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Laparoscopic repair for a congenital lumbar hernia with free fascia lata graft reinforcement
J Ped Surg Case Reports 2 (2014) 101e103
Contents lists available at ScienceDirect
Journal of Pediatric Surgery CASE REPORTS journal homepage: www.jpscasereports.com
Laparoscopic repair for a congenital lumbar hernia with free fascia lata graft reinforcementq Keiichi Morita*, Go Miyano, Hiroshi Nouso, Koji Fukumoto, Masaya Yamoto, Hiromu Miyake, Masakatsu Kaneshiro, Naoto Urushihara Department of Pediatric Surgery, Shizuoka Children’s Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka 420-8660, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 10 January 2014 Received in revised form 3 February 2014 Accepted 3 February 2014 Available online 26 February 2014
Congenital lumbar hernias are rare, and the optimal surgical procedures for hernia repair are still controversial. A 13-month-old girl with a left-sided, 7 cm 7 cm, congenital lumbar hernia underwent laparoscopic repair with autologous free fascia lata graft reinforcement. At 6 months, she was doing well with no recurrence of the hernia. Laparoscopic repair with free fascia lata graft reinforcement is a safe and feasible surgical option for the treatment of large congenital lumbar hernias. Ó 2014 The Authors. Published by Elsevier Inc. All rights reserved.
Key words: Congenital lumbar hernia Fascia lata Laparoscopy Lumbocostovertebral syndrome
Congenital lumbar hernias are rarely seen in infancy and childhood, and only about 60 cases have been reported in the English literature [1]. Less than 35 cases of congenital lumbar hernias were related to the lumbocostovertebral syndrome [2]. The lumbocostovertebral syndrome was defined as the association of congenital lumbar hernia, costal defects, and vertebral anomalies by Touloukian [3]. Because of the rarity of congenital lumbar hernia, appropriate surgical procedures for repair are still controversial, and laparoscopic repair has been reported in only a few cases. The laparoscopic repair of a congenital lumbar hernia related to the lumbocostovertebral syndrome with free fascia lata graft reinforcement is reported. 1. Case report A 2.49-kg female infant was born vaginally at 40 weeks’ gestation. The Apgar score was 9 at 5 min. Immediately after birth, she was noted to have a left-sided, 3 cm 3 cm, lumbar hernia. Computed tomography demonstrated a left-sided lateral lumbar muscular layer defect characterized by ipsilateral 9th to 11th rib
q This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/). * Corresponding author. Tel.: þ81 54 247 6251; fax: þ81 54 247 6259. E-mail address: [email protected] (K. Morita).
agenesis. Furthermore, malformation of the right 1st to 3rd and 8th to 10th ribs and the left 6th to 8th and 12th ribs, Th10 and Th11 hemivertebrae, and a sinistral convex scoliosis were seen. Magnetic resonance imaging revealed a lateral meningocele and a tethered cord. She was referred to our hospital for further treatment at 10 months of age. The lumbar hernia protruded considerably with crying, and it was reducing spontaneously (Fig. 1). The hernial defect enlarged to 7 cm 7 cm, and the hernia sac contained the stomach, spleen, and colon (Fig. 2). Since the hernia sac was adjacent to the lateral meningocele, the meningocele had been previously repaired at 12 months of age. At 13 months of age, the lumbar hernia was repaired laparoscopically. Under general anesthesia, the patient was placed in a semilateral position on her right side. A 5-mm trocar was inserted umbilically, and CO2 was insufflated to a pressure of 8 mm Hg. Under visual 45 5-mm laparoscopic guidance, the other two trocars (5 and 12 mm) were then placed along the midclavicular line in the right upper and left lower quadrants. The hernia sac in the left lumbar wall was inspected, and a peritoneal flap was raised. Since the hernia bulged outward with pneumoperitoneum, the edges of the hernia defect were well identified (Fig. 3). The ventral side of the defect was closed by approximation of the surrounding muscular layers. 2-0 non-absorbable sutures were passed percutaneously through the superior muscular edge of the hernia defect into the peritoneal cavity with a Lapa-Her-Closure needle (Hakko, Nagano, Japan) and passed through the inferior muscular edge of
2213-5766/$ e see front matter Ó 2014 The Authors. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.epsc.2014.02.007
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K. Morita et al. / J Ped Surg Case Reports 2 (2014) 101e103
Fig. 1. Photograph of the patient demonstrating the left-sided lumbar hernia.
