Postoperative Flank Defects, Hernias, and Bulges: A Reliable Method for Repair

Background: Although there is a high incidence of flank defects after lateral abdominal access, there is a paucity of large studies discussing this problem. Most studies express nihilism regarding their surgical management. The goal of this study was to describe the authors' conceptualization of flank defects, with a determination of the number of true hernias versus bulges, and outcomes of surgical repair in these patients. Methods: The authors carried out a 13-year retrospective review of 31 consecutive flank defects repaired by the senior author (G.A.D.). Patients were treated with a 7.5-cm-wide macroporous polypropylene mesh and reapproximation of the abdominal wall to achieve a direct supported repair. There were 19 intraperitoneal placements and 12 placements between the external and internal oblique muscles or preperitoneal space. The prevalence of true hernia versus bulge at the time of repair was noted. Results: There were no surgical-site infections. Two patients developed minor bulges at the prior hernia site: one of these was repaired with additional mesh, and the other one was observed. One small asymptomatic recurrent hernia was noted incidentally on a follow-up computed tomographic scan. Initially, 10 patients had a complete hernia through all layers of the lateral abdominal musculature, 17 patients had dehiscence of the internal oblique and transversus abdominis muscles with an intact external oblique muscle, and four patients had denervation with all layers of the abdominal wall intact. Conclusions: Most flank defects represent true hernias rather than denervation injuries. Direct supported repair of flank hernias using mesh is a safe and effective technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.