Case Report: Complex Hernia Repair Involving Pelvic and Bladder Reconstruction

Presentation

A 64-year-old man was referred to Cleveland Clinic’s Digestive Disease & Surgery Institute for a second opinion on the repair of a large suprapubic hernia, complicated by the lack of a pubic symphysis. He was seen by Ajita Prabhu, MD, a general surgeon specializing in complex hernia surgery.

The hernia resulted from of a chain of events that began with robotic prostatectomy followed by radiation therapy to treat prostate cancer. Subsequently, the patient underwent a laparoscopic inguinal hernia repair. This was complicated by a bladder injury, requiring a cystectomy and the creation of an Indiana pouch. He later developed pubic osteomyelitis, necessitating resection of a large section of pubic symphysis bone. This resulted in a large lower midline incisional hernia with a substantial bony defect that contributed to the complexity of the case.

Formerly an active cyclist, the patient had difficulty walking at the time of his referral to Cleveland Clinic. His quality of life was further compromised by his inability to completely empty his bladder, often resulting in urinary leakage.

Planning

Due to the complexity of this patient’s anatomy, Dr. Prabhu requested consults with Nathan Mesko, MD, Center Director for Orthopaedic Oncology, and Hadley Wood, MD, a genitourinary reconstruction specialist and the Glickman Urological & Kidney Institute’s Vice Chair for Clinician Development.

After all three had met with the patient and reviewed imaging studies and lab tests, they discussed various approaches to the repair, which had not previously been described in the medical literature. To a great degree, its success would depend on reconstructing the pubic symphysis in a manner that would allow permanent placement of anchor points for the surgical mesh used to reinforce abdominal tissue.

After discussing four strategies, the team agreed on one approach, to which the patient consented.

Surgical Treatment

A large midline incision was made and adhesions resulting from previous surgeries released. The patient’s Indiana pouch was mobilized by the urology team, revised to address the patient’s incontinence issues, and temporarily relocated to the abdomen.

Dissection of the pelvis was challenging due to the adhesions and scarring from previous radiotherapy. Posterior component separation was performed on the right and left sides using transversus abdominus release to dissect back to the psoas muscle on both sides.

As dissection reached the pelvis, an attempt was made to take down the hernia sac, but it had adhered to the base of the penis and left testicle. With the help of the urologists, the hernia sac was resected from those structures. The sac was used as a bridge to close the obliterated peritoneum in the lower pelvis. A defect was created in the peritoneum on the patient’s right side and the Indiana pouch brought through.

The orthopaedic team subsequently reconstructed the anterior pelvis using an anterior limited contact dynamic compression plate secured with two 6.5 mm cannulated screws anchored into the anterior column of the pelvis. A 30 x 30 cm synthetic mesh was placed in abdomen in the retrorectus position and sutured directly to the 4-bolt anterior plate and to the remainder of the pubic rami on both sides using bony anchors.

A cruciate incision was made in the mesh, and the Indiana pouch was brought through and checked to ensure there were no kinks. The mesh was sutured on the right side of the abdomen, the fascia was closed and the stoma was matured by the urology team.

Outcome

The patient had an uneventful postoperative course and was discharged on day 8. He quickly returned to long-distance cycling and has had no further problems with bladder leakage.

Discussion

“This patient came to us with a unique problem that many institutions simply don’t have the experience and resources to address,” says Dr. Prabhu. “At our Comprehensive Hernia Center, we perform more than 3,000 hernia repairs a year and welcome complex patients like these.”

The primary challenge in this case was the absence of literature to guide the choice of technique used to restore the missing section of pubis in order to provide a location for fixating the mesh. Dr. Mesko developed several strategies that he shared with Dr. Prabhu, Dr. Wood and a trauma colleague before settling on the use of two screws and an anterior pelvic plate.

“By putting our heads together, we were able to come up with a workable solution that restored the patient’s quality of life,” says Dr. Prabhu.