Open Flank Hernia Repair

Flank hernias can be divided broadly by etiology into hernias that are congenital in nature and hernias that are acquired, often after previous surgery or trauma. Congenital flank hernias, also known as lumbar hernias, are less common than the acquired type and can be subclassified into superior triangle (Grynfeltt) or inferior triangle (Petit) defects. Acquired flank hernias can develop after previous operations, such as iliac bone harvest, trauma, retroperitoneal aortic surgery, or nephrectomy. The anatomic proximity of flank hernias to bony prominences and major neurovascular structures presents a challenge in the durable repair of these hernias. Specifically, the proximity of these lesions to the iliac crest and 12th rib can often limit the amount of tissue present for adequate mesh-tissue overlap.

When considering surgical repair of flank hernias, a computed tomography (CT) scan of the abdomen and pelvis should be performed. Most importantly, CT scan distinguishes a true hernia from a pseudohernia (eg, abdominal wall laxity from denervation after division of the lower thoracic nerves). In addition, a CT scan is essential not only to understanding the patient’s specific anatomy but also for delineating the presence of previous mesh repairs. It also shows the structure of remaining bone because there may be alterations secondary to previous operations in this area. This information is important for planning the appropriate location for prosthetic deployment and any fixation or overlap issues that might arise.

Preoperative counseling detailing the risks of nerve injury leading to numbness, weakness, or chronic pain as well as the risks for vascular and intra-abdominal injury is important.

Given the large incision and extent of dissection, these patients may benefit from the preoperative placement of an epidural catheter for postoperative pain management if no other contraindications exist. Routine preoperative antibiotics for skin flora should be administered.