INTRODUCTION
Previous abdominal surgeries often cause intraabdominal adhesions. This has been shown to have adverse effects on consequent surgeries and perioperative care of the patients[1,2]. In laparoscopic surgery, studies have shown that previous abdominal surgeries prolong the duration of the operation, increase postoperative complication rates, and increase the necessity to convert to open surgery[3-5]. However, none of them reported any difference in the success rates of the operations.
Morbid obesity incidence is increasing worldwide, and it has become a global public health problem[6]. Bariatric surgery is the gold-standard treatment option that reduces the time-dependent mortality of obese patients and provides a means for sustained weight loss and control[7]. The results of a study by Major et al[8] have shown that previous abdominal surgeries in patients with morbid obesity do not affect the excess body weight loss and complication rates following sleeve gastrectomy (LSG) and Rou-en-Y gastric bypass (RYGB). However, the duration of the operation and the length of hospitalization were longer in patients who had previous abdominal operations.
Liver transplantation is a lifesaving procedure that is the gold standard treatment for end-stage liver disease and primary liver cancers[9]. In many countries including Japan, Korea, India, and Turkiye, deceased donor liver donation is not enough, and living donor liver transplantation is the only means of providing the necessary liver grafts to the patients on the waiting list[10]. The majority of donor hepatectomies are performed through laparotomy using the Makuuchi incision which results in big incisions. Studies indicate that wound size and suture length directly affect the risk of incisional hernia[11,12]. The reported incidence of incisional hernia among living donors following living donor nephrectomy is nearly 10%[13]. However, there are not enough studies evaluating the prevalence of incisional hernia among living liver donors. The rates of incisional hernia following liver transplantation are reported to range between 7%-20%. However, most of these studies were performed on the recipients[14]. Living donor hepatectomies involve hepatectomy of the right lobe of the liver which causes left lobe hypertrophy and severe abdominal adhesions[15,16]. This causes a significant problem in subsequent surgeries in the upper abdomen.
We herein present the case of a young male patient, who, two years after a living donor hepatectomy, was admitted for a giant incisional hernia and morbid obesity. His complex surgical history, including severe abdominal adhesions, necessitated a demanding sleeve gastrectomy.
CASE PRESENTATION
Chief complaints
A 30-year-old male patient was admitted to our department for incisional hernia and morbid obesity. The main complaint of the patient was an incisional hernia. The incisional hernia was extensive, and there was a loss of abdominal domain. The patient needed to lose weight before performing a safe incisional hernia repair.
History of present illness
The medical history showed that the patient had donated the right lobe of his liver to his father 10 years ago. Right donor hepatectomy was performed through a Makuuchi incision.
History of past illness
Over the past ten years, the patient has progressively gained weight due to psychological stress and binge eating episodes. Before donor hepatectomy, his weight was 91 kg, his height was 184 cm, and his body mass index (BMI) was 26.9 kg/m2. The patient underwent reoperation due to intraabdominal bleeding on the 2nd postoperative day after donor hepatectomy and was then discharged after 38 days of hospitalization. His time in the intensive care unit was extended due to the reoperation. He weighed 56 kg, and his BMI was 16.5 kg/m2 at the time of his discharge.
Personal and family history
The patient had a gradual weight gain in the past 10 years. He underwent two incisional herniorrhaphy operations in 2016 and 2020. He weighed 110 kg when a massive earthquake occurred in his hometown. The patient had to move out of his hometown, which contributed to his psychological stress. The binge eating episodes increased, and his body weight increased. At the time of our evaluation, his body weight was 136 kg, his height was 184 cm, and his BMI was 40.7 kg/m2.
Physical examination
Our physical examination showed that the donor hepatectomy was performed through a Makuuchi incision, and the fascial defect was 19 cm × 15 cm in size. The loss of domain was extensive because most of the abdominal organs herniated into the incisional hernia sac.
Laboratory examinations
The laboratory tests were normal.
Imaging examinations
Computed tomography scans showed a 19 cm × 15 cm fascial defect (Figure 1). The abdominal and visceral fat caused a tight abdomen, making the incisional hernia repair very difficult due to the loss of domain. We informed the patient about the risks of bariatric surgery and proposed a staged approach, including sleeve gastrectomy followed by an incisional hernia repair after he lost a considerable amount of weight.
Figure 1 Computed tomography images.
A: Computed tomography (CT) images of abdominal hernia in axial section; B: CT images of abdominal hernia in coronal section.