the hernia defect, and then taken out through the abdominal wall, exiting at the entry point. All the sutures were tied within the subcutaneous plane. On the dorsal side, since the postero-superior border of the defect was the rib, the tension to close directly was strong. Therefore, the dorsal defect was repaired with free fascia lata graft reinforcement. A transverse incision approximately 3-cm long was made on the lateral side of the left thigh, and a piece of fascia lata measuring 5 cm 4 cm was harvested. The fascia lata graft with three stay sutures was inserted into the abdominal cavity and positioned (securing the stay sutures to the cardinal points of the hernial edges using a Lapa-Her-Closure needle inserted through the abdominal wall into the abdominal cavity). The ventral suture line and the dorsal defect were covered with a fascia lata graft, and the graft was secured to the surrounding muscular layers with
Fig. 3. Laparoscopic view of the hernial defect (arrows) after raising a peritoneal flap (arrow head).
interrupted 3-0 non-absorbable sutures (Fig. 4). The peritoneal flap was replaced to cover the patch with interrupted 4-0 absorbable sutures. There were no perioperative complications. The patient was discharged on postoperative day 14, and she showed no recurrence of the hernia (Fig. 5) or functional deficit of the left lower limb 6 months after surgery. 2. Discussion Lumbar hernia is defined as the protrusion of organs through a congenital defect in the posterolateral abdominal wall [4]. Lumbar hernias classically occur in three spaces of the lumbar wall: the
Fig. 2. Radiograph showing the hernia sac with the gastric air bubble and air-filled loops of bowel, costovertebral anomalies, and scoliosis.
Fig. 4. The dorsal hernial defect is reinforced with a fascia lata graft (arrow). The peritoneal flap (arrow head) is visible in the left part of the image.
K. Morita et al. / J Ped Surg Case Reports 2 (2014) 101e103
103
free fascia lata graft was chosen. Because the fascia lata is one of the strongest fascial layers in the body, it has often been used for the repair of abdominal defects in adult patients [10]. A free fascia lata graft remains viable after implantation, and it is revascularized within 3 weeks [11]. Since the autologous materials are expected to grow with the patient, we consider that the risk of growth disorder or recurrence after the repair with autologous fascia lata is less than that after repair with prosthetic materials in the long term. A functional deficit of the donor site due to fascial harvest is an important consideration in the pediatric age group. The posterior condensation of the iliotibial tract should be preserved to minimize the risk of lateral knee instability [10]. In our institution, the free fascia lata graft has been used in three pediatric patients (two patients with recurrence of tracheoesophageal fistula, one patient with recurrence of congenital diaphragmatic hernia [12]). All three patients showed no functional deficit of the donor site after fascia lata harvesting. Fig. 5. Photograph 3 months after surgery showing no recurrence of the hernia.
