Hernia after dorsal incision into lumbar region: a case report and review of pathogenesis and treatment

Primary upper lumbar hernia repaired by transabdominal preperitoneal approach technique using a self-expanding mesh with a memory-recoil ring, report of a case

BACKGROUND

Upper lumber hernia is a rare entity which can cause obstruction and strangulation. Laparoscopic technique has been considered effective for such hernia repairs; however, there is no report of use of the self-expanding mesh.

CASE PRESENTATION

A 77-year-old woman visited to our hospital complaining of a bulge of about 5 cm in the left lumbar dorsal region while standing. Abdominal CT and MRI scans showed a fascial defect in the left lumbar abdominal wall and confirmed the presence of a hernia, in which retroperitoneal fatty tissue and the descending colon protruded. Transabdominal preperitoneal repair (TAPP) was performed and the operative findings revealed the hernia orifice, 3 × 2.5 cm in diameter, between two intercostal nerves. To avoid nerve injury or entrapment, the number of mesh fixation was desirable minimum; therefore, a self-expanding mesh with a memory-recoil ring was used. The mesh, 9.5 × 13 cm in diameter, was placed and tacked to the abdominal wall at two points, 1 cm ventral and dorsal to the hernia orifice. The postoperative course was uneventful and no pain or recurrence was observed with follow-up of 6 months.

CONCLUSION

We herein present a case of upper lumber hernia successfully repaired by TAPP with a self-expanding mesh.

Lateral hernia secondary to colorectal submucosal resection repaired by robotic-assisted approach: Case report

Introduction and importance

Lateral abdominal wall defects are a rare event and commonly result from iatrogenic causes and trauma. We report the first known case of flank hernia after endoscopic submucosal resection of a colonic polyp complicated by colonic perforation.

Case presentation

This is a case of a 50-year-old male who underwent endoscopic colonic resection complicated by perforation of the colon. Eight months later, he presented with an enlarging, asymptomatic left flank bulge. CT showed a large flank hernia which was successfully repaired using a robotic transabdominal preperitoneal (TAP) approach.

Clinical discussion

The hypothesis is that the endoscopic resection with colonic perforation caused an iatrogenic injury to the abdominal wall creating a lateral abdominal hernia. Injury to abdominal wall musculature may take months to develop into a clinically apparent hernia. Flank hernias can be successfully repaired using a robotic minimally invasive approach.

Conclusion

Flank bulge and hernias must be included or at least be considered as consequence of a potential complication from endoscopic colonic perforation. Surgeons and endoscopists must be aware of this potential complication and its latent presentation. This case stresses the importance of long-term outcomes monitoring, particularly with innovative procedures.

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Lateral abdominal wall defects are a rare event and commonly occur due to trauma.

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Lateral hernias seldomly can be resulted from myofascial laxity and denervation injury.

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Endoscopic resection may lead thermal injury of the abdominal wall and latent hernia.

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Robotic surgery is a safe and effective platform to repair lateral abdominal hernias.

Laparoscopic repair of traumatic flank hernias

INTRODUCTION

Traumatic flank hernias (TFH) are caused by a blunt abdominal trauma with resultant detachment of the oblique musculofascial complex at the iliac crest and/or costal margin. Given such proximity to the bony structures and essential absence of healthy fascia to anchor the mesh, TFH represent a challenging surgical problem. Although laparoscopic repair of ventral hernias has become very common, no series of laparoscopic repairs of TFH has been reported to date. We present a series of patients undergoing laparoscopic repair of TFH.

METHODS

After retrospective review of prospective hernia database at two Hernia centers, patients undergoing laparoscopic TFH repair were identified and analyzed. Main outcome measures included patient demographics, surgical technique, intraoperative data, and post-operative outcomes.

RESULTS

From December 2007 to December 2013, 14 patients underwent laparoscopic repair of a TFH. Eleven patients had chronically incarcerated viscera within the defect. Operative steps included complete reduction of the hernia sac, pre/retroperitoneal dissection to expose the entire lateral edge of a psoas muscle, defect closure with transabdominal sutures, wide mesh overlap, and transabdominal suture fixation with selective use of bone anchors. The mean operative time was 174 min (range 125-230). Mean estimated blood loss was 65 cc. Mean mesh size was 295 cm². There were no peri-operative complications. Mean hospital stay was 3.1 days and all patients returned to full activities by 6 weeks. At a mean follow-up of 35 months, there have been no recurrences.

