Scientific letter
Uterine Incisional Hernia in a Pregnant Patient
Eventración uterina en paciente gestante
Violeta Camacho Marentea,
, Claudia Olivares Oliverb, Amando Marchal Santiagoc, Juan Antonio Martin Cartesd, Manuel Bustos Jimenezd
Corresponding author
a Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Puerta del Mar, Cádiz, Spain
b Servicio de Cirugía General y del Aparato Digestivo, Hospital San Juan de Dios del Aljarafe, Sevilla, Spain
c Servicio de Cirugía General y del Aparato Digestivo, Hospital Infanta Margarita, Córdoba, Spain
d Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Virgen del Rocío, Sevilla, Spain
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array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Eventración uterina en paciente gestante" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1517 "Ancho" => 1500 "Tamanyo" => 332910 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Incisional hernia with uterus inside, delivery and placement of preaponeurotic mesh.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Incisional hernia after abdominal surgery has an incidence between 5% and 15%.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Pregnancy after abdominal surgery is an independent risk factor for the development of an incisional hernia,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> and herniation of the gravid uterus through an incisional hernia is very rare.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Complications associated with the appearance of this condition during pregnancy as a possible incarceration or strangulation are a serious obstetric problem with important consequences for both the mother and the fetus.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Due to its low incidence, there is no consensus regarding management, which requires individualized treatment.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> In uncomplicated hernias, initial conservative management with abdominal wall repair either intrapartum or in a second stage seems to be a good option.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We present a case of incisional hernia of a gravid uterus in a 34-year-old pregnant patient, who was referred to our unit at week 30<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>1 for suspected uterine herniation. The patient had a history of a previous cesarean section with an infraumbilical midline laparotomy and grade III obesity (weight: 135.4<span class="elsevierStyleHsp" style=""></span>kg and BMI: 49.1) and was being monitored for her high risk of gestational diabetes.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The first trimester of pregnancy passed without incident, but in week 20 of gestation the patient experienced hypogastric pain that prevented her from sitting. During examination, an irreducible tumor was detected at the level of the cesarean section scar. An ultrasound of the abdomen during an office visit revealed a uterine hernia, with no alterations in the fetus.</p><p id="par0030" class="elsevierStylePara elsevierViewall">At week 30<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>1, our team was contacted for evaluation. During the examination, we observed an abdomen corresponding to the weeks of gestation and an incisional hernia through the infraumbilical scar, which became more evident with Valsalva maneuvers. The presence of uterine herniation was confirmed by follow-up ultrasound. Given the complexity of the case, we opted for a multidisciplinary approach with the gynecology team, proposing elective cesarean section, tubal ligation at the express request of the patient, and incisional hernia repair during the same operation, scheduled for week 38 of pregnancy.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Access was created through the previous incision, and the hernia sac was opened to access the uterus placed in forced anteversion position, which required manipulation to visualize the lower segment and conduct hysterotomy using a Kerr incision (transverse incision of the lower segment). The cesarean section was uneventful, giving birth to a live female fetus in transverse position; bilateral tubal occlusion was performed by simple ligation and partial salpingectomy. In the second stage of surgery, an M4W2 incisional hernia was observed (European Hernia Surgery classification) with an aponeurotic defect measuring 15<span class="elsevierStyleHsp" style=""></span>cm in length and 7<span class="elsevierStyleHsp" style=""></span>cm wide. Given the laxity of the abdominal wall, a repair was performed with primary closure using continuous suture of a caliber 0 slow-absorbing monofilament suture material following a 4:1 ratio, placement of a 25<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>15<span class="elsevierStyleHsp" style=""></span>cm polypropylene mesh onlay with a wide pore (1.5<span class="elsevierStyleHsp" style=""></span>mm) and low weight (60<span class="elsevierStyleHsp" style=""></span>g/m<span class="elsevierStyleSup">2</span>), affixed with a double crown of non-absorbable fascia tacks and a minimum overlap of 5<span class="elsevierStyleHsp" style=""></span>cm, followed by the placement of 2 subcutaneous suction drains, all of which proceeded without incident (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The postoperative period was favorable, and the patient was discharged on the 8th postoperative day after confirming no drain discharge.