Mesh trimming and suture reconstruction for wound dehiscence after huge abdominal intercostal hernia repair: A case report

Abstract

Introduction: Abdominal intercostal hernia repair for huge incisional hernia after thoracoabdominal surgery involves a complex anatomical structure. Hence, it is difficult to apply the laparoscopic approach to large hernias in the lateral upper abdomen. Further the optimal approach to mesh exposure without infection after incisional hernia repair is still controversial. Herein, we describe our experience of repairing a huge abdominal intercostal hernia by mesh trimming and suture reconstruction for wound dehiscence.

Presentation of case: A 73-year-old man presented with an incisional hernia in the left flank from just below the eight intercostal space to the transverse umbilical region 6 months after thoracoabdominal aortic aneurysm surgery. Computed tomography revealed an incisional hernia orifice of 17 × 13 cm located on the left flank around the ninth rib. We chose the open approach as treatment because the hernia orifice was large, and we created a mesh placement space in the extraperitoneal cavity and placed expanded polytetrafluoroethylene mesh there with 1-0 nonabsorbable monofilament suture. At postoperative day 26, we observed mesh exposure due to wound dehiscence. Mesh trimming and suture reconstruction for wound dehiscence was performed because there were no signs of wound infection. The postoperative course was uneventful including infection and dehiscence. The patient has been well without recurrence for 14 months since last operation.

Conclusions: Optimal treatment for repair of a large abdominal intercostal hernia with thoracoabdominal location is necessary. Moreover, partial mesh removal may be one of the treatment options for mesh exposure if conditions are met.

Keywords: Abdominal intercostal hernia; Mesh exposure; Wound dehiscence.

Fig. 1

Physical examination: The umbilicus (arrowhead) was positioned toward the right side because of a mass. A reducible mass (arrow) at the left upper quadrant corresponding to about 30 cm.

Fig. 2

Computed tomography (CT) findings. CT revealed a 17 × 13 cm incisional hernia from the ninth rib to the left flank.

Fig. 3

Postoperative day 26 wound findings: 3 × 7 cm mesh exposure due to wound dehiscence without infection.

Fig. 4

Re-operation procedure. (A) Put a crystal violet on the exposed mesh. (B) Local removal of the exposed mesh. Adhesion and abscess were not detected. (C) Overlapping the remaining mesh by 5 mm with 1-0 nonabsorbable suture and retention sutures in the skin. (D) Nodules concealed between meshes to prevent skin damage at the nodules.

Fig. 5

Final wound appearance. The wound is clear without infection and dehiscence at discharge.