Successful eTEP-TAR Repair of Incisional and Umbilical Hernias in a 52-Year-Old Patient

The Surgical Gastroenterology team at PACE Hospitals successfully performed an Extended Totally Extraperitoneal Repair (eTEP) with a Right Transverse Abdominis Release (TAR) on a 52-year-old male who had been struggling with a right subcostal incisional hernia and an umbilical hernia, aiming to improve recovery and minimize complications.

Chief Complaints

A 52-year-old male patient presented to the Gastroenterology Department at PACE Hospitals, Hitech City, Hyderabad, with complaints of swelling near the right subcostal region (located in the right upper quadrant of the abdomen). In addition, the patient had a concurrent umbilical hernia, further complicating his abdominal condition. The swelling in the subcostal region had progressively worsened over time, causing increasing discomfort.

Medical History

The patient had a known medical history of an open cholecystectomy performed in 2012 to remove the gallbladder, which was necessitated by complications such as gallstones or gallbladder inflammation. The open cholecystectomy involved making a larger abdominal incision to access and remove the gallbladder, a procedure typically chosen when laparoscopic methods were not feasible due to complications or the patient's specific condition. This surgical history was relevant to his current presentation, as the previous incision site likely contributed to the development of the right subcostal incisional hernia.

Right subcostal incisional hernia occurs at the site of a previous surgical incision, often due to abdominal wall weakness. An umbilical hernia involves protrusion of abdominal tissue through the abdominal wall at the belly button, which is common in both infants and adults. Both types may require surgical intervention to prevent complications like bowel obstruction or strangulation.

Diagnosis

Upon admission to PACE Hospitals, the patient's vital signs were stable, showing no immediate signs of distress. Following a thorough physical examination, the doctors identified swelling in the right subcostal region (in the right upper quadrant of the abdomen) along with the presence of an umbilical hernia.

Diagnostic tests, including ultrasound imaging and CT scans, later confirmed the diagnosis of a right subcostal incisional hernia and a concurrent umbilical hernia. The clinical findings, in combination with the patient's surgical history of an open cholecystectomy, helped establish the basis for the diagnosis and subsequent treatment plan.

Medical Decision Making (MDM)

After consulting with the interventional and consultant gastroenterologists, Dr. Suresh Kumar S, along with other consultants such as Dr. A Kishore Kumar, conducted a comprehensive evaluation was conducted to determine the most appropriate course of treatment for the patient.

Their collective expertise, drawing on years of experience in abdominal surgery and hernia repair, led to the conclusion that an Extended Totally Extraperitoneal Repair (eTEP) in combination with Right Transverse Abdominis Release (TAR) would be the most appropriate treatment for the patient's right subcostal incisional hernia and umbilical hernia. The decision was based on the need for a minimally invasive yet effective approach to managing both hernias while minimizing post-operative complications and promoting optimal recovery.

Surgical procedure

Upon admission, the patient was thoroughly evaluated and deemed fit for surgery. Following this assessment, the patient underwent an Extended Totally Extraperitoneal Repair (eTEP) in combination with Right Transverse Abdominis Release (TAR).

The procedure was planned carefully to address both hernias. During the procedure, the Extended Totally Extraperitoneal (eTEP) Repair, combined with a Right Transverse Abdominis Release, was chosen as the surgical method due to the complexity of the patient's right subcostal incisional hernia and umbilical hernia. This minimally invasive technique involved making small incisions, through which a laparoscope was inserted to repair the hernia without entering the peritoneal cavity. The Right Transverse Abdominis Release (TAR) procedure involved cutting the muscle layer (specifically the transverse abdominis muscle) for enhanced exposure and access to the hernia site.

During the surgery, mesh was used to reinforce the abdominal wall, ensuring a robust repair. The decision to combine these techniques was based on their ability to improve surgical outcomes by reducing recurrence rates and accelerating recovery time compared to traditional open surgery. This innovative approach was selected to provide the patient with the best possible results, minimizing potential complications and ensuring a faster return to normal activities.

Findings

During the procedure, the surgical team successfully accessed the eTEP plane, which is located posterior to the rectus muscle and anterior to the posterior rectus sheath, starting from above. 



Dense intra-abdominal adhesions were observed near the previous cholecystectomy site, likely a result of the patient’s prior gallbladder removal. 

A 6x6 cm hernial defect was found, with the omentum (fatty tissue) protruding through the defect Additionally, multiple small hernia defects were identified along the right subcostal and anterior abdominal wall, also containing omentum. 

The umbilical hernia was successfully closed using V-lock no. 1 sutures. A 45x45 cm Dynamesh was placed to reinforce the abdominal wall. 

However, complete mesh approximation could not be achieved, so a small midline incision was made to allow for proper buttressing of the mesh, ensuring a secure repair. This approach helped provide optimal support to the abdominal wall, reducing the risk of recurrence.

Postoperative Care

The procedure was smooth and without complications. On post-operative day 1 (POD-1), the patient was started on a liquid diet, which was gradually advanced to a soft diet as tolerated. However, during the recovery phase, the patient's creatinine levels were found to be elevated, along with the presence of proteinuria, which raised suspicion for drug-induced acute kidney injury (AKI) or an underlying kidney condition.

To investigate the renal concerns further, relevant investigations were conducted, including serum creatinine tests, urinalysis, and renal function tests. Based on the results, the patient was managed conservatively, with close monitoring of kidney function, ensuring appropriate treatment was provided to address any renal issues. This included adjusting medications and fluids as needed while ensuring optimal recovery from both the hernia surgery and renal concerns.

Discharge notes

The patient had a satisfactory postoperative recovery and was discharged in a hemodynamically stable condition. Before discharge, the patient received the discharge instructions.

Discharge Medications

Upon discharge, the patient was prescribed antibiotics, proton pump inhibitors (PPIs), pain relievers, laxatives, anticoagulants, mineral supplements, and opioids with instructions to continue a normal diet.

Advice on Discharge

The patient was advised to wear an abdominal binder for 6 weeks, avoid strenuous activities, and continue taking prescribed medications as directed.

Emergency Care

The patient’s guardians were informed to seek admission to the Emergency Ward of PACE Hospitals, if they observe any concerning symptoms, including fever, abdominal pain, or vomiting. These signs could indicate potential complications, such as infection, intestinal obstruction, or other post-operative issues, and Immediate medical attention would be necessary to address them promptly.

Review and follow-up notes

The patient was advised to follow up with the nephrologist, Dr. Kishore, after 1 week, along with the fundus examination report. Additionally, a follow-up appointment was scheduled at the Surgical Gastroenterology OPD after 1 week.

Department of Gastroenterology