OGBN V07 Laparoscopic repair of rare case of interparietal port-site incisional hernia with mesh in sub-lay; pre-peritoneal space
Authors: Khan Jan Sher , Shaalan Ramy , Abdelwahab Sameh , Zino Samer 
Published: December 2022

Abstract

Background
Interparietal hernias are defined as protrusions of intraabdominal contents within the layers of the abdominal wall. Primary interparietal hernias; like Spigelian's hernia are rare, 0.12% to 2% of all abdominal wall hernias. Recently, interparietal hernias are more encountered as incisional hernias. However, very few cases have been reported in literature of interparietal hernia at port site following laparoscopic surgery, keeping in mind that port site hernias incidence varies between 0.74% to 1.47% after laparoscopic surgical procedures. Here we are presenting a rare case of interparietal port site incisional hernia, its management and summarising the key steps for laparoscopic mesh in sub-lay (pre-peritoneal) plane with defect closure.

Methods
We present a case of 72-year-old gentleman, who had robotic prostatectomy in January 2020. He presented towards the end of that year with left lower abdominal ache and discomfort. On examination he had bout 2 cm palpable hernia in LLQ at the site of 11 mm port. CT scan confirms the hernia at port site where internal muscles had been damaged, but external oblique muscle remains intact. Hernia MDT discussion advised conservative management, given low probability of incarceration given the current hernia anatomy, and advised surgical intervention if hernia affecting daily activity and lifestyle. Clinical review after one year, patient describes more discomfort as dull pain that increases with his usual activity like gardening, walking or running, necessitating increasing analgesia for 2,3. The patient believes that this hernia is affecting his life. Repeat scan showed muscular defect within the left iliac fossa, between the left rectus abdominis medially and retracted transversus abdominis and internal oblique muscles laterally. The external oblique muscle and facia along with anterior rectus sheath are intact. After further discussion with patient regarding risks vs benefits, patient opted for surgical treatment with laparoscopic approach

Results
Patient in supine position. Pneumoperitoneum created using Veress needle at Palmer's point, 11mm optical-port in the right lumbar area. Laparoscopy confirmed bulging at the pre marked site of the hernia, another 2×5 mm ports. Bulging identified at hernia site. Anterior parietal peritoneum incised vertically along the midline and dissection carried out laterally to develop the pre-peritoneal space. Defect exposed and assessed. There was a horizontal rupture of the arcuate ligament across the posterior rectus sheath exposing a section of inferior epigastric vessels and rectus muscle. This rupture extends laterally to involve the transverse abdominus and internal obliques muscle total size defect of 6×3 cm. Defect closed with 1.0-Ehtilon that was introduced using Endo Close leaving the free end outside. The defect was closed continuously in two layers then the end was extracted and tied to free end trans-fascially under low abdominal pressure at the end of procedure. 20.3×15.2 Ventralight ST Mesh placed in the pre peritoneal plane after marking the centre with one 2.0-Prolene stitch that was used to anchor the mesh. Mesh was only fixed medially using AbsorbaTack to avoid post operative pain. Then the peritoneum was closed in the midline, covering the mesh using AbsorbaTack.

Conclusions
Interparietal hernias usually present with discomfort, pain or acutely due to incarceration or strangulation. Very little is reported regarding the presentation of interparietal port site hernia as few are reported in literature. This abstract describes a rare interparietal port site incisional hernia that is presented with pain and discomfort, affecting lifestyle. Furthermore, we describe an approach to repair the hernia without disturbing the intact anterior fascia, utilizing a combination of defect closure and synthetic prothesis placed in the pre peritoneal space, thus minimising the chance of future mesh complication. This case highlights not only the importance of closing port site more than 11 mm but more importantly the need to make sure that all abdominal wall layers are included to avoid interparietal hernia at port site.