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Table of Contents
CASE REPORTS
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 128-132

Laparoscopic transabdominal preperitoneal mesh repair of two posterior rectus sheath hernias: A first case series in the published literature


Department of Surgery, University of Saskatchewan, Saskatchewan, Canada

Date of Submission25-Mar-2021
Date of Decision28-Mar-2021
Date of Acceptance12-Apr-2021
Date of Web Publication30-Sep-2021

Correspondence Address:
Prof. Yagan Pillay
Department of General Surgery, University of Saskatchewan, Health Sciences Building, 107 Wiggins Rd B419, Saskatoon, Saskatchewan, S7N 0W8.
Canada
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijawhs.ijawhs_21_21

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  Abstract 

Posterior rectus sheath hernias are a rare type of interparietal hernia previously described in a limited number of case reports. There has only been one published case report of a laparoscopic mesh repair. We present a case series of two posterior rectus sheath hernias diagnosed at laparoscopy. A preperitoneal mesh herniorrhaphy was performed to repair the defects. To our knowledge this is the first time such a repair has been performed for this type of hernia. Both hernia necks were infra-umbilical in position. In all previously reported case reports the hernial necks were supraumbilical in position.This is the first case series to be published of this exceedingly rare type of interparietal hernia.

Keywords: Interparietal hernia, laparoscopic herniorrhaphy, posterior rectus sheath hernia


How to cite this article:
Pon K, Pillay Y. Laparoscopic transabdominal preperitoneal mesh repair of two posterior rectus sheath hernias: A first case series in the published literature. Int J Abdom Wall Hernia Surg 2021;4:128-32

How to cite this URL:
Pon K, Pillay Y. Laparoscopic transabdominal preperitoneal mesh repair of two posterior rectus sheath hernias: A first case series in the published literature. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2021 Dec 6];4:128-32. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/3/92/327062




  Introduction Top


A hernia is an abnormal protrusion of an organ or tissue through a defect in its surrounding muscle wall. Abdominal wall hernias are a commonly encountered condition in surgical practice, with upwards of 400,000 repairs annually in the United States.[1] Posterior rectus sheath hernias are a rare type of interparietal hernia in which the hernia sac lies within the layers of the abdominal wall and does not extend into the subcutaneous tissues.

There have been less then 12 documented cases in the published literature since the first published report in 1937.[2],[3],[4],[5],[6] There is one published report of a laparoscopic repair.[7] In 2019, Loureiro et al. detailed a laparoscopic approach to repairing an incarcerated posterior rectus sheath hernia in a patient presenting with small bowel obstruction. This was done with a polytetrafluoroethylene (PTFE) mesh in an intraperitoneal underlay technique.

There have been no published reports of a laparoscopic preperitoneal mesh repair of a posterior rectus sheath hernia. We present the first case series of two posterior rectus sheath hernias found at the time of a planned laparoscopic inguinal herniorrhaphy. The two hernias were repaired pre-peritoneally with a self-adherent polypropylene (ProGrip©) mesh. This case report was produced in accordance with the CARE reporting checklist.


  Case Reports Top


Case 1

A 72-year-old male patient was referred to surgery with a symptomatic right inguinal hernia. His medical history included a lower midline laparotomy and bowel resection for colon cancer and a left antero-lateral thoracotomy and lung lobectomy for lung cancer. He quit smoking 20 years ago.

His physical examination revealed a right-sided direct inguinal hernia.

He had no obvious abdominal mass clinically but did have a positive cough impulse. There were no other abdominal wall hernias. He was assessed pre-operatively by internal medicine and anesthesia given his significant surgical history. An informed consent was obtained for a laparoscopic transabdominal preperitoneal (TAPP) right inguinal hernia repair.

At laparoscopy, a posterior rectus sheath hernia was found medial to the umbilical ligament [Figure 1]. Peritoneal flaps were raised both superiorly and inferiorly and the hernia contents were reduced. Intraoperatively there was no evidence of a direct or indirect inguinal hernia. The hernia was in close proximity to the inferior epigastric vessels at the posterior edge of the rectus muscle [Figure 2] and included a large lipoma as part of the hernial content [Figure 3].
Figure 1: Direct hernia sac (yellow arrow) between the medial umbilical ligament (green arrow) and inferior epigastric vein (blue arrow)

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Figure 2: Hernial content being reduced (yellow arrow) medial to the inferior epigastric vein (green arrow)

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Figure 3: Large lipoma reduced as part of the hernial content (green arrow)

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The edge of the right posterior rectus muscle was visualized as part of the defect [Figure 4] and [Figure 5].
Figure 4: Hernia neck exposure (yellow arrow) above the pubic symphysis (green arrow) and superomedial to the deep inguinal ring (blue arrow)

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Figure 5: Medial edge of the right posterior rectus muscle (yellow arrow) superomedial to the inguinal ligament (blue arrow) and 3 cm superior to the pubic symphysis (green arrow)

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A ProGrip© self-adherent mesh was placed over the defect with a 2 cm overlap [Figure 6]. The peritoneal flaps were closed over the mesh and secured with AbsorbaTack© absorbable clips [Figure 7]. The patient was discharged home the same day and made an uneventful recovery.
Figure 6: Pre-peritoneal mesh herniorrhaphy with the medial edge over the right pubic arch (yellow arrow)

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Figure 7: Mesh reperitonealisation with the reduced hernia sac in situ (yellow arrow)

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Case 2

A 55-year-old male patient presented with a symptomatic right inguinal hernia which occurred while lifting weights at the gym. His previous surgical history included a right open inguinal mesh herniorrhaphy 25 years ago and his only medical comorbidity was hypercholesterolemia.

Physical examination revealed a right-sided direct inguinal hernia. There was no discernible mass clinically, but he did have a positive cough impulse.

