Aim Endoscopic lateral incisional hernia (IH) repair provides advantages in terms of low infection rates and hospital stay when compared with open repair. Material and Methods 62 years old men with a history of HTA and an open radical right nephrectomy for a renal tumor, developed a symptomatic iliac IH. L2–3 W2 according to the European Hernia Society (EHS) classification was clinically diagnosed and confirmed with a CT scan. Full endoscopic abdominal wall repair with defect closure was proposed. 3 trocars in right retrorectus space were placed. Once the lateral edge of the rectus sheath is reached, the posterior rectus sheath is incised, access to the preperitoneal lateral plane. During hernia sac dissection, an opening of the hernia sac occurs. The posterior layer is closed by a barbed suture, an accessory trocar placement was necessary for the closure. Subsequently, the internal oblique and transversus abdominis muscles that formed the defect were approximated with a barbed suture. During dissection, a right inguinal hernia was identified and repaired. A trimmed 20 x15 cm polipropilene mesh is placed in the preperitoneal space without fixation. Results The patient was discharged on the 3rd postoperative day without complications. Follow-up in the outpatient clinic at 6 months did not show any signs of recurrence. Conclusion Endoscopic abdominal wall reconstruction with posterior component separation is an alternative to the open procedure for lateral IH, providing a complete abdominal wall repair. The mesh is placed extraperitoneal with the advantages in terms of less adhesions and postoperative pain.
Aim The importance of an appropriate patient optimization (botulin toxin and pneumoperitoneum) and adequate surgical technique is highlighted.The possibility of intraoperative monitoring of the nerves that may be injured during posterior component separation is explained Material and methods We present a 74 years old man, past smoker, with history of hypertension, steatohepatitis and chronic bronchopathy Results This is a disastrous but unfortunately not so uncommon story of a failed repair of a simple umbilical hernia with 3 previous unsuccessful attempts of repair with and without mesh. After the last surgery the patient developed a giant incisional hernia with loss of domain. Optimization consisted of improving nutritional status, respiratory physiotherapy, botulin toxin and pneumoperitoneum. The surgery was made using previous skin scar. After dissecting the retrorectus space, a posterior component separation was made with the aid of monitoring the nerves that come to innervate the rectus abdominis. An overextended overlapped was obtained. A patch of absorbable mesh was used to completely close the peritoneum. A combination of absorbable and permanent synthetic mesh was used as giant reinforcement of the visceral sac. The only points of fixation were the Cooper Ligaments. The patient had a satisfactory recovery without complications and was discharged on the 8th postoperative day. Conclusions Loss of domain incisional hernias is a real surgical challenge. The combination of a good preoperative strategy (preoperative neumoperitoneum) and surgical technique (TAR and pannniculectomy) gives a great opportunity to solve very complex cases of incisional hernia.
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