Do not miss any of the new cases! Subscribe above to receive our newsletter! ↑↑

Do not miss the opportunity to download our app on the Google Play Store. Click here to enjoy it.

Previous

Case 196

Next


Click on the images above to zoom in

A 54-year-old female patient, diabetic, BMI of 59.6 kg / m², subjected to bariatric surgery under Fobi-Capella technique by xifoumbilical laparotomy. It evolved with incisional hernia after 4 months (her BMI was 45.4 kg / m²), and it was opted to wait for more weight loss before intervention. After three years, there was stabilization of weight (BMI 37.8 kg / m²), but with greater volume hernia. Requested abdominal computed tomography (CT) to pre-surgical planning (see below).

Given the clinical presentation and CT images attached, which would be the most appropriate approach?

a) Hernia repair with prosthesis.

25%

b) Primary herniorrhaphy followed by abdominoplasty.

25%

c) Preoperative progressive Pneumoperitoneum and hernia repair with prosthesis

25%

d) Separation of external oblique muscle and primary herniorrhaphy.

25%
   

Image Analysis

Image 1: Abdominal CT, axial cut at the level of the L1 vertebra, without contrast.

Presence of massive abdominal hernia. In addition to bowel loops, including the ascending colon (green arrow), the hernia sac also contains part of liver left lobe (red arrow), part of spleen (blue arrow) and pancreas (yellow arrow).

 

Image 1.2: Abdominal CT, axial cut at the level of the T12 vertebra, without contrast. This cut was included here because it allows observing how hernia sac also includes part of the transverse colon (next to the small bowel, in green) and the gallbladder (yellow).

 

Image 2: Abdominal non-contrast CT scan, axial (at T12) and sagittal cuts, respectively. The latter reveals hernia extension, which begins below xiphoid process and is interrupted at umbilical height. Default measures of abdominal wall: transverse axis: 12,1cm; longitudinal: 12,3cm.

These values are classified as giant abdominal incisional hernia, also known as bulky or even complex hernia from other sources.

 

Image 3: Three-dimensional reconstruction of images obtained by abdominal CT, from T8 level to thighs root.

The reconstruction reveals a massive abdominal hernia, shifted to the right, resulting from a midline defect, besides topping adipose tissue. It highlights the important aesthetic damage of this magnitude herniation for patient.

 

Image 4: Multislice abdominal CT technique allows to study the relationship between hernia sac (HSV) and abdominal cavity (ACV) volumes, the same way we study volumes of collections and abscesses, for example. Since they are ellipsoids figures (Figure 1), its volumes are calculated by following mathematical formula:

V = 4/3 x π x longitudinal diameter x transverse diameter x anteroposterior diameter

To calculate volumes were used standardized anatomical landmarks ³ for both cavities diameters, as shown above. We obtained 3.801 cm³ to HSV and 6.897cm³ to ACV, ratio of the former to the latter of 55.11%.

 

Figure 1: The ellipsoid and his three diameters. ³

 


Figure 2: Classic prosthesis positioning:  onlay (blue) and sublay, retrorectal (green) and pre-peritoneal (red). ²

 

Figure 3: Separation of external oblique muscle under separation components technique ²

 

Table 1: Risk factors for incisional hernias development

 

Obesity *

Diabetes Mellitus

Malnutrition

Advanced age

Smoking

COPD

Improper technique

wound complications

Collagenosis

* Main factor associated with giant incisional hernias, specifically.

 

 

Figure 4: Pneumoperitoneum installed in operating room under general anesthesia. The puncture in left upper quadrant was performed with Veress Needle (1) and then inserted into the catheter with a two-way guidewire (2). Pneumoperitoneum installed with ambient air injection using a 50 mL syringe connected to the intra-abdominal catheter (3). Note  final appearance with patient already awaken on the ward (4). Images courtesy of supervisor Professor Rafael C. Barbuto.

