anatomical cadaver dissection approach, we followed the unusual position of the hernia through the abdominal wall below the aponeurosis of the external oblique muscle. After a thorough literature search, we assume that the present hernia containing a hernial sac has not been documented before, especially not in such a multidisciplinary approach comprising radiological, surgical and anatomical localisation and endoscopic treatment in a patient with a clinical situation being aggravated by large cystic kidneys leading to dialysis-dependency. Rare hernias have been described as being often associated with concomitant inguinal or other hernias, a predisposition for the male gender and a pathogenic mechanism related to other soft tissue defects such as cystic kidney disease or cranial aneurysm. Thus, we consider this a unique case that has not been documented in this constellation previously, which may increase the awareness for these rare hernias.

Computed tomographic colonography: Diagnosis of an incarcerated Spigelian hernia

A 68-year-old obese man underwent computed tomographic colonography (CTC) scanning to investigate worsening constipation and lower abdominal discomfort on his left side.Optical colonoscopy was contraindicated because of his comorbidities. A preliminary CTC diagnosis of incarcerated Spigelian hernia was made, based on lateral deviation of thesigmoid colon to the left as well as extrinsic impressions on it, and the central location of the small bowel. Spigelian hernia is a rare form of anterior abdominal wall hernia. CTC can play a role in its diagnosis.

An ovary as unusual contents of an incarcerated umbilical hernia

We present the unusual case of a woman presenting with an incarcerated umbilical hernia. Intraoperatively, the contents of the hernia were found to be an ovary. We outline the clinical presentation of our patient, investigations and management as well as a discussion on unusual contents of umbilical hernias. To our knowledge, this is the first case of a non-malignant ovary incarcerated in an umbilical hernia.

Neurofibroma invading into urinary bladder presenting with symptoms of obstructed defecation and a large perineal hernia

Background

Pelvic floor hernias pose a diagnostic and a treatment challange. Neurofibromatosis is a rare systemic disease, and urinary tract involvement is rare.

Case presentation

Here we report a case of a 54-year-old female with multiple neurofibromatosis who presented with features of obstructed defecation and was found to have a large perineal hernia. At surgery, we found an unusual herniation of a large neuropathic bladder and rectum through a perineal defect. She underwent reduction cystoplasty and repair of the pelvic floor using a prolene mesh. Subsequent histopathological examination confirmed a large neurofibroma infiltrating the urinary bladder.

Conclusion

Neurofibromatosis of the bladder is rare it should be considered as a differential diagnosis in patients presenting with symptoms of obstructed defecation.

Hernia emergencies

Hernia emergencies are commonly encountered by the acute care surgeon. Although the location and contents may vary, the basic principles are constant: address the life-threatening problem first, then perform the safest and most durable hernia repair possible. Mesh reinforcement provides the most durable long-term results. Underlay positioning is associated with the best outcomes. Components separation is a useful technique to achieve tension-free primary fascial reapproximation. The choice of mesh is dictated by the degree of contamination. Internal herniation is rare, and preoperative diagnosis remains difficult. In all hernia emergencies, morbidity is high, and postoperative wound complications should be anticipated.

Primary posterior perineal herniation of urinary bladder

Primary perineal hernia is a rare clinical condition wherein herniation of viscera occurs through pelvic diaphragm. They are usually mistaken for sciatic hernia, rectal prolapse or other diseases in the perineum. Correct identification of the type of hernia by imaging is crucial for planning treatment. We present a case of primary posterior herniation of urinary bladder and rectal wall through levator ani repaired laparoscopically using a mesh repair.

A rare case of interparietal incisional hernia from 8 mm trocar site after robot-assisted laparoscopic prostatectomy

Trocar site hernia arising from 8 mm robotic port is very rare despite the increasing prevalence of robot-assisted surgeries. To date, there had been only a single case reported in the literature. We report a case of small bowel obstruction secondary to an interparietal trocar site incisional hernia after robot-assisted laparoscopic prostatectomy. Meticulous closure of 8 mm robotic trocar sites associated with large peritoneal defect at the end of surgery should be performed.

A differential diagnosis in chronic lower abdominal pain

INTRODUCTION

Spigelian hernias represent 0.12-2.4% of all abdominal wall hernias. Its diagnosis is elusive and requires a high level of conjecture given the disease rarity, vague associated abdominal complaints and frequent lack of consistent physical findings.

PRESENTATION OF CASE

A 60-year-old woman presented with a history of chronic pain in the left lower side of the abdomen. The patient was treated for several diseases with no relief of symptoms. Abdominal ultrasound showed a Spigelian hernia in the lower left abdomen and surgery was scheduled for treatment.

DISCUSSION

A SH is generally an inter-parietal hernia, meaning that the pre-peritoneal fat and the hernia sac penetrate the trasnversus abdominis and internal oblique muscles but remain behind the external oblique aponeurosis. In most of the patients the lack of clinical signs demands radiological investigation. That's the importance of the high grade of suspicious of the disease during the physical exam. The surgical repair is necessary due to the high risk of incarceration-related complications which can occur in up to 21% of cases.