CONCLUSION

Laparoscopic approach to TFH is feasible and safe. It is associated with minimal hospital stay and fast functional recovery. The key components of our approach include wide pre/retroperitoneal with defect closure and subsequent wide mesh underlay coverage with fixation to bony structures using anchors/screws. We believe that the laparoscopic approach should safely considered for the majority of patients with TFH.

Implementation of the trans-abdominal partial extra-peritoneal (TAPE) technique in laparoscopic lumbar hernia repair

Background

There is still not any standardized operative strategy that is well-accepted all over the world for lumbarhernia. We are here to investigate the feasibility of the trans-abdominal partial extra-peritoneal (TAPE) technique in lumbar hernia repair.

Methods

The TAPE technique was applied to 14 patients with lumbar hernia from May 2009 until January 2014. The surgical technique was described in details and follow-ups were performed for further evaluation.

Results

The mean age of the 14 patients was 68 ± 8 years, with the average BMI 25.5 ± 2.1 kg/m². The etiology study showed that 13 cases after surgical operations and one case after trauma. The average size of the hernia defect was 86.8 ± 46.4 cm², while the mean size of the mesh implanted was 275 ± 61.2 cm². The mean operative time was 59.2 ± 8.2 min. There was no intra-operative visceral injury in this serial of cases. There was no conversion case and all patients accepted the TAPE technique successfully. The VAS was 3.8 ± 1.9 and 2.2 ± 1.6 on POD1 and POD3, respectively. The mean post-operative hospital stay was 4.0 ± 1.3 days. The median follow-up time was 33 months. All patients returned to unrestricted movement within 2 weeks after surgery. During the follow-ups, no complication as bulge, seroma, hematoma, wound infection, abscess in surgical area and chronic pain, nor recurrence was observed.

Conclusions

According to our experience in this series of investigations, the TAPE could be a feasible and easy-to-learn technique which can be applied to most of the lumbar hernia repairs.

Lateral Abdominal Wall Defects: The Importance of Anatomy and Technique for a Successful Repair

Flank and lateral abdominal wall defects can be an extremely challenging phenomenon for surgeons to undertake. Their rarity and specific idiosyncrasies in regard to embryologic and anatomical characteristics must be taken into consideration when formulating an operative plan. We will discuss these cardinal points including technical recommendations by notable experts in the field to gain a better understanding in the diagnosis and treatment of this infrequent but morbid occurrence.

Management of giant inferior triangle lumbar hernia (Petit's triangle hernia): A rare complication following delayed breast reconstruction with extended latissimus dorsi myocutaneous flap

INTRODUCTION

Lumbar triangle hernia after breast reconstruction with latissimus dorsi flap (LDMF) is a very rare complication and few cases were previously described. Muscle mobilization and iatrogenic fascia defect are related etiologic factors.

PRESENTATION OF CASE

The authors describe a rare case of lumbar hernia in a 58-year-old woman who underwent delayed left breast reconstruction with LDMF. Two months after surgery, a progressive symptomatic lower left lumbar bulge was observed. The CT scan confirmed the diagnosis and delineated an 18 cm lumbar defect filled with lower and large bowel. At operation, the defect was exposed and the hernia sac reduced. In order to obtain stability, the remained local muscle and fascia flaps were mobilized into the defect. Additional strength was achieved with a two-layer closure of prosthetic mesh (intra/extra peritoneal). The patient is currently in the 10th postoperative year of hernia repair and satisfactory lumbar wall contour was achieved. Neither the recurrence of lumbar hernia nor symptoms compliance was noted.

DISCUSSION

Lumbar hernia is an uncommon complication of LDMF harvest. Although it is a rare disease, general and plastic surgeons must be on alert to avoid complications and misdiagnosis. Seroma differential diagnosis is important in order to avoid bowel perforation due to aspiration. Defect reconstruction is necessary with a muscular and fascia flaps mobilization and synthetic mesh in order to obtain a stable repair.

CONCLUSION

The knowledge of this rare post-operative complication following delayed breast reconstruction is crucial to its surgical management. Early surgical intervention is warranted in order to avoid severe complications.

