WeBSurg, the e-surgical reference of Laparoscopic surgery

WebSurg is a free virtual surgical university, accessible worldwide through the Internet. Our goal is to provide surgeons, scientific societies and the medical industry with the first online continuing medical education in laparoscopic surgery and information on the latest developments in laparoscopic surgery, including NOTES and robotics.

Browse the WORLD
Virtual University
English ▼

WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

LAPAROSCOPIC TREATMENT OF POSTOPERATIVE LUMBAR HERNIA


D Mutter, MD, PhD, C Rodier-Bruant, MD , Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Description


This describes the case of a patient who developed a lumbar hernia after reconstruction of her left breast by a latissimus dorsi musculo-cutaneous flap transposition. This hernia occurred 3 years after the initial operation and was treated by a laparoscopic approach.

2. Keywords


Hernia, laparoscopy

3. Patient


Female, 40-year-old

4. Past medical history


Medical and surgical history: left breast cancer 5 years previous treated by a left mastectomy followed by radiation and chemotherapy and hormonal therapy. 2 years later the patient underwent a left breast reconstruction by a musculo-cutaneous flap of the latissimus dorsi.

5. History of the present illness


The patient consulted her physician after 2 weeks of increasing pain and a sensation of separation in the left posterior flank area. She also noted the appearance of a bulge in the left posterior area under her ribs.

6. Physical examination


The patient is in a perfect state of general health. There is no clinical nor biological abnormalities. The left breast flap appears well-healed. Further exam reveals a subcostal parietal defect in the left lateral position. The defect measures approximately 5 cm in diameter by physical exam and is supple and easily reducible.

7. CT scan 1


CT scan confirms a left posterior retroperitoneal hernia measuring 5 X 5 cm.

8. CT scan 2


This hernia forms a sac containing perirenal fat.
The kidney is progressively leaning towards the hernia orifice.

9. Therapeutic intervention


Due to the progression of hernia symptoms, it was decided to perform surgery. A retroperitoneal laparoscopic repair with mobilization of the kidney and perirenal fat was performed. The hernia orifice was completely dissected and a mesh to reinforce the repair was put in place.

10. Postoperative follow-up


During the postoperative follow-up, the patient complained of pain of nerve-like origin, which seemed to be caused from irritation in the area of the mesh. The pain subsided over the next 8 weeks. 6 months after the intervention, the patient was without pain and in a good general state of health. The left flank was smooth. There were no symptoms of pain, hernia recurrence or persistent nerve irritation.

11. Discussion


Retroperitoneal hernias occurring after latissimus dorsi flaps are rare. The occurrence of these parietal defects many years after the operation, as in our case 3 years postoperatively, are even more exceptionally rare. Laparoscopic repair of these hernias represents an original solution. The retroperitoneal approach allows a complete dissection of the orifice and the placement of a mesh via a small incision. The esthetic and functional benefits of not having a major incision must be taken into account. This approach also better preserves the vascular supply to the latissimus dorsi since it is essentially an antero-lateral approach. The postoperative evolution confirms that this provides an acceptable therapeutic option.