Abdominal Wall Pseudohernia After Shock Wave Lithotripsy: A Rare Cause of Abdominal Wall Bulging

Introduction Abdominal wall pseudohernia (AWP) is a marked protrusion of the abdominal wall due to neuropathy or denervation. It is a well-known complication of abdominal surgery, herpes zoster infection, diabetes and iatrogenic trauma. Here we present the first case of AWP after shock wave lithotripsy (SWL). Case report A 59 years old male presented with symptomatic left flank bulging. He had undergone SWL in 2003 due to a left kidney stone. He had no previous history of abdominal surgery or blunt abdominal trauma. He presented with pain and weightlifting impairment. CT-scan showed muscular atrophy on the left side of the abdominal wall, but no hernia defect (Figure 1). A lateral incision on the bulging area was performed. Muscular atrophy and fatty infiltration were observed. The preperitoneal space was dissected from the retrodiaphragmatic space down to Retzius space, laterally to quadratus lumborum and psoas muscle and medially until linea alba. For reconstruction double preperitoneal mesh technique was used: a biosynthetic resorbable mesh of polyglycolide:trimethylene carbonate copolymer (PGA:TMC) (20 × 30 cm) and a polypropylene mesh (45 × 40 cm). He was discharged after 5 days, without complications. Pathology exam showed myofibers’ atrophy and mature adipose tissue with isolated skeletal muscle. He presented no pain and no clinical relapse after 6 months follow-up. Discussion and Conclusion There are cases of AWP reported after percutaneous nephrolithotomy, videoassisted thoracoscopy or spine surgery, but no case of AWP after SWL was ever reported. CT-scan shows muscular atrophy without hernia defect. Given AWP’s low incidence the optimal approach is controversial, leaving surgery mainly for symptomatic cases.