Lateral abdominal wall reconstruction

Lateral abdominal wall (LAW) defects can manifest as a flank hernias, myofascial laxity/bulges, or full-thickness defects. These defects are quite different from those in the anterior abdominal wall defects and the complexity and limited surgical options make repairing the LAW a challenge for the reconstructive surgeon. LAW reconstruction requires an understanding of the anatomy, physiologic forces, and the impact of deinnervation injury to design and perform successful reconstructions of hernia, bulge, and full-thickness defects. Reconstructive strategies must be tailored to address the inguinal ligament, retroperitoneum, chest wall, and diaphragm. Operative technique must focus on stabilization of the LAW to nonyielding points of fixation at the anatomic borders of the LAW far beyond the musculofascial borders of the defect itself. Thus, hernias, bulges, and full-thickness defects are approached in a similar fashion. Mesh reinforcement is uniformly required in lateral abdominal wall reconstruction. Inlay mesh placement with overlying myofascial coverage is preferred as a first-line option as is the case in anterior abdominal wall reconstruction. However, interposition bridging repairs are often performed as the surrounding myofascial tissue precludes a dual layered closure. The decision to place bioprosthetic or prosthetic mesh depends on surgeon preference, patient comorbidities, and clinical factors of the repair. Regardless of mesh type, the overlying soft tissue must provide stable cutaneous coverage and obliteration of dead space. In cases where the fasciocutaneous flaps surrounding the defect are inadequate for closure, regional pedicled flaps or free flaps are recruited to achieve stable soft tissue coverage.

Surgical options in lumbar hernia: laparoscopic versus open repair. A long-term prospective study

OBJECTIVE

To determine the safety and effectiveness of laparoscopic lumbar hernia repair.

DESIGN

Prospective clinical study.

SETTING

Abdominal wall unit, university hospital.

PATIENTS

Between January 1995 and December 2008, data from 55 consecutive patients who had undergone laparoscopic (n = 35) or open (n = 20) lumbar hernia repair.

MAIN OUTCOME MEASURES

The primary endpoint was recurrence; secondary endpoints were patient outcomes (morbidity, pain, and return to normal activity).

RESULTS

Mean operating time (P = .01), hospital stay, return to normal activity, analgesic consumption, and pain at 1 month (P < .001) were significantly less in the laparoscopic group. Complications were similar in the 2 groups (37% vs 40%, respectively; P = .50). Traumatic hernias increased local complications versus incisional lumbar hernias (71.4% vs 29%; P = .007). Consumption of analgesics (6.8 ± 6.5 vs 18.1 ± 9.1; P < .001) and pain during the first month (no pain: 90% vs 54.3%; P = .015) were significantly less with a lightweight versus medium-weight mesh. The risk factors associated with recurrences development were localization (P = .01) and size (P = .008). Recurrence rates were 2.9% in the laparoscopic group and 15% in the open group (P = .13).

CONCLUSIONS

Outcomes did not differ with respect to morbidity and recurrence rate after long-term follow-up; however, this study suggested that laparoscopic approach for lumbar hernia is safe, effective, and more efficient than open repair and can be considered the procedure of choice. Open surgery may be considered the best option in the diffuse hernias with size larger than 15 cm.

Retromuscular preperitoneal repair of flank hernias

INTRODUCTION

Flank hernias represent a challenging problem to reconstructive surgeons. Their anatomic proximity to the bony prominence and major neurovascular structures limits fixation options and restricts mesh overlap. We present our technique and outcomes of a preperitoneal repair with wide mesh overlap.

METHODS

This study is a retrospective analysis of patients undergoing open flank hernia repair with a retromuscular preperitoneal approach.

RESULTS

Between September 2007 and April 2011, 16 patients, mean age 55 years (range 34-80) and BMI 33 kg/m² (range 26-46), underwent open flank hernia repair. Eight were recurrent hernias; six previously had mesh placed; nine were incarcerated. Mean hernia defect size was 232 cm² (range 25-800). Mean operative time was 178 min (range 105-245). One intraoperative complication, ureteral injury in a transplant recipient, occurred and was primarily repaired without sequela. Two patients developed wound complications, one requiring superficial debridement and another requiring partial excision (<5 %) of the mesh with secondary healing. With a mean follow-up of 16.8 months (range 2-49), no recurrent hernias were noted.

