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A case of incarcerated umbilical hernia in an adult treated by laparoscopic surgery

A case of incarcerated umbilical hernia in an adult treated by laparoscopic surgery A 42-year-old, obese woman was admitted to our hospital 3 h after the sudden development of abdominal pain. Her umbilical region was swollen and she was diagnosed with incarceration of an umbilical hernia by computed tomography. Although we tried, we were unable to reduce the hernia with a manipulative procedure. We decided to perform an emergency laparoscopy. Once general anesthesia was induced, we achieved hernia reduction. From a laparoscopic view, the portion of strangulated small intestine was neither necrotic nor perforated. The size of the hernial orifice was ∼2 × 2 cm, and thus, we selected a 12 × 12 cm composite mesh to cover the hernia defect by at least 5 cm in all directions. The surgical procedure was uneventful and the total operation time was 112 min. The patient recovered uneventfully and was discharged on postoperative day 9. She remains free of recurrence 20 months after surgery. room at our hospital with incarceration of the umbilical hernia. INTRODUCTION The hernia had a size comparable to that of a tennis ball. The pa- Umbilical hernia occurs most frequently in middle-aged women, tient weighed 75 kg and had a height of 140 cm. Her body mass and is caused by a weakening of fibrous connective tissue in the index (BMI) was 38.3 kg/m , which is categorized as obese. Com- umbilical ring secondary to obesity, frequent pregnancies or de- puted tomography imaging showed an umbilical hernia with an liverance, ascites from liver cirrhosis or renal failure. The stand- incarcerated portion of small intestine and a hernial orifice of ard repair is an open umbilical hernioplasty by primary closure of ∼2 cm (Fig. 1). A gentle attempt at reducing the hernia was unsuc- the fascial defects; however, the high recurrence rate associated cessful; therefore, we decided to perform an emergency oper- with this procedure is somewhat problematic. Recently, many ation. After the induction of general anesthesia using a muscle cases of tension-free mesh repair for umbilical hernia have relaxant agent, the hernia was reduced. A 12-mm trocar was been reported [1, 2]. Here, we present a case of an incarcerated inserted just below the epigastric region, and pneumoperito- umbilical hernia treated by laparoscopic mesh repair. Further- neum was established by insufflation with carbon dioxide to a more, we include some bibliographic considerations. 10-mmHg abdominal pressure. Two 5-mm trocars were placed in the right and left lateral abdominal region, respectively. On laparoscopic examination of the abdominal cavity, we identified CASE REPORT the portion of incarcerated small intestine. It was reddish and A 42-year-old woman developed an umbilical hernia and left it congested; however, there was no evidence of necrosis or perfor- untreated. Three years later, she was admitted to the emergency ation (Fig. 2A, arrows). The size of the umbilical hernial orifice Received: November 15, 2014. Revised: December 28, 2014. Accepted: January 1, 2015 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2015. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 2 | Incarcerated umbilical hernia by laparoscopic surgery Figure 1: A computed tomographic scan showing the umbilical hernia and an incarcerated portion of the small intestine. The size of the hernial orifice was ∼2 cm. was ∼2 × 2 cm (Fig. 2B). We selected a 12 × 12 cm composite mesh (Composix™, DAVOL, Inc., Subsidiary of C. R. Bard, Inc., Warwick, RI, USA) to cover the hernial defect by at least 5 cm in all direc- tions. The composite mesh was inserted through the 12-mm tro- car, and it was fixed to the abdominal wall circumferentially by a permanent fixation system (PermaFix™, DAVOL, Inc., Subsidiary of C. R. Bard, Inc.; Fig. 2C). The surgical procedure was uneventful and the total operation time was 112 min. The patient recovered uneventfully and was discharged on postoperative day 9. She re- mains free of recurrence 20 months after surgery. DISCUSSION Ohira et al. reported that the average age of patients with umbil- ical hernia was 59.2 years, and the percentage of female patients was 63.6% (21/33), with an average BMI of 30.6 kg/m , which was much higher than the Japanese standard BMI of 22 kg/m .They also reported that 12 (36.4%) patients were excessively obese (BMI >30 kg/m ) and 10 (30.3%) had liver cirrhosis accompanied with ascites [3]. There is no argument that an operative procedure is the pri- mary treatment for umbilical hernia; the reduction of the incar- cerated contents and closure of the hernial orifice are the basic Figure 2: (A) The strangulated portion of the small intestine was reddish and principles of the surgery. Open umbilical herniorrhaphy with congested; however, there was no evidence of necrosis or