OUTCOME AND FOLLOW-UP
On postoperative day 1, the patient experienced trocar site bleeding at the 10-mm port site where the drain was inserted. This was managed conservatively, and the patient was discharged on postoperative day 5. At the 30-day follow-up, the patient had lost 27 kg.
DISCUSSION
LSG is one of the most frequently performed bariatric procedures. It is effective in treating obesity and associated diseases[17]. However, LSG is more demanding in patients with upper abdominal surgery and associated adhesions[18]. This also has significant implications for patients undergoing RYGB. Approximately 0.020% of planned RYGB procedures are converted to LSG due to massive adhesions. Furthermore, Major et al[8] reported that patients with previous abdominal surgeries undergo LSG more frequently compared to those without.
Donor hepatectomy following LSG is also reported frequently[19,20]. Bariatric surgery, such as sleeve gastrectomy or gastric bypass, is increasingly used to address fatty liver disease in potential living liver donors prior to hepatectomy[20-23]. It also reduces perioperative morbidity for living liver donors[20]. Similarly, concomitant sleeve gastrectomy and hepatic resection have been proposed for patients with hepatocellular carcinoma associated with non-alcoholic fatty liver disease and metabolic syndrome[24].
Treatment of ventral hernia in morbidly obese patients is very challenging[25]. There is an increased risk of wound site complications such as seromas, hematomas, and surgical site infections leading ultimately to an increased risk of recurrences[25]. Therefore, performing bariatric surgery before any ventral hernia repair in selected patients may increase the success rate of the operation[25]. To minimize the risk of complications, we selected a relatively adhesion-free area in the left upper quadrant for initial abdominal insufflation. Following insufflation, a 10-mm trocar was carefully inserted for the camera, and adhesiolysis was performed to create sufficient space for the placement of additional working trocars (Figure 2). Importantly, the Veress needle was removed under direct vision to ensure that no injuries occurred during its insertion. We believe that this technique is particularly useful for laparoscopic procedures in patients with a history of multiple abdominal surgeries and extensive adhesions (Figure 3).
Figure 2 Locations of the trocars.
(C) Camera port (10 mm) inserted 2 cm left to the umbilicus; (W1) Working port 1 (15 mm) inserted at the midclavicular line in the right upper quadrant; (W2) Working port 2 (12 mm) inserted at the anterior axillary line on the left; (A) Assistance port (5 mm) inserted at the intersection of the midclavicular line and the subcostal margin.
Figure 3 Laparoscopic view and total number and sizes of cartridges used during sleeve gastrectomy.
A: Dissection of the lesser omentum by division of the gastrocolic ligament; B: The number and size of endoscopic cartridges used during laparoscopic sleeve gastrectomy.
Repairing ventral hernias with loss of domain is challenging, particularly in obese patients who are more prone to both primary and incisional ventral hernias due to increased intraabdominal pressure and comorbidities that can impair wound healing[26]. Many surgical techniques have been proposed to repair giant ventral hernias[27-30]. In contrast to staged procedures, single-step abdominal wall reconstruction techniques frequently involve the use of acellular dermal matrix mesh to provide immediate fascial reinforcement and support[27,28]. On the other hand, various multiple-step procedures have been proposed for complex ventral hernias, often involving a staged approach that includes preoperative progressive pneumoperitoneum with or without botulinum toxin A, or tissue expansion with progressively larger expanders[29-30]. Multi-step procedures aim to increase abdominal wall compliance and facilitate fascial closure[29]. Bariatric surgery has been proposed as the first step in multi-step procedures for obese patients with complex ventral hernias to reduce abdominal and visceral adiposity[26,30].
Complex ventral hernia repair following liver transplantation has been reported in the literature, with several studies describing the use of various surgical techniques, including component separation and mesh reinforcement[31-33]. While complex ventral hernia repair following liver transplantation has been reported, these studies have focused exclusively on hernia repair in liver recipients. Furthermore, laparoscopic ventral hernia repair has been shown to be safe and effective in recipients reported from a high-volume center[33]. Despite the increasing prevalence of complex ventral hernias, there is a paucity of data regarding their surgical management in living liver donors. This case report presents a unique approach to the management of a complex ventral hernia with loss of domain in a living liver donor, utilizing bariatric surgery as the initial step in a multi-step procedure (Figure 4).
Figure 4
The surgical specimen.
CONCLUSION
In conclusion, this case demonstrates the feasibility and safety of sleeve gastrectomy as the initial step in a multi-step approach to complex ventral hernia repair in a living liver donor with a loss of domain. While technically demanding, this approach can be successful with careful preoperative planning and meticulous surgical technique by a team experienced in minimally invasive surgery.
