Flank hernia and bulging after open nephrectomy: mesh repair by flank or median approach? Report of a novel technique

Abstract

Flank incisions may be associated with flank hernias, which may be complicated with incarceration and strangulation. Furthermore, they may cause a significant limitation of the patient's quality of life. In the period 1997-2006 we performed 15 flank hernia repairs with a prosthetic mesh implantation. From 1997 to 2001 hernias were managed with a standardized mesh implantation through the initial flank incision (seven cases, flank group). Since 2001 we have adopted a novel operative approach in eight patients. Through a median laparotomy and following a transabdominally reduction of the hernia sac, a prosthetic polypropylene mesh [Prolene, Vypro or UltraPro, Ethicon Endo-Surgery (Europe) GmbH, Norderstedt, Germany] overlapping the midline was placed in a sublay technique (median group). The perioperative complication rate was comparable and they consisted mostly of postoperative seromas. A patient from the flank group developed a hernia recurrence two months after surgery. Thirteen patients participated in the annual follow-up for a total follow-up time of five years. In this period we observed only one additional case of hernia recurrence: a patient of the flank group presented with a 3 cm hernia recurrence at the proximal end of the previous operative incision. No recurrence was observed in the median group. As a result the novel technique for open repair of flank incisional hernias we present permits a remodelling of the abdominal wall and is associated with excellent postoperative results.

Atypical Hernias

“…Data from Refs. [39][40][41][42][43][44][45] and colleagues 28 evaluated a few patients undergoing primary repair (14), laparoscopic repair with mesh (10), and open repair with mesh (21), with recurrence rates of 43%, 30%, and 33%, respectively. These investigators also reported that previous sternal wound infection was a risk factor for recurrent hernias after repair, with 6 of 16 patients with recurrences also having a previous sternal wound infection.…”

Abdominal Bulge After Retroperitoneal Dissection

“…2,5 Although limited data to support the following recommendations is available, surgeons have reported the following surgical techniques to reduce iatrogenic flank bulge after retroperitoneal dissection: minimize incision length, 5 direct identification and preservation of intercostal nerves, careful suture placement to avoid nerve strangulation, 15 incision placement superior to the line between the tip of the 12th rib and umbilicus, 14,20 anterior paramedian incision, 2 and limit incisions from entering the intercostal space. 6 Current techniques of abdominal wall reconstruction using fascial fixation of mesh demonstrate high recurrence rates, up to 100%, 10,12 due to failure to address attenuation of the denervated abdominal wall.…”

“…Multiple repair techniques have been described including midline and flank abdominal wall plication, mesh onlay onto the anterior rectus sheath, 9 mesh sublay onto the posterior rectus sheath and extending superficial to the transversus abdominus muscle, 10 and preperitoneal mesh underlay. 11,12 Repair techniques report a wide variety of outcomes, and with 1 exception, recurrence rates in mesh based repair with fascial fixation range from 33% to 100% (Table 1).…”

Focal neuropathies following percutaneous nephrolithotomy (PCNL) – preliminary study

“…These neuropathies may lead to pain, morbidity, reduction of the quality of life, economical problems and legal complaints [11], [16], [17]. Flank incision is accompanied by complications such as pain, intercostals neuropathy, and incisional hernia in 8% to 50% of cases [18], [19], [20], and even testicular pain [20] has been reported. Therefore, small and smaller incisions replace large ones [21].…”