Anterolateral Thigh Flap Repair of Ruptured Incisional Hernia with Intractable Ascites after Laparoscopic Liver Resection: A Case Report

Abstract

INTRODUCTION: Incisional hernia is one of the postoperative complications after abdominal surgery including laparoscopic liver resection. There is often intractable ascites after liver resection, especially for patients with severe cirrhosis. In the present study, we report the case of ruptured incisional hernia due to the pressure from massive ascites, which was successfully repaired using an anterolateral thigh (ALT) flap.

CASE PRESENTATION: A 78-year-old man had hepatocellular carcinoma and underwent laparoscopic left lateral sectionectomy. There was no short-term postoperative complication during hospital stay and at discharge, but approximately 5 months postoperatively, massive ascites gradually accumulated that was intractable, and resistant to diuretic drugs. There was eventually rupture of incisional hernia at the umbilical port scar, caused by strong compression from this ascites. One year postoperatively, the umbilical skin was seen to be perforated and there was intestinal prolapse. Hernia repair using artificial prosthesis was at risk of infecting ascites and leading to peritonitis. In collaboration with plastic surgeons, we therefore planned incisional hernia repair using an ALT flap. There was severe adhesion between the hernia sac and the small intestine, therefore we had to find the edge of the defective rectus sheath with careful dissection. After resection of the hernia sac, the peritoneum could be closed by continuous suture. The ALT flap obtained by plastic surgeons was elevated through an inguinal subcutaneous tunnel, rotating around the preserved perforator of the lateral circumflex femoral artery. Then, we sutured the edge of the rectus sheath and the ALT skin flap. Operation time was 265 min and the amount of intraoperative bleeding was 15 mL. After the operation, the patient felt dramatic improvement of hernia symptoms and he was discharged on the 16th postoperative day without any complications. Ascites was resolved by use of diuretic drugs and cell-free and concentrated ascites reinfusion therapy.

CONCLUSIONS: Intractable ascites is often a problem in cirrhotic patients after liver resection and can become difficult to treat when complicated by abdominal wall incisional hernias. We successfully performed hernia repair using an ALT flap without the use of artificial materials for ruptured incisional hernia caused by intractable ascites.