3. Conclusion superior triangle (Grynfeltt hernia), the inferior triangle (Petit hernia), and diffusely in the lumbar area [4]. Congenital lumbar hernias associated with the lumbocostovertebral syndrome have various forms different from the previous noted classical three types. In the present case, the hernia occurred through the intercostal space between the left 8th and 12th ribs, and it was more superior and more lateral than the Grynfeltt hernia. The present findings are similar to those reported by Akçora [1] and Sengar [2]. The etiology of lumbar hernia in these cases may be associated with the agenesis of ipsilateral multiple ribs and defects of muscles inserted on those ribs [1,2]. Elective surgical repair of a congenital lumbar hernia is suggested at any early age to prevent incarceration and strangulation [5,6]. Furthermore, operative repair before 12 months of age is recommended because the hernia defect may enlarge with growth, as in the present case, making primary direct closure with surrounding tissue difficult [7]. Because of the rarity of congenital lumbar hernia, appropriate surgical procedures are still controversial. Open repair has been performed in most patients [1e3,5e7], and, to the best of our knowledge, laparoscopic repair has been reported in only two patients [8,9]. In the present case, the hernial defect was large, and surrounding abdominal wall muscles were hypoplastic. Therefore, the edges of the muscular layer defect were not clear under general anesthesia. Since the hernia bulged outward with pneumoperitoneum, the edges of the muscular layer defect were identified easily and exactly. From the viewpoint of certain hernial defect closure, we consider that laparoscopic repair is effective for a large hernial defect. The laparoscopic intracorporeal suture technique for direct closure of the hernia defect is technically demanding and doubtful [8]. Placement of full-thickness muscular layer stitches with a Lapa-Her-Closure needle and extracorporeal knot tying in the subcutaneous tissue allow maximum strength of repair. Furthermore, in reinforcing the hernial defect with a fascia lata graft laparoscopically, complete covering of the defect is necessary to prevent recurrence. Initial fixation of the graft with stay sutures and a Lapa-Her-Closure needle enabled correct reinforcement of the hernia defect in the present case. In patients with large hernial defects, reinforcement with prosthetic materials, such as a polypropylene mesh [5,8], is generally performed. However, prosthetic materials may lead to infection, local growth disorders, or recurrences in pediatric patients. Therefore, in the present case, reinforcement with an autologous
Since congenital lumbar hernias associated with the lumbocostovertebral syndrome have various forms, determining the appropriate surgical procedures for individual patients is challenging. Laparoscopic repair with free fascia lata graft reinforcement is a safe and feasible surgical option for large congenital lumbar hernias associated with the lumbocostovertebral syndrome. Consent Written informed consent was obtained from the patient’s parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Conflict of interest statement The authors have no conflict of interest to disclose. References it C. A different type of congenital lumbar hernia [1] Akçora B, Temiz A, Babayig associated with the lumbocostovertebral syndrome. J Pediatr Surg 2008;43: e21e3. [2] Sengar M, Manchanda V, Mohta A, Jain V, Das S. Intercostal variant of lumbar hernia in lumbocostovertebral syndrome: our experience with 6 cases. J Pediatr Surg 2011;46:1974e7. [3] Touloukian RJ. The lumbocostovertebral syndrome: a single somatic defect. Surgery 1972;71:174e81. [4] Stamatiou D, Skandalakis JE, Skandalakis LJ, Mirilas P. Lumbar hernia: surgical anatomy, embryology, and technique of repair. Am Surg 2009;75:202e7. [5] Hancock BJ, Wiseman NE. Incarcerated congenital lumbar hernia associated with the lumbocostovertebral syndrome. J Pediatr Surg 1988;23:782e3. [6] Al-Salem AH, Abu-Srair H, Qaissaruddin S. Focal nodular hyperplasia of the liver with the lumbo-costovertebral syndrome. J Pediatr Surg 1996;31: 1282e4. [7] Lowell DG, Guzzetta PC. Lumbar hernia in a case of posterior meningomyelocele. J Pediatr Surg 1986;21:913e4. [8] Zwaveling S, van der Zee DC. Laparoscopic repair of an isolated congenital bilateral lumbar hernia in an infant. Eur J Pediatr Surg 2012;22:321e3. [9] Jones SL, Thomas I, Hamill J. Laparoscopic lumbar hernia repair in a child with lumbocostovertebral syndrome. J Laparoendosc Adv Surg Tech A 2010;20: 97e8. [10] de Vries Reilingh TS, Bodegom ME, van Goor H, Hartman EH, van der Wilt GJ, Bleichrodt RP. Autologous tissue repair of large abdominal wall defects. Br J Surg 2007;94:791e803. [11] Gallie WE, Le Mesurier AB. Living sutures in the treatment of hernia. Can Med Assoc J 1923;13:469e80. [12] Sugiyama A, Fukumoto K, Fukuzawa H, Watanabe K, Mitsunaga M, Park S, et al. Free fascia lata repair for a second recurrent congenital diaphragmatic hernia. J Pediatr Surg 2011;46:1838e41.