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Two years after the procedure, the patient had a follow-up office visit, at which time there was no evidence of hernia recurrence.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The incidence of incisional hernia during pregnancy is unknown, but it is very rare in Western countries.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> For this reason, there is not enough evidence about its management, so individualized management should be based on the characteristics of the mother, fetus and gestation.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The most frequent symptoms and signs are abdominal pain, vomiting and the appearance of a mass in the region of the previous scar. During examination, a palpable defect can be found in the wall with either reducible or non-reducible content and sometimes abdominal distension.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5–7</span></a> To complete the study, abdominal ultrasound is usually sufficient to determine which structures are contained in the hernia sac. However, sometimes MRI is indicated when the ultrasound does not provide a clear diagnosis.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Once the diagnosis has been made, it is essential to monitor the pregnancy in order to detect uterine changes that could result in delayed intrauterine growth of the fetus. Risk factors associated with this complication have been described, including advanced age, polyhydramnios and multiple gestation.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Although the literature includes approaches during the first months of gestation, both anesthesia and surgery can lead to an increased risk of complications for the mother and the fetus. Therefore, most authors advocate repair during elective cesarean section or in a second phase. In the case of complications, emergency surgery is mandatory. Uterine strangulation in full-term pregnancies is an indication for urgent laparotomy, cesarean section and wall repair in the same operation. When the complication occurs in the early stages of pregnancy, urgent repair of the defect is indicated, assessing fetal viability and continuing gestation if possible.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">5,7</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">This publication has not required any type of funding.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Camacho Marente V, Olivares Oliver C, Marchal Santiago A, Martin Cartes JA, Bustos Jimenez M. Eventración uterina en paciente gestante. Cir Esp. 2020;98:303–305.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1517 "Ancho" => 1500 "Tamanyo" => 332910 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Incisional hernia with uterus inside, delivery and placement of preaponeurotic mesh.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cirugia basada en la evidencia y hernia incisional" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. 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Gupta" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "MedGenMed" "fecha" => "2006" "volumen" => "8" "paginaInicial" => "14" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17415938" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0065" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fullterm pregnancy in umbilical hernia" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Punguyire" 1 => "K.V. Iserson" 2 => "S. 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Charu" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Internet J Gynecol Obstet" "fecha" => "2005" "volumen" => "5" "paginaInicial" => "2" "paginaFinal" => "5" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735077/0000009800000005/v1_202005290846/S2173507720300764/v1_202005290846/en/main.assets" "Apartado" => array:4 [ "identificador" => "15076" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735077/0000009800000005/v1_202005290846/S2173507720300764/v1_202005290846/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173507720300764?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 15 | 0 | 15 |
| 2024 October | 85 | 2 | 87 |
| 2024 September | 89 | 21 | 110 |
| 2024 August | 65 | 11 | 76 |
| 2024 July | 81 | 16 | 97 |
| 2024 June | 58 | 6 | 64 |
| 2024 May | 59 | 5 | 64 |
| 2024 April | 45 | 11 | 56 |
| 2024 March | 62 | 5 | 67 |
| 2024 February | 80 | 1 | 81 |
| 2024 January | 75 | 10 | 85 |
| 2023 December | 117 | 0 | 117 |
| 2023 November | 108 | 7 | 115 |
| 2023 October | 136 | 3 | 139 |
| 2023 September | 78 | 0 | 78 |
| 2023 August | 68 | 2 | 70 |
| 2023 July | 86 | 5 | 91 |
| 2023 June | 73 | 2 | 75 |
| 2023 May | 107 | 4 | 111 |
| 2023 April | 87 | 8 | 95 |
| 2023 March | 108 | 2 | 110 |
| 2023 February | 61 | 3 | 64 |
| 2023 January | 63 | 1 | 64 |
| 2022 December | 90 | 4 | 94 |
| 2022 November | 102 | 8 | 110 |
| 2022 October | 61 | 8 | 69 |
| 2022 September | 62 | 13 | 75 |
| 2022 August | 72 | 11 | 83 |
| 2022 July | 39 | 8 | 47 |
| 2022 June | 40 | 11 | 51 |
| 2022 May | 37 | 15 | 52 |
| 2022 April | 42 | 12 | 54 |
| 2022 March | 42 | 9 | 51 |
| 2022 February | 102 | 6 | 108 |
| 2022 January | 79 | 8 | 87 |
| 2021 December | 46 | 8 | 54 |
| 2021 November | 52 | 11 | 63 |
| 2021 October | 57 | 16 | 73 |
| 2021 September | 34 | 11 | 45 |
| 2021 August | 33 | 11 | 44 |
| 2021 July | 22 | 8 | 30 |
| 2021 June | 20 | 11 | 31 |
| 2021 May | 19 | 11 | 30 |
| 2021 February | 1 | 2 | 3 |
| 2021 January | 0 | 5 | 5 |
| 2020 November | 0 | 3 | 3 |
| 2020 October | 9 | 2 | 11 |
| 2020 September | 7 | 7 | 14 |
| 2020 August | 12 | 12 | 24 |
Show all
