CASE REPORT
Laparoscopic Arcuate Line Hernia Repair Nouredin Messaoudi, MD,* Zainab Amajoud, MD,* Geert Mahieu, MD,w Raymond Bestman, MD,* Steven Pauli, MD,* and Marc Van Cleemput, MD*
Abstract: Arcuate line hernia is considered a surgical rarity. This type of hernia is characterized by protrusion of intraperitoneal structures in a concave parietal fold in the abdominal wall. In this report, we aim to describe the diagnostic images of 2 cases of arcuate line hernia. Laparoscopic repair using a polypropylene mesh with a preattached inflatable balloon has been illustrated as well. Key Words: arcuate line, hernia, laparoscopy, mesh
(Surg Laparosc Endosc Percutan Tech 2014;24:e110–e112)
P
rotrusion of intraperitoneal structures in the arcuate line of the abdominal wall is rare. In this study, the authors present 2 cases of arcuate line hernia. A laparoscopic mesh repair was carried out using a preattached inflatable balloon to facilitate deployment of the prosthesis. To our knowledge, this is the first report of the application of this technique for this purpose. Literature has been reviewed and discussed with reference to the surgical management of this specific type of abdominal wall hernia.
CASE REPORT Case 1 A 57-year-old woman with no previous surgeries or history of trauma was referred by the gastroenterologist for a surgical consult because of intermittent abdominal pain persistent for several months. She described the pain as colicky and localized in her left lower abdomen. Vital signs were normal. Physical examination showed a comfortable patient in no distress, with no signs of peritonitis or intestinal obstruction. A smooth and slightly tender parietal mass was palpated in the left lower abdomen. The remainder of the physical examination revealed no abnormalities. Routine laboratory tests were within the normal range. Computed tomography scan of the abdomen showed protrusion of ileal structures between the rectus muscle and the posterior rectus sheath (Fig. 1A). During laparoscopic exploration, an arcuate line hernia was confirmed (Fig. 1B). A polypropylene mesh was placed laparoscopically to cover the defect. During the postoperative course, no problems were noted. On the following day, the patient was discharged. Four months after surgery, a clinical follow-up confirmed a full recovery and no recurrence.
FIGURE 1. A, Delineation of left arcuate line by protrusion of small-bowel loops. B, Laparoscopic view of the left arcuate line hernia in the first patient.
Case 2 A 39-year-old woman with a history of low back pain underwent anterior lumbar fusion of the L5-S1 segments. The patient reported significant improvement in symptoms on initial Received for publication November 5, 2012; accepted February 1, 2013. From the Departments of *General Surgery; and wOrthopedic Surgery, Monica Hospital, Deurne, Belgium. The authors declare no conflicts of interest. Reprints: Nouredin Messaoudi, MD, Department of General Surgery, Monica Hospital, Florent Pauwelslei 1, b2100 Deurne, Belgium (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
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FIGURE 2. Laparoscopic view of the left arcuate line hernia in the second patient.
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 3, June 2014
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 3, June 2014
Arcuate Line Hernia
FIGURE 3. A, Marking of the skin for mesh size determination. B, Introduction of the prosthesis into the abdominal cavity. C, Laparoscopic retrieval of the hose connected to the balloon. D, Insufflation of the balloon. E, Mesh deployment and positioning facilitated by the balloon after insufflations. F, Mesh fixation using helical tacks. G, Final laparoscopic view of the fixated mesh after removal of the balloon device.
follow-up; however, she complained of a prominence over her incision 1 year later along her left flank. On examination, the incision was found to be intact, and the patient had no signs of infection. A 4-cm tender mass was noted along her flank incision, r
2014 Lippincott Williams & Wilkins
which increased in size with Valsalva. An incisional hernia was clinically suspected. However, diagnostic laparoscopy showed an intact abdominal wall at the level of the incision, but surprisingly a left arcuate line hernia was revealed (Fig. 2). A laparoscopic hernia
www.surgical-laparoscopy.com |
e111
Surg Laparosc Endosc Percutan Tech
Messaoudi et al
Volume 24, Number 3, June 2014
TABLE 1. Literature Review
References Cappeliez et al3 von Meyenfeldt et al1 von Meyenfeldt et al1 Abasbassi et al2 Case 1 Case 2
Age/Gender
Diagnosis
Side of Hernia
Treatment
73/male 53/male 41/male 53/female 57/female 39/female
CT scan Intraoperative Intraoperative CT scan CT scan Intraoperative
Bilateral Left Left Left Left Left
Laparoscopic mesh repair Open mesh repair Open mesh repair Laparoscopic repair (without mesh) Laparoscopic mesh repair Laparoscopic mesh repair
CT indicates computed tomography.
repair with a mesh was carried out. The patient was discharged the next day, and follow-up 2 months after surgery revealed good recovery.