Contents lists available at ScienceDirect
Journal of Pediatric Surgery CASE REPORTS journal homepage: www.jpscasereports.com
Laparoscopic repair for a congenital lumbar hernia with free fascia lata graft reinforcementq Keiichi Morita*, Go Miyano, Hiroshi Nouso, Koji Fukumoto, Masaya Yamoto, Hiromu Miyake, Masakatsu Kaneshiro, Naoto Urushihara Department of Pediatric Surgery, Shizuoka Children’s Hospital, 860 Urushiyama, Aoi-ku, Shizuoka-shi, Shizuoka 420-8660, Japan
a r t i c l e i n f o
a b s t r a c t
Article history: Received 10 January 2014 Received in revised form 3 February 2014 Accepted 3 February 2014 Available online 26 February 2014
Congenital lumbar hernias are rare, and the optimal surgical procedures for hernia repair are still controversial. A 13-month-old girl with a left-sided, 7 cm 7 cm, congenital lumbar hernia underwent laparoscopic repair with autologous free fascia lata graft reinforcement. At 6 months, she was doing well with no recurrence of the hernia. Laparoscopic repair with free fascia lata graft reinforcement is a safe and feasible surgical option for the treatment of large congenital lumbar hernias. Ó 2014 The Authors. Published by Elsevier Inc. All rights reserved.
Key words: Congenital lumbar hernia Fascia lata Laparoscopy Lumbocostovertebral syndrome
Congenital lumbar hernias are rarely seen in infancy and childhood, and only about 60 cases have been reported in the English literature [1]. Less than 35 cases of congenital lumbar hernias were related to the lumbocostovertebral syndrome [2]. The lumbocostovertebral syndrome was defined as the association of congenital lumbar hernia, costal defects, and vertebral anomalies by Touloukian [3]. Because of the rarity of congenital lumbar hernia, appropriate surgical procedures for repair are still controversial, and laparoscopic repair has been reported in only a few cases. The laparoscopic repair of a congenital lumbar hernia related to the lumbocostovertebral syndrome with free fascia lata graft reinforcement is reported. 1. Case report A 2.49-kg female infant was born vaginally at 40 weeks’ gestation. The Apgar score was 9 at 5 min. Immediately after birth, she was noted to have a left-sided, 3 cm 3 cm, lumbar hernia. Computed tomography demonstrated a left-sided lateral lumbar muscular layer defect characterized by ipsilateral 9th to 11th rib
q This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/3.0/). * Corresponding author. Tel.: þ81 54 247 6251; fax: þ81 54 247 6259. E-mail address: [email protected] (K. Morita).
agenesis. Furthermore, malformation of the right 1st to 3rd and 8th to 10th ribs and the left 6th to 8th and 12th ribs, Th10 and Th11 hemivertebrae, and a sinistral convex scoliosis were seen. Magnetic resonance imaging revealed a lateral meningocele and a tethered cord. She was referred to our hospital for further treatment at 10 months of age. The lumbar hernia protruded considerably with crying, and it was reducing spontaneously (Fig. 1). The hernial defect enlarged to 7 cm 7 cm, and the hernia sac contained the stomach, spleen, and colon (Fig. 2). Since the hernia sac was adjacent to the lateral meningocele, the meningocele had been previously repaired at 12 months of age. At 13 months of age, the lumbar hernia was repaired laparoscopically. Under general anesthesia, the patient was placed in a semilateral position on her right side. A 5-mm trocar was inserted umbilically, and CO2 was insufflated to a pressure of 8 mm Hg. Under visual 45 5-mm laparoscopic guidance, the other two trocars (5 and 12 mm) were then placed along the midclavicular line in the right upper and left lower quadrants. The hernia sac in the left lumbar wall was inspected, and a peritoneal flap was raised. Since the hernia bulged outward with pneumoperitoneum, the edges of the hernia defect were well identified (Fig. 3). The ventral side of the defect was closed by approximation of the surrounding muscular layers. 2-0 non-absorbable sutures were passed percutaneously through the superior muscular edge of the hernia defect into the peritoneal cavity with a Lapa-Her-Closure needle (Hakko, Nagano, Japan) and passed through the inferior muscular edge of
2213-5766/$ e see front matter Ó 2014 The Authors. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.epsc.2014.02.007
102
K. Morita et al. / J Ped Surg Case Reports 2 (2014) 101e103
Fig. 1. Photograph of the patient demonstrating the left-sided lumbar hernia.
