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Post-Reconstructive "Paraomental" Hernias: A New Repair For A New Problem

Jeffrey H. Donaldson, Thomas B. Brady
Maine Medical Center, Portland, ME

Objectives:
To describe a new type of abdomino-thoracic hernia that has emerged along pedicled omental flaps used for chest reconstruction and to offer a safe method for definitive repair.
Design:
Case series; retrospective chart review; surgical literature search.
Setting:
Tertiary medical center and teaching hospital.
Patients:
Sixty-one patients underwent laparoscopic omental flap harvest and reconstruction of complicated sternal wounds after cardiothoracic surgery. Of these, four males and three females aged 53 to 80 years were operated for paraomental herniation of abdominal contents into the chest.
Interventions:
Laparoscopic hernia reduction, omental pedicle ligation and mediastinal/diaphragmatic defect repair with prosthetic mesh.
Main Outcome Measures:
Restoration of anatomy, alleviation of symptoms and prevention of recurrence.
Results:
Pre-operative hernia symptoms included palpable/visible mass, pain and nausea. The mean time between omental flap procedure and onset of symptoms was seven months. All patients were operated laparoscopically, with a mean operative time of 164 minutes. The mean defect size was 30 cm2; a mean 175 cm2 of prosthetic mesh was used for repair. Mean length of post-operative hospital stay was three days. The first two patients were repaired with mesh overlying an intact omental pedicle -- both had recurrence. The last five were repaired by ligation of the pedicle and complete defect coverage -- these have not recurred, and the flaps remain viable.
Conclusions:
This is the first series to describe post-reconstructive paraomental hernias and their definitive repair. Laparoscopic pedicle ligation and prosthetic mesh overlay appear to be safe and effective for treating this unique complication.

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