perforation (white the simple fascia suture technique has been widely used by arrows). (B) The size of the umbilical hernial orifice was ∼2× 2 cm. (C) many surgeons and is a long-standing procedure, because it is Composite mesh covering the hernial defect by at least 5 cm in all directions. very simple and may sometimes be performed with local anes- The mesh was fixed to the abdominal wall circumferentially using a tacking thesia. However, the recurrence rate is as high as 10–20% [1, 2]. instrument. Tension-free repair with a mesh was introduced for umbilical or ventral hernia since the 1990s and evidence suggests that open mesh repair has significantly lowered the recurrence rates group. Colon et al. [5] demonstrated that laparoscopic mesh [1, 2]. Arroyo et al. [1] demonstrated a reduced recurrence rate of repair was associated with a significantly lower rate of post- 1% for open mesh repairs of umbilical hernias, compared with operative wound infection compared with open mesh repair in 11% for primary suture repairs. obese patients. Recently, an increasing number of cases of umbilical hernia Advantages of the laparoscopic procedure include measure- treated by a laparoscopic approach have been reported. Gonza- ment of the size of the hernial orifice, a more definite placement lez et al. [4] reported that the laparoscopic repair group pre- of the mesh and verification of the status of the strangulated in- sented lower complication and recurrence rates and faster testine by a laparoscopic view. It is very important to determine rehabilitation into society compared with the open mesh repair the hernial orifice size, because the ideal coverage provides a T. Tsushimi et al. | 3 5-cm overlap in every direction from the defect [6, 7]. Because the REFERENCES size of the hernial orifice was ∼2 cm in the present case, we chose 1. Arroyo A, García P, Pérez F, Andreu J, Candela F, Calpena R. a 12 × 12 cm composite mesh to cover the defect and provide Randomized clinical trial comparing suture and mesh repair an ∼5-cm circumferential coverage. By open mesh repair, it of umbilical hernia in adults. Br J Surg 2001;88:1321–3. may be difficult to ensure an adequate overlap and fixation of 2. Celdrán A, Bazire P, Garcia-Ureña MA, Marijuán JL. H-hernio- the mesh through the small incision; however, it is not difficult plasty: a tension-free repair for umbilical hernia. Br J Surg to perform such a procedure using the tacking instrument by 1995;82:371–2. laparoscopy. 3. Ohira M, Sasaki M, Sakimoto H, Koide K, Etou T, Takahashi M. It is also important to verify the conditions of the strangulated Three cases of irreducible umbilical hernia in adults (in Japa- intestine because the gangrenous intestine must be resected. nese with English abstract). J Jpn Surg Assoc 2004;65:1974–9. This can be easily confirmed by a laparoscopic view once the 4. Gonzalez R, Mason E, Duncan T, Wilson R, Ramshaw BJ. Laparo- strangulated intestine is reduced into the abdominal cavity. scopic versus open umbilical hernia repair. JSLS 2003;7:323–8. Many surgeons hesitate to use a mesh in cases of gangrenous 5. Colon MJ, Kitamura R, Telem DA, Nguyen S, Divino CM. Lap- strangulated intestines, because it may pose a potential risk for aroscopic umbilical hernia repair is the preferred approach mesh infection. However, Abd Ellatif et al. [8] divided patients in obese patients. Am J Surg 2013;205:231–6. with incarcerated hernia into two groups: those who underwent 6. Guérin G, Turquier F. Impact of the defect size, the mesh mesh hernioplasty with resection and anastomosis, and those overlap and the fixation depthonventral hernia repairs: a who did not; there was no significant difference between the combined experimental and numerical approach. Hernia two groups in terms of wound infection and recurrence rates, 2013;17:647–55. and no patients had to undergo reoperation to remove the 7. Lambrecht J. Overlap-coefficient for the relationship between mesh. Considering these advantages, we suggest that laparo- mesh size and defect size in laparoscopic ventral hernia sur- scopic mesh repair should be introduced more aggressively in gery. Hernia 2011;15:473–4. cases of intestinal gangrene secondary to umbilical strangulated 8. Abd Ellatif ME, Negm A, Elmorsy G, Al-Katary M, Yousef Ael-A, hernia. However, late-onset mesh infection should be taken ac- Ellaithy R. Feasibility of mesh repair for strangulated abdom- count when using composite expanded polytetrafluoroethylene inal wall hernias. Int J Surg 2012;10:153–6. mesh [9]. 9. Yamauchi S, Kobayashi H, Ishikawa T, Sugihara K. Two cases of delayed surgical site infection after reconstruction of the CONFLICT OF INTEREST STATEMENT abdominal wall by using a composite mesh (in Japanese with English abstract). J Jpn Surg Assoc 2012;73:2415–20. None declared. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

A case of incarcerated umbilical hernia in an adult treated by laparoscopic surgery

