Massive
ventral hernia with loss of abdominal domain is a particularly complex disease. We present a case of a massive
umbilical hernia with loss of abdominal domain containing the small bowel, colon, and spleen that presented with spontaneous
splenic rupture.
CASE REPORT: The patient was an 82-year-old Caucasian female with multiple comorbidities, on anti-coagulation for
cardiac dysrhythmia with a congenital
umbilical hernia with loss of abdominal domain which had progressed over multiple years. She presented to an outside hospital with history of a left-sided
abdominal pain accompanying
fatigue and weakness.A CT scan of the abdomen revealed an
umbilical hernia with loss of abdominal domain containing the patient's entire small bowel, colon, pancreas, and the spleen. The spleen had ruptured with associated
hemorrhage and
hematoma in the
hernia sac.Management included a multidisciplinary approach with particular attention to comorbidities and hemodynamic monitoring due to
splenic rupture. Given the need for lifetime anticoagulation, a
splenectomy was planned along with simultaneous abdominal wall reconstruction. The patient underwent an exploratory
laparotomy,
splenectomy, bilateral posterior component separation with transversus abdominis release, and a retrorectus/preperitoneal placement of heavy weight
polypropylene mesh.During the postoperative period, the patient remained intubated initially due to elevated airway pressures before transferring to the regular nursing floor. The remainder of the patient's
hospital stay was complicated by a postoperative
ileus requiring nasogastric tube
decompression and a DVT and PE necessitating anticoagulation. The
ileus eventually resolved and diet was slowly advanced. The patient was discharged on POD17.
DISCUSSION: To our knowledge, this is the first report in the literature describing a
splenic rupture that occurred within the
hernia sac of a congenital
umbilical hernia. This report serves to highlight that even with novel cases of massive and atypical
hernias, posterior component separation with transversus abdominis release is a reproducible repair that can be performed with good result in a variety of circumstances.