OPERATIVE TECHNIQUE The patient was administered general anesthesia and placed in the supine position. The surgeon and assistant positioned themselves on the side opposite to the hernia. Pneumoperitoneum was established using carbon dioxide insufflated through a Verres needle inserted in the anterior axillary line at the level of the umbilicus. After reaching a pressure level of 15 mm Hg, a 10-mm trocar was inserted, which was used for a 0-degree laparoscope. Under direct vision, a 5-mm trocar was placed subcostal and another 5-mm trocar was inserted in the flank above the iliac crest, both in the anterior axillary line. Dissecting instruments and grasping forceps were introduced through these 2 ports. In both cases, the hernia was reduced during insufflation; therefore, no adhesiolysis was needed. The skin was marked to determine the size of the prosthesis (Fig. 3A). A polypropylene mesh (20 25 cm) with a preattached inflatable balloon was directly introduced into the abdominal cavity, without the need of transfacial suture placement (Fig. 3B). The inflation hose was retrieved through the abdominal wall using an endoclose device (Fig. 3C). Upon inflation of the balloon, the mesh unrolled and covered the defect (Figs. 3D, E). After positioning the prosthesis, the mesh was fixated to the abdominal wall with helical tacks (Fig. 3F). Once initial fixation was complete, the device was deflated and removed through an existing port. Additional tacks were placed to secure the mesh to the abdominal wall (Fig. 3G).
DISCUSSION Arcuate line hernia is a rare type of interstitial hernia of the anterior abdominal wall. Review of the literature resulted in 4 previously reported symptomatic cases (Table 1).1–3 Through the concave parietal fold created by the anatomic defect, ascending protrusion of intraperitoneal structures can occur. Minimal bulging of adipose tissue is classified as grade 1, whereas a grade 2 arcuate line hernia consists of an actual (although minimal) herniation of omental fat and/or intestinal loops. Prominent herniation of intraperitoneal structures is classified as grade 3.4 Despite the rare occurrence of this entity, an arcuate line hernia should be considered in the differential diagnosis of a lower abdominal flank mass. A computed tomography scan of the abdomen can suggest the diagnosis of an arcuate line hernia, as illustrated in our first case. However, in
e112 | www.surgical-laparoscopy.com
our second patient, an incisional hernia due to previous surgery was strongly considered clinically. Consequently, no further imaging was conducted. After laparoscopic exploration, an arcuate line hernia was confirmed. Surgical management of an arcuate line hernia consists of an open or laparoscopic repair, with or without the use of a mesh. Von Meyenfeldt et al1 have reported 2 cases in which an open surgical approach was used through a transverse incision over the respective rectus abdominus muscle. After reduction of the hernial sac, a polypropylene mesh was sutured to reinforce the defect in the posterior rectus sheath. Abasbassi and colleagues documented a laparoscopic repair in which the parietal fold at the posterior rectus sheath cephalad was cut; no mesh was placed in this case.2 A laparoscopic approach with mesh fixation was reported by Cappeliez and colleagues in the treatment of a bilateral arcuate line hernia in a 73-year-old patient.3 In this study, we present 2 cases of left arcuate line hernia managed laparoscopically by a relatively novel method of mesh deployment using a preattached inflatable balloon. Our experience with this technique is rather encouraging, as it improved efficiency in unrolling and positioning of the prosthesis and consequently reduced operative time. The technique of arcuate line hernia repair presented here incorporates the basic tenants of laparoscopic hernia repair, including wide coverage and appropriate mesh fixation. The deployment and positioning of the mesh was simple and effective. No additional transfacial sutures were needed. The postoperative course of both patients was uneventful. In conclusion, laparoscopic repair of an arcuate line hernia by laparoscopy is feasible and safe and provides an excellent short-term outcome. The balloon technique presented in this study is an ergonomically easy approach to deploy and position the prosthesis. Further studies are needed to evaluate the application of this technique of mesh deployment in the surgical treatment of various types of abdominal wall hernia. REFERENCES 1. von Meyenfeldt E, van Keulen E, Eerenberg J, et al. The linea arcuata hernia: a report of two cases. Hernia. 2010;14:207–209. 2. Abasbassi M, Hendrickx T, Caluwe´ G, et al. Symptomatic linea arcuata hernia. Hernia. 2011;15:229–231. 3. Cappeliez O, Duez V, Alle JL, et al. Bilateral arcuate line hernia. Am J Roentgenol. 2003;180:864–865. 4. Coulier B. Multidetector computed tomography features of linea arcuata (arcuate-line of Douglas) and linea arcuata hernias. Surg Radiol Anat. 2007;29:397–403.
