Incarcerated infraumbilical incisional hernia: a surgical challenge

Incisional hernia continues to be the most challenging type of hernia. Variability in the anatomy and supervening complications add to its complexity. Infraumbilical incisional hernias are usually due to gynecological operations. This may range from a scar of tubal ligation procedure to a Pfannenstiel incision or an infraumbilical scar of caesarian section. The sparse volume of strong anatomical structures in this region poses the biggest challenge during repair. A 54-year-old lady presented with a hernia arising from a scar of previous tubal ligation surgery. The hernia was irreducible with a large mass of omentum in the hernial sac. Laparoscopy was difficult to perform in view of the current state. Hence open surgery was performed. The technique used was creation of a preperitoneal space followed by creation of space between external oblique aponeurosis and underlying muscle. A mesh as placed between the muscular and aponeurotic layer. The post-operative course was uneventful with no recurrence. The anatomical basis of placing the mesh between the muscular and aponeurotic layer or intermediate placement technique is discussed. Creation of space below the aponeurotic level is pivotal in managing infraumbilical incisional hernia. Placing a mesh at this layer below the aponeurosis ensures least complications with excellent result.