Flank Bulge following Retroperitoneal Incisions

Abstract

Sir: Flank incisions occasionally cause laxity of the abdominal wall, resulting in an unsightly bulge. Patients complain of pain and physical deformity causing a decrease in quality of life after the occurrence of flank bulge.1 Secondary to DiBello and Moore’s published success mobilizing myocutaneous flaps as a repair technique for recurrent ventral hernias,2 we use the same principle combined with a mesh onlay for flank hernias. After approval by the institutional review board, we conducted a retrospective case review of all patients who underwent flank bulge repair for cosmesis and pain between 2007 and 2009 at the Department of Surgery at Thomas Jefferson University Hospital. With the patient in the semi–lateral decubitus position, the previous incision is opened. The external oblique muscle is divided and the internal oblique and transversus muscles are identified. The hernia sac is divided, and abdominal contents are reduced. Internal oblique myofascial advancement flaps are released; the inferior flap is secured to the undersurface of the superior internal oblique flap using 1-0 polydioxanone suture, ensuring that no tissue violates the intercostal space. The superior internal oblique muscle flap is advanced over the inferior flap using a “vest-over-pants” technique and secured with 1-0 polydioxanone suture. A mesh onlay patch is secured over the internal oblique muscle and fixed. The external oblique muscles are reapproximated. A Blake drain is placed in the intermuscular space, and skin and subcutaneous tissue are closed in layers (Fig. 1). Our flank hernia repair was performed on eight patients from 2007 to 2009. Six patients had no complaints of pain or flank bulge at 1 year (Fig. 2). Two patients complained about a minimal bulge but experienced relief of pain; they were referred for muscle-strengthening exercises. Several articles have addressed techniques for repair of flank bulges. Peterson and colleagues repaired flank hernias using mesh in a sublay position3 that relieved pain but failed to reduce the physical bulge. Hoffman et al. recommended repairing flank hernias through an abdominoplasty incision and plicated the rectus abdominis muscle transversely. This repair resulted in a large scar and did not ensure complete lack of recurrence.4 Zieren and colleagues approached the flank hernia through a median laparotomy, placing a prosthetic polypropylene mesh in a sublay technique,5 resulting in a second scar and theoretically increasing risk of injury to abdominal organs. Our method of mobilizing the oblique muscles and performing myocutaneous flaps alleviates the problem of muscle laxity. Healthy muscle replaces atrophied muscle. We use the mesh in an onlay technique as an added layer of security that does not require an additional incision or entering the peritoneal cavity. In conclusion, we present a method of myocutaneous advancement flaps with mesh onlay through the original surgical incision that relieves pain and muscle bulge. We believe this method should be used in patients concerned about the cosmetic sequelae of flank incision.Fig. 1: Illustrations of the surgical procedure. (Above, left) An incision is made through the previous incision. (Above, second row) The external oblique is divided. (Above, third row) The hernia sac is identified. (Above, right) The abdominal contents are reduced. (Center, left) Internal oblique myofascial flaps are released. (Center, second row) The inferior flap of the internal oblique is secured to the superior flap. (Center, third row) The superior flap is closed over the inferior flap. (Center, right) Mesh is placed over the myofascial flaps. (Below, left) The external oblique muscle is reapproximated over drains. (Below, second row) The skin is closed primarily.Fig. 2: Preoperative and postoperative results. (Left) Cosmetic defect of a patient who developed a flank hernia after a left nephrectomy. (Right) Postoperatively, the patient had good cosmesis and decreased pain at the hernia site.DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.