CONCLUSION

Open retromuscular preperitoneal repair of flank hernias with iliac bone fixation is technically feasible, allowing wide mesh overlap for a durable repair. This approach may offer advantages of treating abdominal wall laxity and repair of larger defects when compared to laparoscopic approaches.

MDCT of abdominal wall lumbar hernias: anatomical review, pathologic findings and differential diagnosis

PURPOSE

To review the anatomical landmarks of the abdominal wall lumbar region and its normal appearance on multidetector computed tomography (MDCT) and to briefly describe the MDCT features of lumbar hernias.

METHODS

We performed a retrospective search of the imaging report database from November 2007 to October 2011. We retrieved the clinical data and MDCT studies of patients suffering from abdominal wall lumbar hernias. We reviewed the imaging features of abdominal lumbar hernias and compared those with the normal appearance of the lumbar region in asymptomatic individuals.

RESULTS

We classified lumbar wall hernias as diffuse, superior (or Grynfelt-Lesshaft) and inferior (or Petit) lumbar hernias. We briefly describe the imaging features of each subtype and review the anatomy and MDCT appearance of normal lumbar region.

CONCLUSIONS

Currently available MDCT provides an excellent opportunity for reviewing the normal anatomy of the wall lumbar region and may be considered a useful modality for evaluating lumbar hernias.

Laparoscopic incisional lumbar hernia repair

PURPOSE

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.

METHODS

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.

RESULT

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.

CONCLUSIONS

We believe that the laparoscopic approach is feasible, safe, and the least invasive choice for repairing difficult hernias such as incisional lumbar hernias.

Laparoscopic Lumbar Hernia Repair

Lumbar hernias are rare clinical entities that often pose a challenge for repair. Because of the surrounding anatomy, adequate surgical herniorraphy is often difficult. Minimally invasive surgery has become an option for these hernias. Herein, we describe two patients with lumbar hernias (one with a recurrent traumatic hernia and one with an incisional hernia). Both of these hernias were successfully repaired laparoscopically.

Eventrações lombares: revisão tardia de 20 pacientes

INTRODUÇÃO: Desde a primeira descrição em 1731 por DeGarangoet até 1994 poucos casos de hérnia lombar incisional (HLI) foram relatados, restringindo-se a aproximadamente 300 casos. No entanto, esse número deve ser muito maior do que o encontrado na literatura pesquisada1,2. Não há maiores relatos com experiência significativa nesta afecção e, da mesma forma, não há descrição de uma técnica cirúrgica padrão para sua correção. OBJETIVO: Transmitir a experiência dos autores, alcançada no tratamento cirúrgico dos pacientes com HLI, confrontando-a com os dados vigentes na literatura. MÉTODO: Foram analisados, retrospectivamente, 20 casos de hérnia lombar submetidos ao tratamento cirúrgico no Serviço de Cirurgia Geral da ISCMPA/FFFCMPA nos últimos 10 anos. RESULTADOS: Foram identificados 20 pacientes, a idade média foi de 49 anos (28 - 68 anos). A maioria (19 casos) correspondeu a hérnias incisionais lombares. O seguimento médio foi de 60 meses (5-72 meses), porém sete casos não compareceram às revisões ambulatoriais de rotina. Não houve recidiva nos casos acompanhados em um seguimento que variou de seis meses a 8,5 anos. Em um caso persistiu o abaulamento, dois apresentaram seroma, e um apresentou infecção de ferida operatória. CONCLUSÕES: Os autores recomendam a intervenção convencional, com reparo primário nos casos com diâmetro inferior a 5 cm e a utilização de tela nos casos em que há tensão na linha de sutura.

Assessment of body image alteration after renal surgery using a novel three-dimensional laser scanner

OBJECTIVES

To evaluate the utility of a newly developed three-dimensional (3D) body surface laser scanner and evaluate the body surface image of patients undergoing renal surgery to determine the impact of surgery on body image alterations.

METHODS

The body surface image in the upright position was obtained using the Bodyline Scanner (Hamamatsu Photonics K.K., Hamamatsu, Japan), a 3D body surface laser scanner, in 27 patients who had undergone renal surgery. We compared the objective results of body image scanning with the subjective results of a self-administered questionnaire on perception and concern about body image alteration.

