Reconstruction of the symphysis pubis to repair a complex midline hernia in the setting of congenital bladder exstrophy

Abstract

Purpose: A 40-year-old man with congenital midline defect and wide pubic symphysis diastasis secondary to bladder exstrophy presented with a massive incisional hernia resulting from complications of multiple prior abdominal repairs. Using a multi-disciplinary team of general, plastic, and urologic surgeons, we performed a complex hernia repair including creation of a pubic symphysis with rib graft for inferior fixation of mesh.

Methods: The skin graft overlying the peritoneum was excised, and the posterior rectus sheath mobilized, then re-approximated. The previously augmented bladder and urethra were mobilized into the pelvis, after which a rib graft was constructed from the 7th rib and used to create a symphysis pubis using a mortise joint. This rib graft was used to fix the inferior portion of a 20 × 25 cm porcine xenograft mesh in a retro-rectus position. With the defect closed, prior skin scars were excised and the wound closed over multiple drains.

Results: The patient tolerated the procedure well. His post-operative course was complicated by a vesico-cutaneous fistula and associated urinary tract and wound infections. This resolved by drainage with a urethral catheter and bilateral percutaneous nephrostomies. The patient has subsequently healed well with an intact hernia repair. The increased intra-abdominal pressure from his intact abdominal wall has been associated with increased stress urinary incontinence.

Conclusions: Although a difficult operation prone to serious complications, reconstruction of the symphysis pubis is an effective means for creating an inferior border to affix mesh in complex hernia repairs associated with bladder exstrophy.

Fig. 1

A Pre-operative photograph showing a large traumatic parapubic hernia in the setting of repaired bladder exstrophy

Fig. 2

Computed axial tomography (CT) demonstrating the hernia sac and pubic diastasis

Fig. 3

CT demonstrating the reconstructed pubic symphysis. Placement of a 7th rib bone graft with mortise joints created an inferior fixation point for a biologic mesh

Fig. 4

Porcine xenograft biologic mesh placed in the retro-rectus position, with fixation to the fascia of the abdominal wall and inferiorly to the rib graft

Fig. 5

The patient’s abdomen several months following the repair, showing closure of the hernia defect and healing of incisions