Delayed Abdominal Pseudohernia in Young Patient After Lateral Lumbar Interbody Fusion Procedure: Case Report

Abdominal pseudohernia in a child after surgical correction of congenital scoliosis: case report

Abdominal wall relaxation is a rare complication of various surgical procedures or diseases, when the intercostal or upper lumbar nerves are affected, and the innervation of the muscles of the abdominal wall is damaged. The result is a mass that can visually mimic a ventral hernia. We present a clinical case and the results of a literature review on this topic.

Clinical case

The 2 years 5 months patient diagnosed with a congenital deformity of the spine (posterolateral hemivertebra) underwent extraction of the hemivertebra from the retroperitoneal approach. In the postoperative period, a pseudohernial protrusion of the anterior abdominal wall was observed. 4.5 months later the protrusion resolved spontaneously.

Discussion

Abdominal wall relaxation is studied worldwide and is presented primarily as clinical case reports, mainly in older patients with neurological diseases. Single cases of this pathology are described among children. The Th10-Th12 roots are most often affected. Possible manifestations include: bloating and abdominal pain, pseudo-obstruction of the small and/or large intestine, and constipation. In the described case, only unilateral bloating at rest was observed, which increased with crying and strain. The natural course and prognosis of this diagnosis are usually favorable-the recovery period, according to the literature, takes an average of 4-5 months, which also coincided with our case.

Conclusion

Pseudohernias are a rare complication and may can occur during correction of spinal deformities in children. This condition is a transient disorder of the anterior abdominal wall muscles, the cause of which may be neuropathy caused by infection, metabolic disorders, or mechanical damage. The main principles of treatment of this condition include active observation and symptomatic therapy. The prognosis is usually favorable.

Lateral Lumbar Interbody Fusion: Review of Surgical Technique and Postoperative Multimodality Imaging Findings

The lateral lumbar interbody fusion (LLIF) approach is a minimally invasive surgery that can be used as an alternative to traditional lumbar interbody fusion techniques. LLIF accesses the intervertebral disk through the retroperitoneum and psoas muscle to avoid major vessels and visceral organs. The exposure of retroperitoneal structures during LLIF leads to unique complications compared with other surgical approaches. An understanding of the surgical technique and its associated potential complications is necessary for radiologists who interpret imaging before and after LLIF. Preoperative imaging must carefully assess the location of anatomic structures, including major retroperitoneal vasculature, lumbar nerve roots, lumbosacral plexus, and the genitofemoral nerve, relative to the psoas muscle. Multiple imaging modalities can be used in postoperative assessment including radiographs, CT, CT myelography, and MRI. Of these, CT is the preferred modality, because it can assess a range of complications relating to both the retroperitoneal exposure and the spinal instrumentation, as well as bone integrity and fusion status. This article describes surgical approaches for lumbar interbody fusion, comparing the approaches' indications, contraindications, advantages, and disadvantages; reviews the surgical technique of LLIF and relevant anatomic considerations; and illustrates for interpreting radiologists the normal postoperative findings and potential postsurgical complications of LLIF.

[Abdominal pseudohernia: diagnosis and treatment]

OBJECTIVE

To present an effective treatment strategy for abdominal pseudohernia considering own clinical experience and literature data.

MATERIAL AND METHODS

The authors report surgical treatment of 2 patients and therapeutic management of 1 patient with abdominal pseudohernia. Moreover, current state of this problem is analyzed according to literature data in Pubmed, Google and e-library databases.

RESULTS. P

Seudohernia is followed by asymmetrical protrusion of abdominal wall, prolapsed site is not involved in breathing; patients cannot tense muscles in the affected area. T8-L2 skin sensitivity impairment or hyperesthesia may be observed. Denervation is confirmed by electroneuromyography. Ultrasound, CT and MRI reveal no defect in abdominal wall. However, its thinning within denervation area is visualized. Treatment is determined by the cause and reversibility of denervation. If mechanical damage (intersection) of T8-L2 nerves following trauma or any manipulation is absent, the main cause is herpes zoster neuropathy. Surgical treatment is not indicated. Antiherpetic therapy and physical therapy result functional restoration of abdominal wall muscles within 2-4 months. In case of mechanical cause of pseudohernia, it is advisable to wait at least a year after denervation for real assessment of situation. Partial or complete re-innervation is possible throughout this period. Surgical treatment is indicated if re-innervation is absent. An effective technique presented in this manuscript is reconstruction of the prolapsed area with several imbrication sutures in several planes up to symmetry with contralateral area with subsequent reinforcement with a mesh implant if necessary. There were no relapses in 2 our patients within 5 and 7 years, respectively.

CONCLUSION

In our opinion, this report is the first manuscript devoted to systematic analysis of diagnosis and treatment of abdominal pseudohernia in available literature. Surgical treatment is not indicated for postherpetic pseudohernia. It is carried out for pseudohernia persisting for more than 1 year if its cause is trauma or any manipulation.