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Oxford University Press
Copyright
Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2015.
eISSN
2042-8812
DOI
10.1093/jscr/rjv001
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25672973
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Abstract

A 42-year-old, obese woman was admitted to our hospital 3 h after the sudden development of abdominal pain. Her umbilical region was swollen and she was diagnosed with incarceration of an umbilical hernia by computed tomography. Although we tried, we were unable to reduce the hernia with a manipulative procedure. We decided to perform an emergency laparoscopy. Once general anesthesia was induced, we achieved hernia reduction. From a laparoscopic view, the portion of strangulated small intestine was neither necrotic nor perforated. The size of the hernial orifice was ∼2 × 2 cm, and thus, we selected a 12 × 12 cm composite mesh to cover the hernia defect by at least 5 cm in all directions. The surgical procedure was uneventful and the total operation time was 112 min. The patient recovered uneventfully and was discharged on postoperative day 9. She remains free of recurrence 20 months after surgery. room at our hospital with incarceration of the umbilical hernia. INTRODUCTION The hernia had a size comparable to that of a tennis ball. The pa- Umbilical hernia occurs most frequently in middle-aged women, tient weighed 75 kg and had a height of 140 cm. Her body mass and is caused by a weakening of fibrous connective tissue in the index (BMI) was 38.3 kg/m , which is categorized as obese. Com- umbilical ring secondary to obesity, frequent pregnancies or de- puted tomography imaging showed an umbilical hernia with an liverance, ascites from liver cirrhosis or renal failure. The stand- incarcerated portion of small intestine and a hernial orifice of ard repair is an open umbilical hernioplasty by primary closure of ∼2 cm (Fig. 1). A gentle attempt at reducing the hernia was unsuc- the fascial defects; however, the high recurrence rate associated cessful; therefore, we decided to perform an emergency oper- with this procedure is somewhat problematic. Recently, many ation. After the induction of general anesthesia using a muscle cases of tension-free mesh repair for umbilical hernia have relaxant agent, the hernia was reduced. A 12-mm trocar was been reported [1, 2]. Here, we present a case of an incarcerated inserted just below the epigastric region, and pneumoperito- umbilical hernia treated by laparoscopic mesh repair. Further- neum was established by insufflation with carbon dioxide to a more, we include some bibliographic considerations. 10-mmHg abdominal pressure. Two 5-mm trocars were placed in the right and left lateral abdominal region, respectively. On laparoscopic examination of the abdominal cavity, we identified CASE REPORT the portion of incarcerated small intestine. It was reddish and A 42-year-old woman developed an umbilical hernia and left it congested; however, there was no evidence of necrosis or perfor- untreated. Three years later, she was admitted to the emergency ation (Fig. 2A, arrows). The size of the umbilical hernial orifice Received: November 15, 2014. Revised: December 28, 2014. Accepted: January 1, 2015 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author 2015. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com 1 2 | Incarcerated umbilical hernia by laparoscopic surgery Figure 1: A computed tomographic scan showing the umbilical hernia and an incarcerated portion of the small intestine. The size of the hernial orifice was ∼2 cm. was ∼2 × 2 cm (Fig. 2B). We selected a 12 × 12 cm composite mesh (Composix™, DAVOL, Inc., Subsidiary of C. R. Bard, Inc., Warwick, RI, USA) to cover the hernial defect by at least 5 cm in all direc- tions. The composite mesh was inserted through the 12-mm tro- car, and it was fixed to the abdominal wall circumferentially by a permanent fixation system (PermaFix™, DAVOL, Inc., Subsidiary of C. R. Bard, Inc.; Fig. 2C). The surgical procedure was uneventful and the total operation time was 112 min. The patient recovered uneventfully and was discharged on postoperative day 9. She re- mains free of recurrence 20 months after surgery. DISCUSSION Ohira et al. reported that the average age of patients with umbil- ical hernia was 59.2 years, and the percentage of female patients was 63.6% (21/33), with an average BMI of 30.6 kg/m , which was much higher than the Japanese standard BMI of 22 kg/m .They also reported that 12 (36.4%) patients were excessively obese (BMI >30 kg/m ) and 10 (30.3%) had liver cirrhosis accompanied with ascites [3]. There is no argument that an operative procedure is the pri- mary treatment for umbilical hernia; the reduction of the incar- cerated contents and closure of the hernial orifice are the basic Figure 2: (A) The strangulated portion of the small intestine was reddish and principles of the surgery. Open umbilical herniorrhaphy with congested; however, there was no