r
2014 Lippincott Williams & Wilkins
Laparoscopic Arcuate Line Hernia Repair Nouredin Messaoudi, MD,* Zainab Amajoud, MD,* Geert Mahieu, MD,w Raymond Bestman, MD,* Steven Pauli, MD,* and Marc Van Cleemput, MD*
Abstract: Arcuate line hernia is considered a surgical rarity. This type of hernia is characterized by protrusion of intraperitoneal structures in a concave parietal fold in the abdominal wall. In this report, we aim to describe the diagnostic images of 2 cases of arcuate line hernia. Laparoscopic repair using a polypropylene mesh with a preattached inflatable balloon has been illustrated as well. Key Words: arcuate line, hernia, laparoscopy, mesh
(Surg Laparosc Endosc Percutan Tech 2014;24:e110–e112)
P
rotrusion of intraperitoneal structures in the arcuate line of the abdominal wall is rare. In this study, the authors present 2 cases of arcuate line hernia. A laparoscopic mesh repair was carried out using a preattached inflatable balloon to facilitate deployment of the prosthesis. To our knowledge, this is the first report of the application of this technique for this purpose. Literature has been reviewed and discussed with reference to the surgical management of this specific type of abdominal wall hernia.
CASE REPORT Case 1 A 57-year-old woman with no previous surgeries or history of trauma was referred by the gastroenterologist for a surgical consult because of intermittent abdominal pain persistent for several months. She described the pain as colicky and localized in her left lower abdomen. Vital signs were normal. Physical examination showed a comfortable patient in no distress, with no signs of peritonitis or intestinal obstruction. A smooth and slightly tender parietal mass was palpated in the left lower abdomen. The remainder of the physical examination revealed no abnormalities. Routine laboratory tests were within the normal range. Computed tomography scan of the abdomen showed protrusion of ileal structures between the rectus muscle and the posterior rectus sheath (Fig. 1A). During laparoscopic exploration, an arcuate line hernia was confirmed (Fig. 1B). A polypropylene mesh was placed laparoscopically to cover the defect. During the postoperative course, no problems were noted. On the following day, the patient was discharged. Four months after surgery, a clinical follow-up confirmed a full recovery and no recurrence.
FIGURE 1. A, Delineation of left arcuate line by protrusion of small-bowel loops. B, Laparoscopic view of the left arcuate line hernia in the first patient.
Case 2 A 39-year-old woman with a history of low back pain underwent anterior lumbar fusion of the L5-S1 segments. The patient reported significant improvement in symptoms on initial Received for publication November 5, 2012; accepted February 1, 2013. From the Departments of *General Surgery; and wOrthopedic Surgery, Monica Hospital, Deurne, Belgium. The authors declare no conflicts of interest. Reprints: Nouredin Messaoudi, MD, Department of General Surgery, Monica Hospital, Florent Pauwelslei 1, b2100 Deurne, Belgium (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
e110 | www.surgical-laparoscopy.com
FIGURE 2. Laparoscopic view of the left arcuate line hernia in the second patient.
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 3, June 2014
Surg Laparosc Endosc Percutan Tech
Volume 24, Number 3, June 2014
Arcuate Line Hernia
FIGURE 3. A, Marking of the skin for mesh size determination. B, Introduction of the prosthesis into the abdominal cavity. C, Laparoscopic retrieval of the hose connected to the balloon. D, Insufflation of the balloon. E, Mesh deployment and positioning facilitated by the balloon after insufflations. F, Mesh fixation using helical tacks. G, Final laparoscopic view of the fixated mesh after removal of the balloon device.
follow-up; however, she complained of a prominence over her incision 1 year later along her left flank. On examination, the incision was found to be intact, and the patient had no signs of infection. A 4-cm tender mass was noted along her flank incision, r
2014 Lippincott Williams & Wilkins
which increased in size with Valsalva. An incisional hernia was clinically suspected. However, diagnostic laparoscopy showed an intact abdominal wall at the level of the incision, but surprisingly a left arcuate line hernia was revealed (Fig. 2). A laparoscopic hernia
www.surgical-laparoscopy.com |
e111
Surg Laparosc Endosc Percutan Tech
Messaoudi et al
Volume 24, Number 3, June 2014
TABLE 1. Literature Review
References Cappeliez et al3 von Meyenfeldt et al1 von Meyenfeldt et al1 Abasbassi et al2 Case 1 Case 2
Age/Gender
Diagnosis
Side of Hernia
Treatment
73/male 53/male 41/male 53/female 57/female 39/female
CT scan Intraoperative Intraoperative CT scan CT scan Intraoperative
Bilateral Left Left Left Left Left
Laparoscopic mesh repair Open mesh repair Open mesh repair Laparoscopic repair (without mesh) Laparoscopic mesh repair Laparoscopic mesh repair
CT indicates computed tomography.
repair with a mesh was carried out. The patient was discharged the next day, and follow-up 2 months after surgery revealed good recovery.
