Adhesive Complications in a Patient After Ventral Hernia IPOM Repair - Case 1

A 21-year-old woman was referred to our department for laparoscopic repair of linea alba hernia and gastroesophageal reflux disease with radiological and clinical symptoms. She had no previous abdominal surgery and no other concomitant disorders. Preoperative imaging studies showed normal chest x-ray and no additional abnormalities on abdominal ultrasound scan. Gastroscopy showed sliding hiatus hernia with acid reflux. The surgery was performed under general anaesthesia. Intraoperatively oeso­phageal hiatal hernia and hernia of the linea alba above the umbilicus, without adhesions, were seen. WTP anti-reflux operation was performed [10] (with fixation of Prolene mesh, specially cut, about 4 × 4 cm in size, to the diaphragmatic crura and angle of His restoration by suturing the fundus of the stomach to the left side of the abdominal oesophagus). IPOM procedure was performed for linea alba hernia, using Dynamesh® 20 × 12 cm, positioned with four full-thickness PDS sutures in the corners and Endo Hernia stapler with titanium staples in the “double crown” technique [11]. There were no perioperative complications and the patient was discharged on the fifth postoperative day. She was readmitted five months later because of abdominal wall acute pain localized in the midline above the navel. There were no abnormalities on abdominal ultrasound, high-resolution computed tomography (HRCT), or chest X-ray. She was qualified for diagnostic laparoscopy. There was a small umbilical hernia in the trocar site (outside the mesh) and adhesions between the mesh and greater omentum and the left lobe of the liver. Adhesions were released and the umbilical hernia was fixed by an open approach through a small incision with primary PDS suturing. Oxycel (oxidized cellulose – supposed to have anti-adhesive properties similar to Proceed mesh) was placed on the left lobe of the liver. No other abnormalities were noted. Again the postoperative course was uneventful, with withdrawal of pain. The patient was admitted again on 06.2010 due to acute recurrent abdominal pain localized in a similar location. She had a second-look laparoscopy – intraoperatively two single adhesions between the large bowel and recurrent umbilical hernia (approximately 3 cm in diameter) as well as massive adhesions of the Dynamesh and left lobe of the liver were found. Once more, the adhesions were freed. The umbilical hernia was treated with IPOM technique using Parietex Composite mesh (12 cm in diameter, stitches with Protack staples). The postoperative course was uneventful and the patient was discharged on the third postoperative day. During the five months of follow-up, she had acute abdominal pain twice, the last episode two months ago.