evidence of necrosis or perforation (white the simple fascia suture technique has been widely used by arrows). (B) The size of the umbilical hernial orifice was ∼2× 2 cm. (C) many surgeons and is a long-standing procedure, because it is Composite mesh covering the hernial defect by at least 5 cm in all directions. very simple and may sometimes be performed with local anes- The mesh was fixed to the abdominal wall circumferentially using a tacking thesia. However, the recurrence rate is as high as 10–20% [1, 2]. instrument. Tension-free repair with a mesh was introduced for umbilical or ventral hernia since the 1990s and evidence suggests that open mesh repair has significantly lowered the recurrence rates group. Colon et al. [5] demonstrated that laparoscopic mesh [1, 2]. Arroyo et al. [1] demonstrated a reduced recurrence rate of repair was associated with a significantly lower rate of post- 1% for open mesh repairs of umbilical hernias, compared with operative wound infection compared with open mesh repair in 11% for primary suture repairs. obese patients. Recently, an increasing number of cases of umbilical hernia Advantages of the laparoscopic procedure include measure- treated by a laparoscopic approach have been reported. Gonza- ment of the size of the hernial orifice, a more definite placement lez et al. [4] reported that the laparoscopic repair group pre- of the mesh and verification of the status of the strangulated in- sented lower complication and recurrence rates and faster testine by a laparoscopic view. It is very important to determine rehabilitation into society compared with the open mesh repair the hernial orifice size, because the ideal coverage provides a T. Tsushimi et al. | 3 5-cm overlap in every direction from the defect [6, 7]. Because the REFERENCES size of the hernial orifice was ∼2 cm in the present case, we chose 1. Arroyo A, García P, Pérez F, Andreu J, Candela F, Calpena R. a 12 × 12 cm composite mesh to cover the defect and provide Randomized clinical trial comparing suture and mesh repair an ∼5-cm circumferential coverage. By open mesh repair, it of umbilical hernia in adults. Br J Surg 2001;88:1321–3. may be difficult to ensure an adequate overlap and fixation of 2. Celdrán A, Bazire P, Garcia-Ureña MA, Marijuán JL. H-hernio- the mesh through the small incision; however, it is not difficult plasty: a tension-free repair for umbilical hernia. Br J Surg to perform such a procedure using the tacking instrument by 1995;82:371–2. laparoscopy. 3. Ohira M, Sasaki M, Sakimoto H, Koide K, Etou T, Takahashi M. It is also important to verify the conditions of the strangulated Three cases of irreducible umbilical hernia in adults (in Japa- intestine because the gangrenous intestine must be resected. nese with English abstract). J Jpn Surg Assoc 2004;65:1974–9. This can be easily confirmed by a laparoscopic view once the 4. Gonzalez R, Mason E, Duncan T, Wilson R, Ramshaw BJ. Laparo- strangulated intestine is reduced into the abdominal cavity. scopic versus open umbilical hernia repair. JSLS 2003;7:323–8. Many surgeons hesitate to use a mesh in cases of gangrenous 5. Colon MJ, Kitamura R, Telem DA, Nguyen S, Divino CM. Lap- strangulated intestines, because it may pose a potential risk for aroscopic umbilical hernia repair is the preferred approach mesh infection. However, Abd Ellatif et al. [8] divided patients in obese patients. Am J Surg 2013;205:231–6. with incarcerated hernia into two groups: those who underwent 6. Guérin G, Turquier F. Impact of the defect size, the mesh mesh hernioplasty with resection and anastomosis, and those overlap and the fixation depthonventral hernia repairs: a who did not; there was no significant difference between the combined experimental and numerical approach. Hernia two groups in terms of wound infection and recurrence rates, 2013;17:647–55. and no patients had to undergo reoperation to remove the 7. Lambrecht J. Overlap-coefficient for the relationship between mesh. Considering these advantages, we suggest that laparo- mesh size and defect size in laparoscopic ventral hernia sur- scopic mesh repair should be introduced more aggressively in gery. Hernia 2011;15:473–4. cases of intestinal gangrene secondary to umbilical strangulated 8. Abd Ellatif ME, Negm A, Elmorsy G, Al-Katary M, Yousef Ael-A, hernia. However, late-onset mesh infection should be taken ac- Ellaithy R. Feasibility of mesh repair for strangulated abdom- count when using composite expanded polytetrafluoroethylene inal wall hernias. Int J Surg 2012;10:153–6. mesh [9]. 9. Yamauchi S, Kobayashi H, Ishikawa T, Sugihara K. Two cases of delayed surgical site infection after reconstruction of the CONFLICT OF INTEREST STATEMENT abdominal wall by using a composite mesh (in Japanese with English abstract). J Jpn Surg Assoc 2012;73:2415–20. None declared.

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Journal of Surgical Case ReportsOxford University Press

Published: Feb 11, 2015

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