Ventral Hernia Strangulation After Insufflation for Laparoscopic Procedure: A Case Report

Hernias develop from fascial or muscle weakness in the abdominal wall from increased intraabdominal pressure or can be acquired congenitally [1]. The majority of hernias are reducible, where the contents within the hernia can be manually pushed back into the abdominal cavity; however, some can become incarcerated, where their contents are no longer able to be manually placed back inside the abdominal cavity, as seen in our patient whose hernia was chronically incarcerated [1]. Incarcerated hernias, if not causing pain or bowel obstruction are not surgical emergencies, but do have a risk of progressing to strangulation, in which the blood supply to intestines becomes compromised, resulting in ischemic bowel, that necessitates emergency surgical intervention [1, 18]. Once the hernia becomes strangulated and has created a closed loop of ischemic bowel, emergency surgery is required.

For patients undergoing laparoscopic procedures, insufflation or pneumoperitoneum is created using trocars and a gas, generally carbon dioxide [7].  There are different levels of pressure that can be utilized during laparoscopic procedures including low, medium, and high pressure measuring 5-7 mm Hg, 12-15 mm Hg, and >20 mm Hg respectively, although the majority of laparoscopic procedures require at around 15mmHg [8, 9, 12, 21]. When insufflating the peritoneum, the hernia sac may also increase in size [13, 14, 15]. In fact, this is utilized in preoperative progressive pneumoperitoneum which is used for patients with complex hernias with significant loss of domain, an intervention that our patient may have benefited from when undergoing herniorrhaphy in a non-acute setting [14,15]. This allows for closure of the abdominal wall to be tension-free despite the large loss of domain [13]. Many incarcerated and strangulated hernias are still managed with an open procedure [17]. One complication of insufflation includes changes in hemodynamic stability including bradycardia, decreased cardiac output, and increased preload and afterload [4]. There is evidence these effects can be decreased when using low pressures and titrating the increase in pressure more slowly [10, 11]. Other complications of pneumoperitoneum include carbon dioxide embolism, increased airway pressures, pneumothorax, hypercarbia, hypoxemia, subcutaneous emphysema, and a decrease in pulmonary compliance [4].

Although there are no absolute contraindications to laparoscopic insufflation, current guidelines by the International Endohernia Society for relative contraindications to laparoscopic procedure include patient age and hernia size [5]. This study by Bittner et al. outlines that patients with an increased age are at a higher risk for complications due to laparoscopic insufflation and that hernias greater than 10 centimeters are more likely to recur when fixed with a laparoscopic approach when compared to an open approach [5]. Another study by Srivastava and Niranjan recommends guidelines for determining if a patient should or should not undergo laparoscopic insufflation [7]. These guidelines detail safe practices to reduce complications during laparoscopic procedures and recommend that patients with cardiopulmonary compromise should not undergo these procedures without high-risk informed consent [7].

Currently, there are no guidelines or contraindications to performing laparoscopic procedures in patients with known hernias and little data exists in current literature on acute incarceration and strangulation of hernias [5]. Similarly, there has yet to be a universally accepted mechanism to describe hernias as small, medium, or large; although, Muyusoms et al. proposes a classification system for abdominal wall hernias by the European Hernia Society [16]. Each of these makes studying the effect of insufflation on known hernias difficult. However, due to the severity of a strangulated hernias and the measures that must be taken to minimize mortality and complications in such cases, there should be more exploration into risk factors that causes hernias to become strangulated including the use of insufflation. In the setting of known abdominal hernia prior to laparoscopic procedures, consideration should be given to the potential increased rate of hernia complications post-operatively including incarceration and strangulation.