the hernia defect, and then taken out through the abdominal wall, exiting at the entry point. All the sutures were tied within the subcutaneous plane. On the dorsal side, since the postero-superior border of the defect was the rib, the tension to close directly was strong. Therefore, the dorsal defect was repaired with free fascia lata graft reinforcement. A transverse incision approximately 3-cm long was made on the lateral side of the left thigh, and a piece of fascia lata measuring 5 cm 4 cm was harvested. The fascia lata graft with three stay sutures was inserted into the abdominal cavity and positioned (securing the stay sutures to the cardinal points of the hernial edges using a Lapa-Her-Closure needle inserted through the abdominal wall into the abdominal cavity). The ventral suture line and the dorsal defect were covered with a fascia lata graft, and the graft was secured to the surrounding muscular layers with
Fig. 3. Laparoscopic view of the hernial defect (arrows) after raising a peritoneal flap (arrow head).
interrupted 3-0 non-absorbable sutures (Fig. 4). The peritoneal flap was replaced to cover the patch with interrupted 4-0 absorbable sutures. There were no perioperative complications. The patient was discharged on postoperative day 14, and she showed no recurrence of the hernia (Fig. 5) or functional deficit of the left lower limb 6 months after surgery. 2. Discussion Lumbar hernia is defined as the protrusion of organs through a congenital defect in the posterolateral abdominal wall [4]. Lumbar hernias classically occur in three spaces of the lumbar wall: the
Fig. 2. Radiograph showing the hernia sac with the gastric air bubble and air-filled loops of bowel, costovertebral anomalies, and scoliosis.
Fig. 4. The dorsal hernial defect is reinforced with a fascia lata graft (arrow). The peritoneal flap (arrow head) is visible in the left part of the image.
K. Morita et al. / J Ped Surg Case Reports 2 (2014) 101e103
103
free fascia lata graft was chosen. Because the fascia lata is one of the strongest fascial layers in the body, it has often been used for the repair of abdominal defects in adult patients [10]. A free fascia lata graft remains viable after implantation, and it is revascularized within 3 weeks [11]. Since the autologous materials are expected to grow with the patient, we consider that the risk of growth disorder or recurrence after the repair with autologous fascia lata is less than that after repair with prosthetic materials in the long term. A functional deficit of the donor site due to fascial harvest is an important consideration in the pediatric age group. The posterior condensation of the iliotibial tract should be preserved to minimize the risk of lateral knee instability [10]. In our institution, the free fascia lata graft has been used in three pediatric patients (two patients with recurrence of tracheoesophageal fistula, one patient with recurrence of congenital diaphragmatic hernia [12]). All three patients showed no functional deficit of the donor site after fascia lata harvesting. Fig. 5. Photograph 3 months after surgery showing no recurrence of the hernia.