RESULTS

The abdominal body surface area and volume of the operative side was significantly larger than that of the contralateral side in 18 patients undergoing renal surgery using a flank incision (median area 50.7%, P = 0.002; volume 51.2%, P <0.001). A statistically significant difference was not observed in 9 patients undergoing transperitoneal or laparoscopic surgery (median area 50.0%, P = 0.34; volume 49.9%, P = 0.40). The volume alteration measured by the 3D body surface laser scanner correlated with the patients' perception (P = 0.01) and concern (P = 0.03) about postoperative body image alteration as assessed by the self-administered questionnaire.

CONCLUSIONS

The 3D body surface scanner is promising as a tool in the medical field in that it enables a computerized body image to be constructed in the upright position that reflects patients' subjective perceptions well. Using this, we observed that the flank incision causes postoperative changes in body image perceptible to the patient and a cause for concern.

Laparoscopic management of inferior lumbar hernia (Petit triangle hernia)

Lumbar hernias are rare defects in the posterolateral abdominal wall that may be congenital or acquired. We present a case of laparoscopic approach to repair an acquired inferior triangle (Petit) lumbar hernia in a woman by using polytetrafluoroethylene mesh. The size of the hernia was 8 x 10 cm. The length of her hospital stay was 2 days. The patient resumed normal activities in less than 2 weeks. The main advantage of this approach is excellent operative visualization, thus avoiding injury to structures near the hernia during repair. Patients benefit from a minimally invasive approach with less pain, shortened hospital course, less analgesic requirements, better cosmetic result, and minimal life-style interference.

A novel technique of lumbar hernia repair using bone anchor fixation

Lumbar hernias are difficult to repair due to their proximity to bone and inadequate surrounding tissue to buttress the repair. We analyzed the outcome of patients undergoing a novel retromuscular lumbar hernia repair technique. The repair was performed in ten patients using a polypropylene or polytetrafluoroethylene mesh placed in an extraperitoneal, retromuscular position with at least 5 cm overlap of the hernia defect. The mesh was fixed with circumferential, transfascial, permanent sutures and inferiorly fixed to the iliac crest by suture bone anchors. Five hernias were recurrent, and five were incarcerated; seven were incisional hernias, and three were posttraumatic. Back and abdominal pain was the most common presenting symptom. Mean hernia size was 227 cm(2) (60-504) with a mesh size of 620 cm(2) (224-936). Mean operative time was 181 min (120-269), with a mean blood loss of 128 ml (50-200). Mean length of stay was 5.2 days (2-10), and morphine equivalent requirement was 200 mg (47-460). There were no postoperative complications or deaths. After a mean follow-up of 40 months (3-99) there have been no recurrences. Our sublay repair of lumbar hernias with permanent suture fixation is safe and to date has resulted in no recurrences. Suture bone anchors ensure secure fixation of the mesh to the iliac crest and may eliminate a common area of recurrence.

Lumbar hernia: clinical analysis of 11 cases

BACKGROUND

Lumbar hernia is a relatively rare phenomenon. The aim of this study was to investigate the clinical manifestation, the diagnosis of lumbar hernia, and the outcome of the surgical procedure.

METHODS

Eleven cases of lumbar hernia were studied by clinical observation retrospectively from July 1998 to July 2000.

RESULTS

All the patients were diagnosed clinically and confirmed operatively. The typical manifestation was a semi-spherical painful mass in the superior or inferior triangle. If the gut was incarcerated, bowel obstruction may subsequently develop. Ten of the eleven patients were treated successfully.

CONCLUSIONS

The clinical symptoms and signs usually allow for easy diagnosis. Excision of the sac and high ligation, followed by repair using either surrounding tissue or prosthetic material, provided satisfactory results.

The retroperitoneoscopic repair of a lumbar hernia of Petit. Case report and review of literature

In this paper, we comment on a patient who consulted us because of his "lower backpain" together with the appearance of a small swelling at the left side. Anamnesis and clinical examination were suggestive and further simple diagnostic methods confirmed the exceptional diagnosis of a "lumbar hernia of Petit". We describe the retroperitoneoscopic approach of this hernia, its reduction and the fixation of a polypropylene mesh at the surrounding structures with a Tacker. This approach provided a good postoperative comfort, a shorter hospital stay and an early recovery of autonomy and activity. Furthermore, we give a review of the literature concerning lumbar hernias and the evolution of the different reconstruction techniques.

