Laparoscopic Repair of Large Ventral Hernia Following Abdominal Radical Hysterectomy for Cervical Cancer

Abstract

Background: Incisional hernia is a common complication after a major abdominal gynecologic operation. Laparoscopic repair with a mesh prosthesis is a surgical modality of choice as an alternative to conventional open repair. Case: A 52-year-old woman underwent radical abdominal surgery in 2001 because she had cervical cancer. An abdominal mass had developed since 2008, measuring 8×8×4 cm. Abdominal computed tomography scanning performed at the current presentation of this patient confirmed that she had an incisional hernia at the midline of the abdominal wall. Laparoscopic hernioplasty was performed using an intraperitoneal prolene mesh and suture fixation. Results: The patient had an uneventful recovery. No recurrence has occurred as noted on outpatient follow-up. Conclusions: Laparoscopic repair of incisional hernia has been accepted as a safe and effective method. The current authors took advantage of this surgical modality to treat this patient. The desired outcome was achieved to address her large incisional hernia. (J GYNECOL SURG 30:32)

Introduction

Incisional hernia is one of the most common problems after abdominal surgery, and this kind of hernia accounts for up to 16.9% of complications after major gynecologic oncology operations. Conventional open repair with a suture technique produces a high recurrence rate, while laparoscopic repair with a mesh prosthesis yields a better outcome, a lower infection rate, and a shorter hospital stay. Herein is a case of laparoscopic repair of a large incisional hernia after abdominal radical hysterectomy that was performed to address cervical cancer.

Case

In 2001, a 52-year-old female underwent an abdominal radical hysterectomy to address a cervical adenocarcinoma, FIGO [International Federation of Gynecology and Obstetrics] stage Ib, and was given adjuvant chemoradiation because of pelvic lymph node metastases. Her good condition was noted on a regular 7-year follow-up, until an abdominal mass had developed, since 2008, that caused tenderness and intermittent constipation and urinary symptoms, such as urgency and frequency. As the mass grew larger, this patient's symptoms also worsened gradually. An incisional hernia was diagnosed during this regular follow-up in 2008.

The patient had no history of diabetes mellitus, hypertension, or other systemic diseases. She denied any substance abuse, such as tobacco, alcohol, or betel nuts. No abdominal major surgery other than the radical hysterectomy for cervical adenocarcinoma was recorded. Her body mass index was 24.5 on this current admission. A physical examination showed a bulging, nonreducible mass measuring 8×8×4 cm (Fig. 1A; Fig 1B shows repair of the problem via herniorrhapy) over the previous midline incision wound scar. An abdominal computed tomography scan revealed a horizontal defect at the midline of the abdominal wall measuring 3.75cm (Fig. 2). Surgical intervention with a minimally invasive procedure was chosen.

FIG. 1.

(A) The patient's bulging hernia measured 8×4 cm. (B) The patient's abdominal wall after herniorrhapy.

FIG. 2.

An abdominal computed tomography scan revealed a horizontal midline defect with bowel protrusion (white arrow) measuring 3.75 cm.

Laparoscopic surgery was performed using a Lee-Huang point, with a first and major trocar and three accessory trocars over the lower abdomen. The hernia sac was 3 cm below the umbilicus, with a defect measuring 8×4 cm (Fig. 3A). There was an extensive adhesion over the previous surgical site, thus, extensive enterolysis and a polypropylene mesh (also known as prolene mesh), with 3 cm overlapping peripherally to the lesion, was inserted into the hernia sac. Transfascial suture fixation was done at 4 directions. The opening sac was closed with an interrupted extracorporeal suture using 1-0 prolene (Figs. 1B and 3B). There was no subsequent air pouch observed after the entire procedure was completed. The patient had a good recovery and was discharged 3 days after the operation.

FIG. 3.

(A) The hernia sac measured 8×4 cm after enterolysis. (B) The sac was closed using a prolene mesh with an extracorporeal suture.

Results

On the tenth postoperative day, she had mild cutaneous ecchymosis without tenderness. Expectant management was applied and spontaneous improvement was noted with no complaints. As of 4 years, the patient had a desirable recovery without clinical recurrence.

Discussion

Incisional hernia is one of the most common complications following a laparotomy. The incidence of incisional hernia after major gynecologic oncology operations, such as extended abdominal hysterectomy to address cervical or endometrial malignancies, has been reported to be up to 16.9%.¹ Conventional open repair of these hernias with a suture technique yields a failure rate of 63%, while the application of a mesh prosthesis decreases the risk of recurrence to 32%.² After the introduction of laparoscopic repair in the 1990s, this minimally invasive procedure with alloplastic materials is gaining increased acceptance in the field of incisional hernia repair.³ In a review of studies, it was found that, compared to conventional open repair, the minimally invasive technique was considered to be safe, with fewer complications, such as wound infection and hematoma formation.⁴ However, inconclusive results were observed when comparing factors such as subsequent seroma formation, and acute and chronic pain. The majority of the trials involving similar issues showed shorter hospital stays after laparoscopic repair, especially for patients who had had longer routine hospital stays (≥5 days) in conventional repair groups, although these results were heterogeneous. The recurrence rate after repair with mesh insertion via laparoscopic and open surgery seemed to be similar, but these results were not conclusive because of short-term follow-up in the studies.

Conclusions

Theoretically, a higher risk of injury to intra-abdominal organs should also be considered. In the current case, a short hospital stay and a desirable treatment outcome were observed, but further long-term follow-up is still required to detect any delayed recurrences.

Disclosure Statement

No competing financial conflicts exist.

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