There were no other abdominal wall hernias and he had a scar over his right groin in keeping with his previous open surgical herniorrhaphy. He signed an informed consent for a laparoscopic transabdominal herniorrhaphy.

Intraoperatively we discovered a midline defect supra-pubically [Figure 8],[Figure 9][Figure 10]. He had no laparoscopic evidence of a direct or indirect inguinal hernia. A preperitoneal mesh herniorrhaphy was performed after raising superior and inferior peritoneal flaps. The peritoneal flaps were then closed with absorbable tacks [Figure 11] and [Figure 12].
Figure 8: Suprapubic midline defect (green arrow) above the pubic symphysis (blue arrow) with the medial umbilical ligament laterally (gold arrow)

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Figure 9: Midline hernial defect (yellow arrow) superior to the pubic symphysis (bipolar forceps)

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Figure 10: Hernial defect (yellow arrow) in relation to the left (green arrow) and right (blue arrow) pubic rami

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Figure 11: Preperitoneal mesh repair crossing over to the left side with the pubic symphysis position (green arrow)

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Figure 12: Mesh reperitonealisation

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He made an uneventful recovery with no obvious surgical complications on his post-operative evaluation.


  Discussion Top


This case series contributes to the paucity of available research on posterior rectus sheath hernias and lead to an increased awareness of this rare clinical entity. The diagnosis is usually made by radiological imaging, most commonly computerised tomography (CT).[3],[8] In our case series it was laparoscopy that identified these rare interparietal hernias, highlighting the advantage of laparoscopy as a diagnostic tool and a therapeutic instrument especially in abdominal wall herniorrhaphy.

This is the first documented case series of laparoscopic herniorrhaphy for posterior rectus sheath hernias. The preperitoneal mesh repair prevents mesh exposure to the bowel and abdominal organs. Although rare, complications of an intraperitoneal mesh may include adhesion and erosion of the bowel and omentum.[9]

In comparison with open herniorrhaphy, laparoscopic benefits include decreased postoperative pain, earlier patient recovery, and a shorter hospital stay.[10] It allows visualization of the interior aspect of the abdominal wall, which can identify radiologically undetected hernia defects.

This facilitates an accurate mesh fixation with a symmetrical hernial neck overlap.[11]

Aetiology of the posterior rectus sheath hernia remains nebulous. One theory involves the absence of a full-thickness posterior rectus sheath below the arcuate line. This anatomical absence in collaboration with increased intra-abdominal pressure, is thought to develop the hernial defect.[6] Our first patient had a previous lower midline laparotomy which may have contributed to weakening of his linea alba below the arcuate line. Despite the weakness inferior to the arcuate line all published reports to date have recorded hernial defects superior to the umbilicus.[7]

This case series is the first to report both hernial defects inferior to the umbilicus and the arcuate line. The majority of published reports have documented trauma or previous abdominal surgery as a precipitating factor.[5] Congenital posterior rectus sheath defects are extremely rare as in our second case report. This patient did not have any previous midline abdominal surgery or trauma as a contributing factor to his hernia development.


  Conclusion Top


We present the first published case series of two infra-umbilical posterior rectus sheath hernias discovered incidentally at diagnostic laparoscopy and their subsequent preperitoneal mesh repair.

Declaration of patient consent

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient.

All authors have completed the ICMJE uniform disclosure form. The authors have no conflicts of interest to declare. The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Poulose BK, Shelton J, Phillips S, Moore D, Nealon W, Penson D, et al. Epidemiology and cost of ventral hernia repair: Making the case for hernia research. Hernia 2012;16:179-83.  Back to cited text no. 1
    
2.
Losanoff JE, Basson MD, Gruber SA. Spontaneous hernia through the posterior rectus abdominis sheath: Case report and review of the published literature 1937–2008. Hernia 2009;5:555-8.  Back to cited text no. 2
    
3.
Ng CW, Sandstrom A, Lim G. Spontaneous posterior rectus sheath hernia: A case report. J Med Case Rep 2018;12:96.  Back to cited text no. 3
    
4.
Reznichenko A. Case of Rare Abdominal Wall Hernia. J of Curr Surg 2014;3:99-100.  Back to cited text no. 4
    
5.
Lenobel S, Lenobel R, Yu J. Posterior rectus sheath hernia causing intermittent small bowel obstruction. J Radiol Case Rep 2014;8:25-9.  Back to cited text no. 5
    
6.
Connell P, Hennebry J, Alsanjari S, Chakravartty R, Sabala M. Incidental non-complicated posterior rectus sheath hernia. BJR Case Rep 2020;6:20190072.  Back to cited text no. 6
    
7.
Loureiro R, Marques A, Constantino J, Casimiro C. Laparoscopic approach for a spontaneous posterior rectus sheath hernia. J of Surg Case Rep 2019;5:rjz161.  Back to cited text no. 7
    
8.
Aguirre DA, Santosa AC, Casola G, Sirlin CB. Abdominal wall hernias: Imaging features, complications, and diagnostic pitfalls at multi-detector row CT. Radiographics 2005;25: 1501-20.  Back to cited text no. 8
    
9.
Prasad P, Tantia O, Patle NM, Khanna S, Sen B. Laparoscopic ventral hernia repair: A comparative study of transabdominal preperitoneal versus intraperitoneal onlay mesh repair. J Laparoendosc Adv Surg Tewch A 2011;21:477-83.  Back to cited text no. 9
    
10.
Zahiri HR. Abdominal Wall Hernia. Curr Probl Surg 2018;8:286-317.  Back to cited text no. 10
    
11.
Misiakos EP, Patapis P, Zavras N, Tzanetis P, Machairas A. Current trends in laparoscopic ventral hernia repair. JSLS2015;19:e2015.00048.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]



 

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