OPERATIVE TECHNIQUE The patient was administered general anesthesia and placed in the supine position. The surgeon and assistant positioned themselves on the side opposite to the hernia. Pneumoperitoneum was established using carbon dioxide insufflated through a Verres needle inserted in the anterior axillary line at the level of the umbilicus. After reaching a pressure level of 15 mm Hg, a 10-mm trocar was inserted, which was used for a 0-degree laparoscope. Under direct vision, a 5-mm trocar was placed subcostal and another 5-mm trocar was inserted in the flank above the iliac crest, both in the anterior axillary line. Dissecting instruments and grasping forceps were introduced through these 2 ports. In both cases, the hernia was reduced during insufflation; therefore, no adhesiolysis was needed. The skin was marked to determine the size of the prosthesis (Fig. 3A). A polypropylene mesh (20 25 cm) with a preattached inflatable balloon was directly introduced into the abdominal cavity, without the need of transfacial suture placement (Fig. 3B). The inflation hose was retrieved through the abdominal wall using an endoclose device (Fig. 3C). Upon inflation of the balloon, the mesh unrolled and covered the defect (Figs. 3D, E). After positioning the prosthesis, the mesh was fixated to the abdominal wall with helical tacks (Fig. 3F). Once initial fixation was complete, the device was deflated and removed through an existing port. Additional tacks were placed to secure the mesh to the abdominal wall (Fig. 3G).
DISCUSSION Arcuate line hernia is a rare type of interstitial hernia of the anterior abdominal wall. Review of the literature resulted in 4 previously reported symptomatic cases (Table 1).1–3 Through the concave parietal fold created by the anatomic defect, ascending protrusion of intraperitoneal structures can occur. Minimal bulging of adipose tissue is classified as grade 1, whereas a grade 2 arcuate line hernia consists of an actual (although minimal) herniation of omental fat and/or intestinal loops. Prominent herniation of intraperitoneal structures is classified as grade 3.4 Despite the rare occurrence of this entity, an arcuate line hernia should be considered in the differential diagnosis of a lower abdominal flank mass. A computed tomography scan of the abdomen can suggest the diagnosis of an arcuate line hernia, as illustrated in our first case. However, in
e112 | www.surgical-laparoscopy.com
our second patient, an incisional hernia due to previous surgery was strongly considered clinically. Consequently, no further imaging was conducted. After laparoscopic exploration, an arcuate line hernia was confirmed. Surgical management of an arcuate line hernia consists of an open or laparoscopic repair, with or without the use of a mesh. Von Meyenfeldt et al1 have reported 2 cases in which an open surgical approach was used through a transverse incision over the respective rectus abdominus muscle. After reduction of the hernial sac, a polypropylene mesh was sutured to reinforce the defect in the posterior rectus sheath. Abasbassi and colleagues documented a laparoscopic repair in which the parietal fold at the posterior rectus sheath cephalad was cut; no mesh was placed in this case.2 A laparoscopic approach with mesh fixation was reported by Cappeliez and colleagues in the treatment of a bilateral arcuate line hernia in a 73-year-old patient.3 In this study, we present 2 cases of left arcuate line hernia managed laparoscopically by a relatively novel method of mesh deployment using a preattached inflatable balloon. Our experience with this technique is rather encouraging, as it improved efficiency in unrolling and positioning of the prosthesis and consequently reduced operative time. The technique of arcuate line hernia repair presented here incorporates the basic tenants of laparoscopic hernia repair, including wide coverage and appropriate mesh fixation. The deployment and positioning of the mesh was simple and effective. No additional transfacial sutures were needed. The postoperative course of both patients was uneventful. In conclusion, laparoscopic repair of an arcuate line hernia by laparoscopy is feasible and safe and provides an excellent short-term outcome. The balloon technique presented in this study is an ergonomically easy approach to deploy and position the prosthesis. Further studies are needed to evaluate the application of this technique of mesh deployment in the surgical treatment of various types of abdominal wall hernia. REFERENCES 1. von Meyenfeldt E, van Keulen E, Eerenberg J, et al. The linea arcuata hernia: a report of two cases. Hernia. 2010;14:207–209. 2. Abasbassi M, Hendrickx T, Caluwe´ G, et al. Symptomatic linea arcuata hernia. Hernia. 2011;15:229–231. 3. Cappeliez O, Duez V, Alle JL, et al. Bilateral arcuate line hernia. Am J Roentgenol. 2003;180:864–865. 4. Coulier B. Multidetector computed tomography features of linea arcuata (arcuate-line of Douglas) and linea arcuata hernias. Surg Radiol Anat. 2007;29:397–403.
r
2014 Lippincott Williams & Wilkins