CONCLUSION

It's important to think in the Spigelian hernia as cause of lower abdominal pain to prompt indicate surgical repair and provide the patient's symptom relief. Also the type of repair is dependent on the surgeon's choice and also the means available in each center.

Laparoscopic total extraperitoneal repair of lumbar hernia

Lumbar hernia is a rare surgical entity without a standard method of repair. With advancements in laparoscopic techniques, successful lumbar herniorrhaphy can be achieved by the creation of a completely extraperitoneal working space and secure fixation of a wide posterior mesh. We present a total extraperitoneal laparoendoscopic repair of lumbar hernia, which allowed for minimal invasiveness while providing excellent anatomical identification, easy mobilization of contents and wide secure mesh fixation. A total extraperitoneal method of lumbar hernia repair by laparoscopic approach is feasible and may be an ideal option.

Epigastric hernia following DIEP flap breast reconstruction: complication or coincidence?

OBJECTIVE

Donor site hernias are a rare but well recognised complication of deep inferior epigastric perforator (DIEP) flap breast reconstruction but there are no reported cases of epigastric hernias after such surgery. We report three patients who developed symptomatic epigastric hernias within 2-8 months after discharge from follow-up.

PATIENTS AND METHODS

Patients who were referred to the Breast Plastic Surgery Clinic with symptomatic epigastric hernias following DIEP flap breast reconstruction were retrospectively reviewed.

RESULTS

The three patients were aged between 50 and 70 years. Their mean BMI was 29 and none were smokers or diabetic. The incidences of other predisposing factors were: previous abdominal surgery (1/3), heavy lifting (2/3) and multiparity (2/3). They were successfully treated laparoscopically (2) or by open technique (1) confirming the CT scan findings.

DISCUSSION AND CONCLUSION

The aetiology of epigastric hernias is obscure in general. The association with DIEP flap harvest may be purely coincidental. However, it appears that abdominal flap harvest predisposed these patients to epigastric hernias. One or more of the following factors may have caused either weakness of the anterior abdominal wall or increased intraabdominal pressure: * Short-term partial denervation of the rectus abdominis muscle; * Heavy lifting; * Previous surgery; obesity; multiple pregnancies; * Tight plication of the infraumbilical rectus sheath and muscle. This series of 3 symptomatic epigastric hernias following DIEP flap breast reconstruction is interesting as it documents donor site morbidity at a site distant from the exact site of flap harvest; this subject merits further detailed investigation.

Spigelian hernia as a cause of small bowel obstruction

Spigelian hernia is a rare abdominal wall defect usually appearing between the abdominal muscle lateral to the rectus abdominis and through a debilitated spigelian aponeurosis. Spigelian hernias account for 0.12% to 2.4% of all abdominal wall hernias with a 17-24% risk of strangulation. We report the case of a 77-year-old male that presented with small bowel obstruction with incarcerated spigelian hernia which was successfully treated with a Ventralex hernia patch (Bard Access Systems, Inc., Murray Hill, NJ). A small open incision over the incarcerated hernia was a safe and effective method of repairing an incarcerated spigelian hernia in an urgent fashion.

Perineal Hernia: Surgical Anatomy, Embryology, and Technique of Repair

Perineal hernia is the protrusion into the perineum of intraperitoneal or extraperitoneal contents through a congenital or acquired defect of the pelvic diaphragm. The first case was reported by de Garangeot in 1743. Perineal hernias may occur anteriorly or posteriorly to the superficial transverse perineal muscles. Congenital perineal hernia is a rare entity. Failure of regression of the peritoneal cul de sac of the embryo is considered a predisposing factor for hernia formation. Acquired perineal hernias are primary or secondary. Primarily acquired perineal hernias are caused by factors associated with increased intra-abdominal pressure. They are more common in females as a result of the broader female pelvis and the attenuation of the pelvic floor during pregnancy and childbirth. Secondarily acquired perineal hernias are incisional hernias associated with extensive pelvic operations such as abdominoperineal resection of the anorectum and pelvic exenteration. Pain in the perineal area, intestinal obstruction, topical skin erosion, and difficulty with urination necessitate the surgical repair of a perineal hernia. This can be accomplished through transabdominal, perineal, or combined abdominoperineal approaches. The defect in the muscles of the pelvic diaphragm may be closed either with direct suturing or by using autogenous tissues or synthetic mesh.

Colonic obstruction secondary to incarcerated Spigelian hernia in a severely obese patient

Spigelian hernia is a rare hernia of the ventral abdominal wall accounting for 1-2% of all hernias. Incarceration of a Spigelian hernia has been reported in 17-24% of the cases. We herein describe an extremely rare case of a colonic obstruction secondary to an incarcerated Spigelian hernia in a severely obese patient. Physical examination was inconclusive and diagnosis was established by computed tomography scans. The patient underwent an open intraperitoneal mesh repair. A high level of suspicion and awareness is required as clinical findings of a Spigelian hernia are often nonspecific especially in obese patients. Computed tomography scan provides detailed information for the surgical planning. Open mesh repair is safe in the emergent surgical intervention of a complicated Spigelian hernia in severely obese patients.