Sean C O’connor, MD, Kathryn Sobba, MD, Stephen Mcnatt, Myron Powell. Wake Forest Baptist Medical Center
Introduction: Retro muscular sublay repair of complex ventral hernias has been a popular technique since it was first described in the 1980’s. The surgical robot has allowed this technique to be applied in a much less invasive way. Here we report two cases of Intraparietal hernia; a rare complication of robotic Rives-Stoppa repair which represents failure of the posterior rectus layer causing exposure of mesh, herniation of the bowel and possible obstruction.
Case Series: Patient 1 presented to the emergency room on POD 6 after robotic Rives-stoppa incisional hernia repair with bowel obstruction due to an incarcerated interparietal hernia. She underwent diagnostic laparoscopy where a 5 cm defect in peritoneum and posterior fascia was identified at the superior aspect of the previous repair. Progrip mesh was intact and small bowel had herniated through this posterior fascial defect and was adherent to the mesh with a clear transition point. The bowel was reduced and the defect was covered using IPOM technique. The coated mesh was transfixed with trans fascial sutures and absorbable tacks (Video 1). Patient 2 presented to clinic 7 months post operatively with epigastric pain and CT showed an intraparietal hernia with herniated omentum. The omentum was reduced laparoscopically which revealed both primary mesh failure as well as a posterior rectus failure. The mesh was well peritonealized, so the posterior rectus space was obliterated with trans-fascial sutures and the mesh defect was closed from the outside with permanent suture. (Video 2)
Discussion: These cases highlight the principles of the Rives-Stoppa technique, including the importance of creating a tension free closure of all layers of the abdominal wall. Robotic technique does not allow for the same tactile sensation as open surgery, thus tension on the fascial layers can be difficult to assess. Surgeons rely on visualization of slack in the fascial closure, pre-operative imaging and use of transverse abdominal release when necessary to reduce tension. Interparietal hernias can be successfully managed with IPOM coverage of the defect if the uncoated mesh is not yet peritonealized and bowel is adherent 1. If the mesh is well peritonealized and there is no concern for small bowel adhesions or fistula formation, the posterior rectus space can simply be obliterated with transfascial sutures or tacks without additional mesh placement 2. As robotic technique rapidly gains popularity, it is essential that rare complications such as these to are documented and discussed to ensure quality outcomes.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 92504
Program Number: V378
Presentation Session: Panel: How Would You Approach This? Complex and Challenging Hernia Case Presentations
Presentation Type: Panel