Lateral and Oblique Lumbar Interbody Fusion-Current Concepts and a Review of Recent Literature

PURPOSE

To review the relevant recent literature regarding minimally invasive, lateral, and oblique approaches to the anterior lumbar spine, with a particular focus on the operative and postoperative complications.

METHODS

A literature search was performed on Pubmed and Web of Science using combinations of the following keywords and their acronyms: lateral lumbar interbody fusion (LLIF), oblique lateral interbody fusion (OLIF), anterior-to-psoas approach (ATP), direct lateral interbody fusion (DLIF), extreme lateral interbody fusion (XLIF), and minimally invasive surgery (MIS). All results from January 2016 through January 2019 were evaluated and all studies evaluating complications and/or outcomes were included in the review.

RECENT FINDINGS

Transient neurological deficit, particularly sensorimotor symptoms of the ipsilateral thigh, remains the most common complication seen in LLIF. Best available current literature demonstrates that approximately 30-40% of patients have postoperative deficits, primarily of the proximal leg. Permanent symptoms are less common, affecting 4-5% of cases. Newer techniques to reduce this rate include different retractors, direct visualization of the nerves, and intraoperative neuromonitoring. OLIF may have lower deficit rates, but the available literature is limited. Subsidence rates in both LLIF and OLIF are comparable to ALIF (anterior lumbar interbody fusion), but further study is required. Supplemental posterior fixation is an active area of investigation that shows favorable biomechanical results, but additional clinical studies are needed. Minimally invasive lumbar interbody fusion techniques continue to advance rapidly. As these techniques continue to mature, evidence-based risk-stratification systems are required to better guide both the patient and clinician in the joint decision-making process for the optimal surgical approach.

Complication avoidance in minimally invasive spinal surgery

Minimally invasive techniques in spinal surgery allow surgeons to perform operations with less of the approach-related morbidity inherent to traditional open procedures. Yet these muscle-sparing procedures come with a unique set of risks that stem from the novel approaches, limited exposure, and/or a restricted working corridor that they employ. The literature suggests that these operations can be performed without an increased rate of complication once the associated learning curve has been surmounted, suggesting that knowledge of and experience with the nuances of these procedures are essential for patient safety. The present article describes the complications specific to a variety of minimally invasive spinal surgeries and provides guidance on how to avoid them.

Delayed Incisional Hernia Following Minimally Invasive Trans-Psoas Lumbar Spine Surgery: Report of a Rare Complication and Management

Background

Lateral lumbar interbody fusion (LLIF) has proved to be a safe tool in the armamentarium of spine surgeons for a variety of lumbar disorders. However, it has some complications related to specific approaches. Incisional hernia following abdominal surgery and anterior spinal surgery is commonly described; however, it is extremely rare following LLIF, with only 1 case reported in short postoperative period. In this report we present the first case of delayed presentation of true incisional hernia following a LLIF procedure and highlight its presentation, mechanism, possible preventive measures, and management.

Methods

We report a 57-year-old lady who underwent L3-4 LLIF. She presented with vague pain in a healed scar area that had no swelling until two years postsurgery, when she developed a painful swelling. On examination, it appeared to be a herniation of abdominal contents.

Results

She underwent a laparoscopic hernia repair surgery. The muscular layers were found to be intact with an attenuated transversalis fascia layer. The repair was reinforced by polypropylene mesh. There was no recurrence at the 6-month follow-up.

Conclusions

Incisional hernia can occur following LLIF months to years following surgery and can have varied presentation. Tight external oblique closure should be performed because the transversalis fascia often cannot be repaired and the quality of a layered closure of the deep obliques is often disappointing. The treating surgeon should be aware of this complication and aggressively surveil for the warning signs, and patients should be counseled about this potential complication.

Stereotactic navigation for the prepsoas oblique lateral lumbar interbody fusion: technical note and case series

The prepsoas retroperitoneal approach is a minimally invasive technique used for anterior lumbar interbody fusion. The approach may have a more favorable risk profile than the transpsoas approach, decreasing the risks that come with dissecting through the psoas muscle. However, the oblique angle of the spine in the prepsoas approach can be disorienting and challenging. This technical report provides an overview of the use of navigation in prepsoas oblique lateral lumbar interbody fusion in a series of 49 patients.

Lateral Lumbar Interbody Fusion-Outcomes and Complications

PURPOSE OF REVIEW

Lateral lumbar interbody fusion (LLIF) is a relatively new, minimally invasive technique for interbody fusion. The goal of this review is to provide a general overview of LLIF with a special focus on outcomes and complications.

RECENT FINDINGS

Since the first description of the technique in 2006, the indications for LLIF have expanded and the rate of LLIF procedures performed in the USA has increased. LLIF has several theoretical advantages compared to other approaches including the preservation of the anterior and posterior annular/ligamentous structures, insertion of wide cages resting on the dense apophyseal ring bilaterally, and augmentation of disc height with indirect decompression of neural elements. Favorable long-term outcomes and a reduced risk of visceral/vascular injuries, incidental dural tears, and perioperative infections have been reported. However, approach-related complications such as motor and sensory deficits remain a concern. In well-indicated patients, LLIF can be a safe procedure used for a variety of indications.