Hernia Heptathalon

Document Type

Conference Proceeding

Publication Date

4-2025

Publication Title

Surgical Endoscopy

Abstract

Presentation: The patient is a 72-year-old female who presents with chronic bilateral lower abdominal pain. She has a history of chronic pain with daily narcotic use and is a 50-pack year smoker. There is no history of previous hernia repairs. On exam, she has a reducible left inguinal hernia. CT imaging demonstrated bilateral inguinal hernias, a right Spigelian hernia, as well as an anterior diaphragmatic hernia containing transverse colon. After cessation of tobacco use for six weeks, a minimally invasive-robotic assisted surgical repair of her inguinal and diaphragmatic hernias was offered.

Operative Approach: Three 8 mm robotic trocars were placed across the abdomen. Five separate hernia defects were noted in the lower abdomen: a Pantaloon hernia and incarcerated obturator hernia on the left, and Spigelian, incarcerated obturator and femoral hernias on the right. Bilateral TAPP inguinal hernia repairs were performed with placement of a mid-weight mesh. The Spigelian defect, containing pre-peritoneal fat, was approximated with barbed suture. The robot was rotated 180 degrees for repair of the diaphragmatic hernia. The transverse colon was reduced from the mediastinum and the falciform ligament divided. The hernia sac was reduced and divided. The final defect measured 9 cm 9 5 cm and was repaired using multiple interrupted horizontal mattress permanent sutures without undue tension. An underlay coated permanent mesh was placed.

Post-Operative Course: The patient was admitted overnight and had an uneventful postoperative course. She continued to do well postoperatively, with resolution of her chronic lower abdominal pain.

Discussion: Obturator and femoral hernias are rare, with a prevalence of 1–4% and less than 1%, respectively. Both are typically found in elderly patients, more commonly in women. Anterior (Morgagni) diaphragmatic hernias are particularly rare, constituting 1–3% of all congenital diaphragmatic hernias. Morgagni hernias may go undiagnosed until adulthood if symptomatic. Unlike inguinal hernias, which require repair once symptomatic, operative repair of femoral, obturator, and diaphragmatic hernias are recommended when identified. The simultaneous presence of an inguinal, obturator, femoral, Spigelian and diaphragmatic hernia with subsequent repair in the same patient has not been reported in the literature. Here we reported a unique case in which six separate hernias are repaired concurrently via robotic approach. Although a rare case, the Xi robotic system proved advantageous, allowing surgical repair deep within the pelvis to high on the diaphragm without moving ports, the patient, or the robot.

Volume

39

Issue

Suppl 1

First Page

S440

Last Page

S441

Comments

SAGES Annual Meeting, March 12–15, 2025, Long Beach, CA

DOI

10.1007/s00464-025-11690-9

ISSN

1432-2218

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