Juan José Espert (Gastrointestinal Surgery and Abdominal Wall, Senior Specialist)
Hospital Clínic, Barcelona, Spain
A 65 year old female with history of a knee fracture requiring surgery with bone graft taken from the right iliac crest in 1999 presented a soft tissue mass associated with discomfort at her right flank one year later.
Physical examination revealed, a moderately sized, reducible bulge just under the graft scar along the right iliac crest. Further investigation was performed by CT Scan that showed a right lumbar hernia that contained a portion of colon located below the 12th rib and above the iliac crest. At this time the patient did not have symptoms of bowel obstruction.
The first treatment was performed by anterior approach with a tension free mesh repair that was fixated to the surrounding abdominal fascia and the periosteum of the iliac crest.
Postoperative recovery was uneventful. However, the patient had a recurrence of the hernia thirteen years later.
This time a transabdominal laparoscopic approach was used to treat the hernia relapse. The patient was in prone position, a total of three trocars were used, two of 12mm located at the umbilicus and epigastrium and one of 5mm in suprapubic position. The camera was a 30º.
Notice the colon attached to the hernia sac, the first manoeuvre is to individualize the colon using the hook. Step by step the psoas muscle and the abdominal wall are exposed. The defect measured between 7-5cm.
Surgical treatment was done by using a tension-free double layer mesh that was fixated with absorbable takers to the abdominal wall and the periosteum of the iliac crest. The surgery took 60min without intra or postoperative events.
The patient started the oral intake 6 hours after surgery and left the hospital the next day. At 3 months after there is no relapse.