 

Figure 5: Preoperative images of giant abdominal hernia, prior to preoperative progressive pneumoperitoneum (PPP). Taken from: Tanaka EY, Yoo JH, Rodrigues Jr. AJ, Utiyama RM, Birolini D, Rasslan S. A computerized tomography scan method for calculating the hernia sac and abdominal cavity volume in complex large incisional hernia with loss of domain. Hernia 2010; 14:63-69

 

 

Figure 6: Postoperative Scenes (immediately and after 7 days, respectively) of hernia repair with prosthesis after use of PPP and without performing abdominoplasty. Taken from: Tanaka EY, Yoo JH, Rodrigues Jr. AJ, Utiyama RM, Birolini D, Rasslan S. A computerized tomography scan method for calculating the hernia sac and abdominal cavity volume in complex large incisional hernia with loss of domain. Hernia 2010; 14:63-69

Highlights

- The incisional hernia is an abnormal projection of abdominal contents through the surgical scar and its diagnosis is clinical (laparotomy history + herniation of abdominal contents);

- Incisional hernia is classified as giant, also known as bulky or complex as the major axis of the fascia defect is greater than 10 cm, with variations in the literature;

- Risk factors are : type 2 diabetes mellitus, advanced age, malnutrition and obesity, and that performing bariatric surgery by laparoscopy is a protective factor for hernia development (compared to laparotomy);

- The ratio of sac and the abdominal cavity volumes greater than 25% is suggestive of intra-abdominal domain loss and indication for preoperative progressive pneumoperitoneum;

- Repair of giant hernia is elective. If you opted for correction, sublay mesh placement, with or without PPP and abdominoplasty is recommended.

References

- Bikhchandani J, Fitzgibbons RJ. Repair of Giant Ventral Hernias. Advances in Surgery 2013 Set; 47:1-27.

- Deerenberg EB, Timmermans L, Hogerzeil DP, Slieker JC, Eilers PHC, Jeekel J, Lange JF. A systematic review of the surgical treatment of large incisional hernia. Hernia 2015; 19:89-101.

- Tanaka EY, Yoo JH, Rodrigues Jr. AJ, Utiyama RM, Birolini D, Rasslan S. A computerized tomography scan method for calculating the hernia sac and abdominal cavity volume in complex large incisional hernia with loss of domain. Hernia 2010; 14:63-69.

- Minossi JG, Oliveira WK, Llanos JC, Ielo SM, Hasimoto CN, Pereira RSC. O uso do pneumoperitônio progressivo no pré-operatório das hérnias volumosas da parede abdominal. Arquivos de Gastroenterologia 2009 abr/jun; 46:121-126.

- Sabbagh C, Dumont F, Robert B, Badaoui R, Verhaeghe P, Regimbeau JM. Peritoneal volume is predictive of tension-free fascia closure of large incisional hérnias with loss of domain: a prospective study. Hernia 2011; 15:559-565.

- Slater NJ, Montgomery A, Berrevoet F, Carbonell AM, Chang A, Franklin M, Kercher KW, Lammers BJ, Parra-Davilla E, Roll S, Towfigh S, van Geffen E, Conze J, van Goor H, Criteria for definition of a complex abdominal wall hernia. Hernia 2014; 18:7-17.

Authors

André Ribeiro Guimarães, acadêmico do décimo período da Faculdade de Medicina da Universidade Federal de Minas Gerais.

E-mail: guimaraesandrer[arroba]hotmail.com

 

Bárbara Mello Faria, acadêmica do décimo período da Faculdade de Medicina da Universidade Federal de Minas Gerais.

E-mail: barbaramellofaria[arroba]gmail.com

 

Isabela Lopes Barbosa, acadêmica do décimo período da Faculdade de Medicina da Universidade Federal de Minas Gerais. 

E-mail: isalopesbarbosa[arroba]gmail.com

Supervisors

Rafael Calvão Barbuto, professor adjunto do departamento de cirurgia da Faculdade de Medicina da Universidade Federal de Minas Gerais.

E-mail: rafaelbarbuto[arroba]gmail.com

 

Marcela Ferreira Nicoliello, médica radiologista e especializanda do 4º ano em Ressonância Magnética  no Hospital Mater Dei.

E-mail: marcela_nicoliello[arroba]yahoo.com.br

Reviewers

Fábio Satake, Hércules Riani, Barbara Queiroz, Rafael Waldolato, Júlia Petrocchi ,Viviane Parisotto

Acknowledgements

We are greatly thankful to the patient and family, who consented us to use radiological images for this case report. Unfortunately, the patient passed away posteriorly by a condition not related to abdominal hernia. We wish our condolences to family and acquaintances.

Translated by

Ana Júlia Bicalho, 6th year medical student at UFMG School of Medicine.

E-mail: anajuliabicalho[at]gmail.com

 

 

Commentics

Sorry, there is a database connection problem.

Please check back again shortly.

Bookmark and Share




Unfortunately there is no english translation available yet for this case.

Please refer to the Portuguese version instead or come back later.





Follow us:      Twitter  |    Facebook  |    Get the news  |    E-mail