Stepwise hybrid surgical treatment of inguinal-scrotal and recurrent large lumbar hernias with domain loss in an obese patient with diabetes mellitus

Aim. This article aims to demonstrate the feasibility of stepwise hybrid surgical treatment for large concomitant ventral hernias with domain loss in a patient with severe coexisting pathology, based on a clinical case managed by the authors.

Methods. An analysis was conducted of a stepwise hybrid – laparoscopic and open – surgical treatment in a 63-year-old patient with inguinal-scrotal and recurrent large lumbar hernias with domain loss, complicated by obesity and diabetes mellitus. To assess the risk of compartment syndrome in the patient, computed tomography was performed, revealing a hernia contents volume-to-abdominal cavity ratio index of 28 %.

Results. A stepwise hybrid surgical treatment – a combination of laparoscopy and the open method – was performed with the use of an uncovered mesh endoprosthesis with an interval of six weeks. Taking into account the high risk of incarceration at the first stage, the inguinal-scrotal hernia was corrected. At the second stage, the recurrent lumbar hernia was eliminated with the addition of the laparoscopic method by open excision of the postoperative scar flap. The hernial defect is covered with a mesh located between the peritoneum and the duplication of the muscular-aponeurotic flap. The postoperative period was uneventful. An analysis of recent literature has revealed that the issue of selecting treatment tactics remains unresolved due to the rare occurrence of this condition. Modern approaches to the treatment of lateral abdominal hernias, including minimally invasive methods – laparoscopic, robotic and hybrid – are analysed, with a focus on methods for preventing compartment syndrome. The application of the stepwise hybrid approach used in a positive outcome after 11 months of follow-up.

Conclusion. At the first stage, it is advisable to operate on a hernia with a high risk of incarceration. The main direction in the treatment of this pathology should be the minimisation of surgical trauma and the prevention of compartment syndrome.

1. Bauer K, Vogel R, Heinzelmann F, Büchler P, Mück B. Robotic-assisted surgery for lateral ventral hernias — experience of robot-assisted methods for retromuscular and preperitoneal abdominal wall reconstruction. Hernia. 2024 Oct;28(5):1951—1960. https://doi.org/10.1007/s10029-024-03132-7

2. Lutsevich OE, Balkarov BA. Method of treatment of complex inguinal-scrotal hernias by combining open and laparoscopic access. Patent RF № 2549478. 2015. 12 p. (in Russ.).

3. Beffa LR, Margiotta AL, Carbonell AM. Flank and Lumbar Hernia Repair. Surg Clin North Am. 2018 Jun;98(3):593—605. https://doi.org/10.1016/j.suc.2018.01.009

4. Kohler G, Kaltenbock R, Fehrer HJ, Fugger R, Gang O. Management der lateralen Bauchwandhernien. Chirurg. 2022;93:373—380 (in German). https://doi.org/10.1007/s00104-021-01537-z

5. Wijerathne S, Malik S, Usmani F, Lomanto D. Minimally invasive repair for lateral ventral hernia: tailored approach from a hernia centre at a tertiary care institution. Hernia. 2021 Apr;25(2):399—410. https://doi.org/10.1007/s10029-020-02284-6

6. Tanaka EY, Yoo JH, Rodrigues AJ Jr, Utiyama EM, Birolini D, Rasslan S. A computerized tomography scan method for calculating the hernia sac and abdominal cavity volume in complex large incisional hernia with loss of domain. Hernia. 2010 Feb;14(1):63—69. https://doi.org/10.1007/s10029-009-0560-8

7. Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, Pascual MH. Classification of primary and incisional abdominal wall hernias. Hernia. 2010;13(4):407—414. https://doi.org/10.1007/s10029-009-0518-x

8. Sun J, Chen Х, Li J, ZhangY, Dong F, Zheng М. Implementation of the trans-abdominal partial extraperitoneal (TAPE) technique in laparoscopic lumbar hernia repair. BMC Surg. 2015 Oct;28:15:118. https://doi.org/10.1186/s12893-015-0104-3

9. Amaral PHF, Tastaldi L, Barros PHF, Abreu Neto IP, Hernani BL, Brasil H, Mendes CJL, Franciss MY, Pacheco AM Jr, Altenfelder R Silva, Roll S. Combined open and laparoscopic approach for repair of flank hernias: technique description and medium-term outcomes of a single surgeon. Hernia. 2019 Feb;23(1):157—165. https://doi.org/10.1007/s10029-019-01880-5