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

Abstract

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.

A Case of an Atraumatic Posterior Perirenal Lumbar Hernia

“…Lumbar hernias are a rare finding [1], requiring surgical attention because of the high risk of incarceration and potential risk of strangulation [7]. Lumbar hernias can be acquired secondary to surgical procedures [2][3][4] or they can be primarily acquired [8]. Primarily acquired (spontaneous/atraumatic) lumbar hernias represent 55% of all lumbar hernias [8].…”

“…Retroperitoneal lumbar hernias are rare and consequentially have limited standardized treatment recommendations [1]. Posterior perirenal hernias are a form of lumbar hernia that can be related to surgical procedures [2][3][4] or can be primary, i.e., spontaneous and unrelated to surgery [4]. Incisional hernias have been noted in post-renal transplants [2], retroperitoneal robotic partial nephrectomies [3], and general renal surgeries [4].…”

“…Posterior perirenal hernias are a form of lumbar hernia that can be related to surgical procedures [ 2 - 4 ] or can be primary, i.e., spontaneous and unrelated to surgery [ 4 ]. Incisional hernias have been noted in post-renal transplants [ 2 ], retroperitoneal robotic partial nephrectomies [ 3 ], and general renal surgeries [ 4 ]. In large defects where the kidney is involved, a supportive mesh has been used to repair the defect [ 5 - 6 ].…”