Yoshimura Tomohiro, Hayami Shinya, Miyamoto Atsushi, Nakamura Kensuke, Tachibana Satsuki, Shimizu Atsushi, Kitahata Yuji, Sato Masatoshi, Matsumoto Kyohei, Asamura Shinichi, Kawai Manabu
Second Department of Surgery, School of Medicine, Wakayama Medical University, Wakayama, Wakayama, Japan.
Department of Plastic Surgery, School of Medicine, Wakayama Medical University, Wakayama, Wakayama, Japan.
Surg Case Rep. 2025;11(1). doi: 10.70352/scrj.cr.24-0124. Epub 2025 Jul 17.
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.
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.
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.
切口疝是包括腹腔镜肝切除术在内的腹部手术后的并发症之一。肝切除术后常出现顽固性腹水，尤其是严重肝硬化患者。在本研究中，我们报告了一例因大量腹水压迫导致切口疝破裂的病例，该病例通过股前外侧（ALT）皮瓣成功修复。
一名78岁男性患有肝细胞癌，接受了腹腔镜左外叶切除术。住院期间及出院时术后短期内无并发症，但术后约5个月，逐渐出现大量顽固性腹水，对利尿剂耐药。最终，脐部切口瘢痕处的切口疝因腹水的强烈压迫而破裂。术后1年，可见脐部皮肤穿孔，肠管脱出。使用人工假体进行疝修补有感染腹水并导致腹膜炎的风险。因此，我们与整形外科医生合作，计划使用ALT皮瓣进行切口疝修补。疝囊与小肠之间存在严重粘连，因此我们必须仔细解剖找到腹直肌鞘缺损边缘。切除疝囊后，可连续缝合关闭腹膜。整形外科医生获取的ALT皮瓣通过腹股沟皮下隧道提起，围绕旋股外侧动脉保留的穿支旋转。然后，我们缝合腹直肌鞘边缘和ALT皮瓣。手术时间为265分钟，术中出血量为15毫升。术后，患者疝症状明显改善，术后第16天出院，无任何并发症。通过使用利尿剂和无细胞浓缩腹水回输疗法，腹水得到缓解。
顽固性腹水在肝切除术后的肝硬化患者中常常是一个问题，当合并腹壁切口疝时可能变得难以治疗。我们成功地使用ALT皮瓣进行了疝修补，未使用人工材料治疗由顽固性腹水引起的切口疝破裂。
