Incisional Hernia Repair After Left Nephrectomy With Component Separation Using Transversus Abdominis Release (Tar) Technique

Abstract Aim To present a difficult case of an incisional hernia repair in left lateral abdomen requiring a dissection respecting the anatomical planes and important structures. Material and Methods An 82-year-old woman with osteoarthritis, colonic diverticulosis, hypertension and a BMI of 37 presented to the outpatient clinic with symptoms of back pain and a large incisional hernia post left laparoscopic nephrectomy. On clinical examination the hernia was large and irreducible containing bowel and very close to the iliac crest. The CT scan of the abdomen and pelvis showed a defect of 5.5 cm. This was the area of the removal of the specimen (left kidney) Procedure Incision on previous one and extended medially. Dissection of hernia sac. Sac was preserved. Defect was on the lateral edge of rectus abdominis and oblique muscles. Identification of inferior epigastric vessels on the left, close to the linea semilunaris. Vessels were preserved. Preperitoneal plane was created (pretransversalis fascia) and dissecting medially, arcuate line was recognised and preserved. Posterior sheath of the rectus abdominis was dissected and followed laterally. Dissection continued by releasing the transversus abdominis and entering the posterior fascia (TAR plane). Left Iliohypogastric nerve was recognised and preserved. Dissection towards left superior iliac crest. Preperitoneal plane was dissected towards the left inguinal ligament and linked with the preperitoneal plane that was created medially, before. Closure of the fascias aiming to close the peritoneal cavity by suturing together the lateral border of the posterior rectus sheath, the posterior transversus abdominis fascia and the pretransversalis fascia lower (Use of a continuous absorbable suture). In order to protect the inferior epigastric vessel and the dichypogastric nerve from the mesh, the remnant of the preserved sac was used posteriorly. A 15 × 15 lightweight microporous polypropylene mesh was used in the retrorectus/retro-transversus abdominis/retro- internal oblique muscles area – no fixation was used. A 14 Fr redivac drain was used at the area of the placement of the mesh (Medial drain). Closure of the anterior fascias of the left rectus abdominis/External oblique and the internal oblique's aponeurosis with non-absorbable suture. Results The patient's postoperative course included a seroma detected on postoperative day 5, which was drained by interventional radiology. She was discharged on postoperative day 9. Unfortunately, she had to be readmitted 2 weeks later with a painful recurrent seroma that required drainage under ultrasound guidance. At 3 months follow-up the patient is well and asymptomatic. Conclusion A good knowledge of the anatomy is crucial for hernia repairs involving several different planes and located in the lateral abdominal wall, especially if the patient is obese. Seroma is a common and acceptable complication and mesh infection can be avoided depending on the technique used during the repair and the position of the mesh. A surgeon with an interest and experience in abdominal wall surgery can offer a safe and efficient approach to these cases.