Case Report: Abdominal Wall Reconstruction in a High-Risk Patient With Incisional Hernia and Complications From Oncological Treatment.

Introduction: A high risk patient with evisceration underwent to abdominal wall reconstruction without mesh or drains. We present a case of a 62 years-old female patient with a significant medical history of Wilson's disease-related hepatopathy Child-Pugh class B classification, sequelae of a stroke, and relevant surgical background including total hysterectomy, oophorectomy, and Hartmann's procedure for ovarian neoplasm stage 3. The patient developed a large incisional hernia in the midline incision while undergoing Bevacizumab (Avastin) treatment for clinical oncology. During an attempt at skin closure due to erosion and necrosis, there was progressive deterioration leading to evisceration. We opted for abdominal wall reconstruction by transposing the hernia sac without using mesh and employing hemostatic powder (Arista) to mitigate the risk of bleeding in a high-risk patient due to recent bevacizumab use and hepatopathy. The patient had a favorable postoperative course without any other intervention in abdominal wall. Patient developed worsening hepatic function with the presence of ascites, constipation, and disorientation. On the 6th day postoperative, a tomography was performed, which showed colonic distension without obstructive factors and a slight amount of supra-aponeurotic fluid. The patient was discharged on the 10th day postoperative after improvement of the condition with clinical treatment. The patient has been progressing under outpatient follow-up for 5 months, with a resumption of chemotherapy cycles and no evidence of hernia recurrence. Conclusion: Further studies and long-term follow-up are necessary to evaluate the efficacy and safety of hernia sac transposition as a mesh-free technique and the use of hemostatic powder without drains in high-risk patients. However, our case highlights the potential feasibility of these approaches in carefully selected cases.

INTERNAL HERNIA FOLLOWING LAPAROSCOPIC ROUX-EN-Y GASTRIC BY-PASS: INDICATIVE FACTORS FOR EARLY REPAIR.

BACKGROUND: Internal hernia (IH) following laparoscopic Roux-en-Y gastric bypass (LRYGB) is a major complication that challenges the surgeon due to its non-specific presentation and necessity of early repair. Delayed diagnosis and surgical intervention of IH might lead to increased morbidity of patients and impairments in their quality of life. OBJECTIVE: To evaluate the predictive factors for early diagnosis and surgical repair of IH after LRYGB. METHODS: This study analyzed 38 patients during the postoperative period of LRYGB who presented clinical manifestations suggestive of IH after an average of 24 months following the bariatric procedure. RESULTS: The sample consisted of 10 men and 28 women, with a mean age of 37.5 years and a mean body mass index (BMI) of 39.6 kg/m2 before LRYGB. All patients presented pain, 23 presented abdominal distension, 10 had nausea and 12 were vomiting; three of them had dysphagia, three had diarrhea and one had gastro-esophageal reflux. The patients presented symptoms for an average of 15 days, varying from 3 to 50 days. Seventeen (45.9%) patients were seen once, while the other 20 (54.1%) went to the emergency room twice or more times. Exploratory laparoscopy was performed on all patients, being converted to laparotomy in three cases. Petersen hernia was confirmed in 22 (57.9%). Petersen space was closed in all patients and the IH correction was performed in 20 (52.6%) cases. The herniated loop showed signs of vascular suffering in seven patients, and two (5.3%) had irreversible ischemia, requiring bowel resection. CONCLUSION: The presence of recurrent abdominal pain is one of the main indicators for the diagnosis of IH after LRYGB. Patients operated at an early stage, even with negative imaging tests for this disease, benefited from rapid and simple procedures without major complications.

Hérnia interna após bypass gástrico em Y de Roux laparoscópico: fatores indicativos para um reparo precoce / Internal hernia following laparoscopic roux-en-y gastric by-pass: indicative factors for early repair

ABSTRACT BACKGROUND: Internal hernia (IH) following laparoscopic Roux-en-Y gastric bypass (LRYGB) is a major complication that challenges the surgeon due to its non-specific presentation and necessity of early repair. Delayed diagnosis and surgical intervention of IH might lead to increased morbidity of patients and impairments in their quality of life. OBJECTIVE: To evaluate the predictive factors for early diagnosis and surgical repair of IH after LRYGB. METHODS: This study analyzed 38 patients during the postoperative period of LRYGB who presented clinical manifestations suggestive of IH after an average of 24 months following the bariatric procedure. RESULTS: The sample consisted of 10 men and 28 women, with a mean age of 37.5 years and a mean body mass index (BMI) of 39.6 kg/m2 before LRYGB. All patients presented pain, 23 presented abdominal distension, 10 had nausea and 12 were vomiting; three of them had dysphagia, three had diarrhea and one had gastro-esophageal reflux. The patients presented symptoms for an average of 15 days, varying from 3 to 50 days. Seventeen (45.9%) patients were seen once, while the other 20 (54.1%) went to the emergency room twice or more times. Exploratory laparoscopy was performed on all patients, being converted to laparotomy in three cases. Petersen hernia was confirmed in 22 (57.9%). Petersen space was closed in all patients and the IH correction was performed in 20 (52.6%) cases. The herniated loop showed signs of vascular suffering in seven patients, and two (5.3%) had irreversible ischemia, requiring bowel resection. CONCLUSION: The presence of recurrent abdominal pain is one of the main indicators for the diagnosis of IH after LRYGB. Patients operated at an early stage, even with negative imaging tests for this disease, benefited from rapid and simple procedures without major complications.

RESUMO CONTEXTO: Hérnia interna (HI) após bypass gástrico em Y de Roux laparoscópico (BGYRL) é uma complicação importante que desafia o cirurgião devido à sua apresentação inespecífica e necessidade de reparo precoce. Um diagnóstico e intervenção cirúrgica tardios para HI pode levar a um aumento na morbidade dos pacientes e trazer grandes prejuízos para a qualidade de vida destes. OBJETIVO: Avaliar os fatores preditivos para um diagnóstico e reparo cirúrgico precoces de HI após BGYRL. MÉTODOS: Este estudo analisou 38 pacientes durante o período pós-operatório de BGYRL que apresentaram manifestações clínicas sugestivas de HI após um período de, aproximadamente, 24 meses do procedimento bariátrico. RESULTADOS: A amostra foi composta por 10 homens e 28 mulheres, com idade média de 37,5 anos e IMC médio de 39,6 Kg/m2 antes do BGYRL. Todos os pacientes apresentaram dor abdominal, 23 apresentaram distensão abdominal, 10 tiveram náusea e 12 apresentaram vômitos; três apresentaram disfagia, três tiveram diarreia e um apresentou refluxo gastresofágico. Os pacientes apresentaram sintomas por um período médio de 15 dias, variando de 3 a 50 dias. Dezessete (45,9%) pacientes foram atendidos apenas uma vez, enquanto os outros 20 (54,1%) foram ao setor de emergência duas ou mais vezes. Laparoscopia exploratória foi realizada em todos os pacientes, havendo conversão para laparotomia em apenas três casos. Hérnia de Petersen foi confirmada em 22 (57,9%) casos. O espaço de Petersen foi fechado em todos os pacientes, e a correção de HI foi realizada em 20 (52,6%) casos. As alças intestinais herniadas mostraram sinais de sofrimento vascular em sete pacientes, e dois (5,3%) apresentaram isquemia irreversível, necessitando de ressecção intestinal. CONCLUSÃO: A presença de dor abdominal recorrente é um dos principais indicadores para o diagnóstico de HI após BGYRL. Pacientes operados em estágios precoces, mesmo quando os exames de imagem se apresentam negativos, se beneficiam de procedimentos rápidos e simples, sem grandes complicações.