Adam S Weltz, MD1, Zachary Sanford, MD1, Devinder Singh2, Robert Hanley3, David Todd4, Igor Belyansky1. 1Department of Surgery, Anne Arundel Medical Center, 2Department of Plastic Surgery, Anne Arundel Medical Center, 3Department of Urology, Anne Arundel Medical Center, 4Department of Radiology, Anne Arundel Medical Center
Introduction: Giant inguinoscrotal hernias (GIH) are groin hernias that extend below the mid-thigh when standing, negatively impacting daily activity. To date there are no reports utilizing progressive pneumoperitoneum (PP), botulinum toxin A injection (BTI), and enhanced view-totally extraperitoneal technique (eTEP) on the same patient at time of GIH repair. In this report we present a unique minimally invasive multi-disciplinary approach to address GIH.
Case Presentation: A 59-year-old gentleman presented with lifelong bilateral inguinal hernias and a right hernia that enlarged such that the distal-most aspect of the hernia sac nearly reached the floor when standing. Additionally there was a voluminous accumulation of ascitic fluid in the sac as well as the entirety of his small intestine and majority of his colon. As a result, he had complete loss of abdominal domain. Surprisingly, he had no other major medical co-morbidities on preoperative evaluation.
Four weeks before surgery botulinum toxin A was injected to facilitate abdominal wall musculature relaxation before peritoneal dialysis catheter was placed laparoscopically for progressive pneumoperitoneum to stretch the abdominal cavity, making room for the return of visera. The following week a foley catheter was placed and cystoscopy performed before the eTEP procedure. The left retrorectus space was developed under direct vision down to the space of Retzius, followed by release of the transversus abdominis muscle from cephalad to caudal direction and by contralateral crossover. The space was developed from the subcostal region down to the myopectineal orifice.
We addressed the left side hernia first, with myopectineal orifice dissection performed. Portions of the posterior lamella of left internal oblique and transversus abdominis were released. We then reduced a large left cord lipoma. 12×16-cm mesh covered the myopectineal orifice. Next, we explored the groin through a right incision, discovering a sliding hernia unable to be safely reduced laparoscopically. The sac was sharply opened and distal portion ligated under direct vision with intestines successfully reduced. The inguinal canal floor was closed then roofed with internal oblique muscle and transversalis fascia. 12×16 mesh was placed in the right groin covering the myopectineal orifice and 20×30-cm mesh covered the left and right hernia mesh to stabilize the abdominal wall.
Reconstruction including partial scrotectomy and scrotal plasty using adjacent tissue transfer technique was completed. The patient tolerated the procedure well, was discharged home on POD 5, and seen in clinic one month postoperatively doing well with minimal scrotal swelling and no sign of recurrence.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 88250
Program Number: V093
Presentation Session: Plenary 1 Session
Presentation Type: Video