3. Conclusion superior triangle (Grynfeltt hernia), the inferior triangle (Petit hernia), and diffusely in the lumbar area [4]. Congenital lumbar hernias associated with the lumbocostovertebral syndrome have various forms different from the previous noted classical three types. In the present case, the hernia occurred through the intercostal space between the left 8th and 12th ribs, and it was more superior and more lateral than the Grynfeltt hernia. The present findings are similar to those reported by Akçora [1] and Sengar [2]. The etiology of lumbar hernia in these cases may be associated with the agenesis of ipsilateral multiple ribs and defects of muscles inserted on those ribs [1,2]. Elective surgical repair of a congenital lumbar hernia is suggested at any early age to prevent incarceration and strangulation [5,6]. Furthermore, operative repair before 12 months of age is recommended because the hernia defect may enlarge with growth, as in the present case, making primary direct closure with surrounding tissue difficult [7]. Because of the rarity of congenital lumbar hernia, appropriate surgical procedures are still controversial. Open repair has been performed in most patients [1e3,5e7], and, to the best of our knowledge, laparoscopic repair has been reported in only two patients [8,9]. In the present case, the hernial defect was large, and surrounding abdominal wall muscles were hypoplastic. Therefore, the edges of the muscular layer defect were not clear under general anesthesia. Since the hernia bulged outward with pneumoperitoneum, the edges of the muscular layer defect were identified easily and exactly. From the viewpoint of certain hernial defect closure, we consider that laparoscopic repair is effective for a large hernial defect. The laparoscopic intracorporeal suture technique for direct closure of the hernia defect is technically demanding and doubtful [8]. Placement of full-thickness muscular layer stitches with a Lapa-Her-Closure needle and extracorporeal knot tying in the subcutaneous tissue allow maximum strength of repair. Furthermore, in reinforcing the hernial defect with a fascia lata graft laparoscopically, complete covering of the defect is necessary to prevent recurrence. Initial fixation of the graft with stay sutures and a Lapa-Her-Closure needle enabled correct reinforcement of the hernia defect in the present case. In patients with large hernial defects, reinforcement with prosthetic materials, such as a polypropylene mesh [5,8], is generally performed. However, prosthetic materials may lead to infection, local growth disorders, or recurrences in pediatric patients. Therefore, in the present case, reinforcement with an autologous
Since congenital lumbar hernias associated with the lumbocostovertebral syndrome have various forms, determining the appropriate surgical procedures for individual patients is challenging. Laparoscopic repair with free fascia lata graft reinforcement is a safe and feasible surgical option for large congenital lumbar hernias associated with the lumbocostovertebral syndrome. Consent Written informed consent was obtained from the patient’s parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. Conflict of interest statement The authors have no conflict of interest to disclose. References it C. A different type of congenital lumbar hernia [1] Akçora B, Temiz A, Babayig associated with the lumbocostovertebral syndrome. J Pediatr Surg 2008;43: e21e3. [2] Sengar M, Manchanda V, Mohta A, Jain V, Das S. Intercostal variant of lumbar hernia in lumbocostovertebral syndrome: our experience with 6 cases. J Pediatr Surg 2011;46:1974e7. [3] Touloukian RJ. The lumbocostovertebral syndrome: a single somatic defect. Surgery 1972;71:174e81. [4] Stamatiou D, Skandalakis JE, Skandalakis LJ, Mirilas P. Lumbar hernia: surgical anatomy, embryology, and technique of repair. Am Surg 2009;75:202e7. [5] Hancock BJ, Wiseman NE. Incarcerated congenital lumbar hernia associated with the lumbocostovertebral syndrome. J Pediatr Surg 1988;23:782e3. [6] Al-Salem AH, Abu-Srair H, Qaissaruddin S. Focal nodular hyperplasia of the liver with the lumbo-costovertebral syndrome. J Pediatr Surg 1996;31: 1282e4. [7] Lowell DG, Guzzetta PC. Lumbar hernia in a case of posterior meningomyelocele. J Pediatr Surg 1986;21:913e4. [8] Zwaveling S, van der Zee DC. Laparoscopic repair of an isolated congenital bilateral lumbar hernia in an infant. Eur J Pediatr Surg 2012;22:321e3. [9] Jones SL, Thomas I, Hamill J. Laparoscopic lumbar hernia repair in a child with lumbocostovertebral syndrome. J Laparoendosc Adv Surg Tech A 2010;20: 97e8. [10] de Vries Reilingh TS, Bodegom ME, van Goor H, Hartman EH, van der Wilt GJ, Bleichrodt RP. Autologous tissue repair of large abdominal wall defects. Br J Surg 2007;94:791e803. [11] Gallie WE, Le Mesurier AB. Living sutures in the treatment of hernia. Can Med Assoc J 1923;13:469e80. [12] Sugiyama A, Fukumoto K, Fukuzawa H, Watanabe K, Mitsunaga M, Park S, et al. Free fascia lata repair for a second recurrent congenital diaphragmatic hernia. J Pediatr Surg 2011;46:1838e41.