|Year : 2019 | Volume
| Issue : 4 | Page : 149-151
Open mesh repair of interstitial hernia containing small bowel
Nisarg Y Mehta, Jesse Casaubon, Ramon Benedicto
Wyckoff Heights Medical Center, Brooklyn, NY, USA
|Date of Submission||06-Apr-2019|
|Date of Decision||08-Apr-2019|
|Date of Acceptance||21-May-2019|
|Date of Web Publication||22-Oct-2019|
Dr. Nisarg Y Mehta
Wyckoff Heights Medical Center, 374 Stockholm Street, Brooklyn, NY 11237
Source of Support: None, Conflict of Interest: None
Interparietal hernias are rare entities of the anterior abdominal wall in which the hernia sac protrudes between peritoneum, fascia, muscle, or subcutaneous tissue. There are three types of interparietal hernias: interstitial, superficial, and preperitoneal. The interstitial type hernia is rare and involves herniation between the abdominal wall musculature and fascial planes. Diagnosis is rarely made preoperatively, and treatment consists of operative reduction of the hernia sac with primary tissue or mesh repair. Repair of interparietal hernias can be performed open or laparoscopically. We report the case of a 40-year-old male who presented with an incarcerated interstitial hernia which contained small bowel and had developed after open appendectomy performed 20 years prior. The hernia was repaired using the open technique and employed a mesh for reinforcement. The patient tolerated the procedure well and remained free of recurrence.
Keywords: Interstitial hernia, mesh repair, open repair
|How to cite this article:|
Mehta NY, Casaubon J, Benedicto R. Open mesh repair of interstitial hernia containing small bowel. Int J Abdom Wall Hernia Surg 2019;2:149-51
| Introduction|| |
The general surgeon is well acquainted with many of the common anterior abdominal wall hernias. While the majority of hernias are umbilical, incisional, ventral, or Spigelia More Detailsn, there exists a number of rare variants which are much less frequently encountered. Interparietal hernias are uncommon and not extensively documented in the literature. The hernia sac is found between the aponeuroses of the abdominal wall muscles, and the contents are neither easily palpable nor present directly under the subcutaneous tissue. On the other hand, incisional hernia usually occurs due to the fascial defect status post an operation; this leads to the hernia contents protruding out through the defect up to the subcutaneous tissue.
| Case Report|| |
A 40-year-old male presented to the surgery clinic complaining of a bulging mass which had developed during the previous 4 years. It was located at the site of an open appendectomy performed 20 years prior via McBurney incision for perforated appendicitis. He had no other past medical or surgical history. On physical examination, a bulging mass was appreciated deep to the open appendectomy incision containing what seemed to be loops of bowel. The hernia was not reducible. A computed tomography (CT) of the abdomen and pelvis had been obtained which demonstrated loops of viable and nonobstructed small bowel [Figure 1]. The diagnosis of incisional hernia was suspected based on the history, examination, and imaging, and the patient was offered elective surgical repair.
|Figure 1: Computed tomography demonstrating viable small bowel located within the hernia|
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Under general anesthesia, surgical exploration was carried out utilizing the previous appendectomy incision. Electrocautery was used to dissect through subcutaneous tissue until the external oblique muscle was encountered. The muscle was incised in the orientation of its fibers. At this point, a large hernia sac containing incarcerated small bowel and omentum was found tracking over the internal oblique aponeurosis. The hernia sac and its contents had not violated through the external oblique but instead had traveled along the fascial plane between the internal and external oblique. The neck of the hernia measured 4 cm (as seen in [Figure 2] and [Figure 3]). Once the content of hernia sac (small bowel and omentum) was evaluated and reduced back in the peritoneal cavity and sac was ligated, the defect was inspected. Extensive lysis of adhesions was performed to free all fascial edges. Mesh was placed in intraperitoneal fashion and tacked with tackers circumferentially. Size of the defect at this point was measured to be 4 cm × 3.5 cm. A 6.4 cm Ventralex ST hernia patch (BARD, Warwick, RI) was used to close the defect in a tension-free manner. The fascia of the internal oblique and then the external oblique were closed over the mesh before the skin approximation.
|Figure 2: Computed tomography demonstrating the defect in the muscle layer|
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|Figure 3: Computed tomography showing the bowel contents entering the hernia sac|
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The patient was discharged after the procedure. He was seen in the surgery clinic 4 weeks after surgery and did not exhibit any sign of recurrence or complication.
| Discussion|| |
Interstitial hernia is one type of interparietal hernia. There are three different types of interparietal hernias that are distinguished based on the location of herniation:
- Preperitoneal hernia: hernia sac located between the peritoneum and transversalis fascia
- Interstitial hernia: hernia sac located between muscular layers of the abdominal wall
- Superficial hernia: hernia sac located between the external oblique fascia and subcutaneous tissue.
Interstitial hernias are rare, occurring with a frequency of 0.08%–1.6%. They have varied etiologic causes which differ by age group. In adults, they are generally seen after the age of 40 years and are due to weakness of the abdominal wall musculature. They often follow previous abdominal surgery, as with our patient. In pediatric patients, they present containing undescended testes due to narrow inguinal canal.,
Diagnosis of interstitial hernia is difficult preoperatively. They are often confused with ventral, spigelian, inguinal, or incisional hernias. CT scan is the most useful preoperative imaging modality. Sonogram and magnetic resonance imaging can be used as adjuncts. In the case of our patient, the preliminary diagnosis that was made in the clinic was incarcerated incisional hernia due to the findings on physical examination and CT scan.
Once diagnosed, the treatment of interstitial hernia is operative repair. There have been various articles in the literature comparing laparoscopic versus open repair. Operative time, postoperative pain, complications, and recurrence rates are some of the factors by which the techniques are compared. Mean operative time is longer when laparoscopy is utilized. This has been attributed to adhesiolysis and the technical difficulty of placing the mesh. Several studies note that the perioperative complication rate of the laparoscopic approach is higher than open. Iatrogenic bowel injury and bladder perforation are some of the common perioperative complications. No significant difference was noted in terms of postoperative pain in either group. Recurrence rates measured by several trials for both the approaches revealed a slightly lower recurrence with the open approach. After reviewing the above-stated risk versus the benefits of open and laparoscopic surgery and noting the surgeons' preference and experience, we decided to offer the patient an open repair with mesh of the interstitial hernia status postappendectomy.
Various studies in the past have compared suture versus mesh repair. Unanimously, recurrence rate is significantly lower with mesh. That said, perioperative complications are higher when mesh is employed. Common complications include surgical site infection, chronic sinus tract, abscess formation, erosion, and small bowel obstruction.
Open repair of interstitial hernia was undertaken due to surgeon preference in our case. We found that the hernial sac had protruded through the transversus abdominis and the internal oblique muscular layers but did not violate the external oblique. An underlay mesh was placed over the defect in the anterior abdominal wall musculature to reinforce the large fascial defect.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We believe that during open appendectomy previously, the muscle layers and the peritoneal defect may not have been closed in the standard fashion, or that infection from appendiceal perforation may have caused breakdown in the closure. This created a defect which, over time, led to the hernia formation.
| Conclusion|| |
Interstitial hernias mimic other more common hernias of the anteriorly wall which complicates preoperative diagnosis. The treatment strategy is similar to that of any ventral hernia including the use of mesh to minimize recurrence.
Our patient's case is unique because the hernia likely resulted from improperly closed peritoneal or fascial layers of the abdominal wall during his previous appendectomy, or the underlying infection itself. The patient underwent standard open herniorrhaphy with mesh and was doing well in follow-up.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]