Totally extraperitoneal laparoendoscopic repair of lumbar hernia

BACKGROUND

The repair of congenital and acquired lumbar hernias has remained a significant surgical challenge for over three centuries. Transperitoneal laparoendoscopic techniques have been reported that have achieved success in repairing these difficult hernias using a variety of synthetic mesh. Careful review of the surgical literature addressing the repair of lumbar hernia reveals that only fourteen successful cases have been reported using minimally invasive techniques. All of these cases elected a transperitonal approach to repair. Encouraged by established success in the repair of inguinal hernia using an extraperitoneal approach, the repair of a large inferior triangle lumbar hernia was attempted using overlapping synthetic mesh technique while remaining entirely in an extraperitoneal plane.

METHODS

A seventy-eight-year-old patient presented for repair of a large symptomatic right lumbar hernia, one year following iliac bone harvest for lumbar laminectomy/fusion. Under general anesthesia, the patient was placed in a lateral decubitus position with lumbar roll in place. Using a muscle splitting dissection through the lateral abdominal musculature, a plane was developed bluntly between the transversalus muscle and the peritoneum. Using a three trocar technique, the plane was matured posteriorly, achieving an ample working space to identify the hernia and complete a synthetic mesh (PTFE) repair.

RESULTS

A large inferior triangle lumbar hernia was successfully repaired using overlapping synthetic mesh technique while remaining entirely in an extraperitoneal plane. Eighteen month reevaluation including physical examination and computer tomographic (CT) study confirms successful repair without recurrence of symptoms.

CONCLUSIONS

A totally extraperitoneal approach to the identification, mobilization, and repair of lumbar hernia can be successfully accomplished using established laparoendoscopic surgical techniques.

Body image alteration after flank incision: relationship between the results of objective evaluation using computerized tomography and patient perception

PURPOSE

We evaluated subjective and objective alterations in body image and configuration of patients who underwent urological surgery via a flank incision.

MATERIALS AND METHODS

Eligible for study were 17 patients who underwent urological surgery via an 11th rib transcostal incision. Preoperative and postoperative abdominal computerized tomography were used for evaluation. The intra-abdominal contents surrounded by the vertebral bones and muscles forming the body trunk were divided into 4 subspaces. The areas of these 4 portions were measured and the calculated ratio of the contents of each portion determined preoperatively was compared with that determined postoperatively. Of the 17 patients 15 answered a questionnaire on the perception and bother of body image alteration. We compared their subjective answers with objective results using computerized tomography.

RESULTS

The ratio of the ipsilateral-dorsal portion significantly increased postoperatively from 18.7% to 21.9% at the L2 level (p <0.001), 19.7% to 23.1% at the L3 level (p = 0.002) and 18.3% to 21.2% at the L4 level (p = 0.003). Posterolateral bulging was typically observed at the L2 level. Of the 15 patients who answered the questionnaire 9 (60%) perceived and 4 (27%) were bothered by body image alteration to at least a moderate extent. The ratio of increase in the ipsilateral-dorsal portion was significantly higher in the 9 patients who perceived at least moderate body image alteration than in the remaining 6 (2.2% versus 4.6%, p = 0.031).

CONCLUSIONS

The intra-abdominal contents deviated in the ipsilateral-dorsal direction with the patient supine after flank incision done via the 11th rib transcostal approach. This change, typically represented by posterolateral bulging, results in an altered patient body image.

Sublay prosthetic repair for incisional hernia of the flank

PURPOSE

A large hernia after flank incision for nephrectomy is a challenging problem in hernia surgery. In recent decades preperitoneal prosthetic herniorrhaphy became a widely accepted procedure for hernias of the abdominal wall. To evaluate the outcome of mesh hernia repair of the flank we reviewed our data on all patients who underwent preperitoneal mesh repair.

MATERIALS AND METHODS

We identified 4 patients who underwent prosthesis repair after incisional hernia of the flank within the last 6 years. The primary reason for surgery was nephrectomy in 2 cases, pyeloplasty in 1 and complicated kidney cyst resection in 1. Mean followup time was 33 months.

RESULTS

In a mean operative time +/- SD of 208 +/- 55 minutes the patients underwent incisional hernia repair with prosthesis implantation in the sublay position. In 3 patients an expanded polytetrafluoroethylene patch was used and in 1 polypropylene mesh was implanted. Mean prosthesis size was 25 x 38 cm. (950 +/- 300 cm. ). There were no postoperative complications. Patients were discharged from the hospital after a mean of 15 +/- 2 days. Followup revealed that none of the 4 patients with flank incision had recurrent hernia. Pain persisted in 3 patients after flank incision. However, no regular analgesic drug prescription was necessary.

CONCLUSIONS

Mesh repair for incisional flank hernia provides reinforcement of the hernia. However, the flank remains paralyzed with a muscle bulge and some patients have persistent discomfort.

Isolation and characterization of monoclonal antibodies specific for protein conformational epitopes present in prostate-specific membrane antigen (PSMA)

Prostate-specific membrane antigen (PSMA) is a 750-amino acid glycoprotein highly expressed in malignant prostate tissues. PSMA reacts with the murine monoclonal antibody 7E11.C5, whose binding epitope has been mapped to the N-terminal of the protein distributed on the cytoplasmic side of the plasma membrane. We have developed murine monoclonal antibodies specific for extracellular epitopes of PSMA. Three of these antibodies--1G9, 3C6, and 4D4--display distinct binding properties consistent with their recognition of conformational epitopes within native PSMA. Results indicate this panel of antibodies binds to native full-length PSMA, but not to fusion proteins containing portions of the linear sequence of the protein. Antibody binding is greatly reduced upon heat denaturation of native PSMA, and these antibodies do not detect PSMA by Western blot. Immunoprecipitation experiments demonstrate the ability of each to bind to full-length PSMA as well as PSM', a form of the protein missing the first 57 amino acids. These results indicate each antibody is specific for an epitope within the extracellular domain, a region spanning residues 44-750. Flow cytometric experiments indicate strong specific binding to live LNCaP cells. Antibody inhibition studies demonstrate that these antibodies recognize at least two distinct epitopes. Taken together, the results demonstrate that these antibodies are specific for native protein conformational epitopes within the extracellular domain. Their properties, in particular strong binding to live cancer cells, make them ideal candidates that are clearly superior to linear sequence epitope specific antibodies for in vivo applications.

Laparoscopic repair of lumbar hernias

BACKGROUND

Lumbar hernias are rare defects in the posterolateral abdominal wall that may be congenital or acquired. Repairing these defects is difficult by virtue of their location and the inherent weakness of the surrounding tissues. We report a series of seven patients who had their lumbar hernias repaired laparoscopically at two institutions.

STUDY DESIGN

We retrospectively reviewed all lumbar hernias repaired laparoscopically in our institutions within the last 16 months (August 1996 to November 1997). Postoperative followup was 1-15 months.

RESULTS

Seven patients underwent laparoscopic repair. Five hernias were acquired defects and two were congenital. One to three defects were found per patient. The average size of the hernia defect was 77.8 cm2. We used a polypropylene or a polytetrafluoroethylene mesh in all patients; the average size of the mesh used was 336.4 cm2. The average length of hospital stay was 1.7 days. One patient returned with an abscess over the mesh, which necessitated removal of the graft. Otherwise, there were no complications, and the remaining six patients had no recurrences after followup of 1-14 months.

CONCLUSIONS

The laparoscopic approach is safe and effective for repairing lumbar hernias. Advantages of this approach include excellent operative visualization, decreased hospital stay postoperatively, and a solid repair without recurrence during shortterm followup.

Role of laparoscopy in the diagnosis and treatment of prostate cancer

Laparoscopic surgical techniques were originally applied to the staging of prostate cancer in the form of laparoscopic pelvic lymph node dissection. The efficiency of laparoscopic pelvic lymph node dissection has proven to be comparable to open lymphadenectomy in tissue yield and also shows a considerable decrease in postoperative morbidity. Subsequently, laparoscopy has been used as an adjuvant to perineal prostatectomy for preliminary dissection of the seminal vesicles. Laparoscopic radical prostatectomy has been performed but the long-term efficacy of this treatment is unknown at this point. Future clinical applications of laparoscopic surgical techniques in the diagnosis and treatment of prostate cancer include harvesting of primary and metastatic prostatic tissue for adjuvant gene therapies for prostate cancer.