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Procedia - Social and Behavioral Sciences 117 (2014) 660 – 664

ICSPEK 2013

The Laparoscopic Cure of the Parietal Golden Standard Defects

for the Rapid Recovery of Professional Athletes
Teodor Dan Potecăa, Daniela Elena Mihăilab, Anca Potecă a, Silviu Pițurua*,
Gabriel Pițigoia, Cătălin Păunescua
a
"Carol Davila'' University of Medicine and Pharmacy, Dionisie Lupu Street no. 37, Bucharest, 020022,Romania
b
Clinical Hospital Colentina, Stefan cel Mare street No. 19 - 21, Bucharest, 72202, Romania

Abstract

Abdominal hernia repair procedures are some of the most common procedures in a surgical department. Among the causes of
hernia we can mention the existence of a natural anatomical orifice in a weak area of the abdominal wall and the pressure
variation on the wall. Lately, the golden standard for antero-lateral wall defects repair has become the laparoscopic approach.
Due to the fact that the Spiegelian hernia diagnosis has a surgical treatment indication, the purpose of this paper is to highlight
the advantages of the laparoscopic method in the recovery of performance athletes. This paper is a case study of a professional
karate athlete, who was treated for a left Spiegel hernia with a laparoscopic alloplastic procedure. Results: the postoperative
recovery lasted for 2 days, as opposed to 5-day recovery in hospital which would be required by applying the classical
procedure, minimal postoperatory pain was experienced and there was fast professional reinstatement - the usual training was
resumed 2 weeks after the surgery (while with the classical approach it would have required at least a month of recovery) and
participation in competitions after 3 months. No recurrences have been observed during follow-up.

© 2013
© 2013 The
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Selection and
Selection peer-review
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of ICSPEK

Key words: professional athlete, spiegel hernia, laparoscopic alloplastic reapair of a parietal wall defect;

1. Background

Hernia is the protrusion of the peritoneal cavity organs, wrapped up in the peritoneum to the subcutaneous
layer through a preformed anatomical orifice. Traumatic abdominal wall hernias from blunt trauma usually occur

* Corresponding author. Tel.:+00766257566

E-mail address: m_e_d_iv@yahoo.com

1877-0428 © 2013 The Authors. Published by Elsevier Ltd.

Selection and peer-review under responsibility of ICPESK 2013.
doi:10.1016/j.sbspro.2014.02.278
 Teodor Dan Potecă et al. / Procedia - Social and Behavioral Sciences 117 (2014) 660 – 664 661

as a consequence of motor vehicle collisions where the force is tangential, sudden, and severe. The foundation of
any effective hernia repair is to identify the anatomical landmarks for fixation of the mesh material. In addition, it
is generally accepted that the mesh must extend 3cm to 5cm beyond the defect (Wilson, Davis & Rosser, 2012).
Regarding Spiegel hernia or antero-lateral wall, it is a hernia through the Spiegel fascia, the aponeurotic layer
between the right side rectus abdominis muscle and the semilunar line, developed most frequently on or below the
arcuate line. This type of hernia does not always develop a visible hernia sack, it bears a small orifice with low
risk of strangulation and are diagnosed by echography or CT's (Brătucu, 2009).
We herein report a case of spigelian hernia, pre-operatively diagnosed as an incisional hernia (Uchiyama et al.,
1998). Clinicians need to be aware of these hernias when dealing with lower abdominal swellings and have a high
index of suspicion even in the presence of negative clinical and CT findings (Demetriou et al., 2012). Mostly,
these hernias lie in the "spigelian hernia belt," a transverse 6-cm-wide zone above the interspinal plane; lower
hernias are rare and should be differentiated from direct inguinal or supravescical hernias (Skandalakis et al.,
2006).
According to the last studies, various techniques for repair of an incisional hernia are available for the surgeon.
Conventional suture techniques are quick and easy to perform but they are associated with an unacceptable rate of
recurrence and therefore should only be used in exceptional cases (Conze et al., 2010).
The cure of this type of hernia is purely alloplastic, the procedures are both classical and laparoscopic. The
properties of the meshes used in laparoscopy are: affordable price; no potential for adhesions; good memory
(elasticity and re-expansion); good tissue integration; minimum contraction; "user-friendly"; low risk, of
superinfection, fistulisation or seroma formation.
Recent research (Śmietański et al., 2012) demonstrated that the elongation between certain points can exceed
100% on some axes. This phenomenon would involve adapting the rigid implant to the abdominal wall
movements, requiring doubling the size of the prosthesis, an impossible phenomenon due to the mechanical
properties.
The composite meshes are the most suitable in laparoscopic intraperitoneal procedures due to the polyester
coating, making rapidly the incorporation into the wall and the adhesion to it, while collagen films in contact with
the abdominal viscera prevent the formation of adhesions, preventing complications such as obstruction, fistula
and superinfection. Meshes built of dense woven propylene, the substance most commonly used in the production
of prosthetic materials in hernia surgery, are characterized by low biocompatibility (Bury et al., 2012).
Given the high rate of incarceration/strangulation, the diagnosis of Spigelian hernia is an indication for
surgical repair (David & David, 2002), the purpose of this study is to highlight the obvious advantages of
laparoscopic surgery in the rapid recovery of athletes, for them to quickly return to their sorts activity. Moreover
this study aims to highlight the merits of laparoscopic surgery, compared to classical surgical interventions, and
the benefits to improve the quality of patients life .

2. Material and methods

2.1. Case study

Patient AM, urban, aged 28, with 18 years of competition experience in practicing Karate, with a total number
of 31 competitions, both nationally and internationally, amassing 50 medals in sports career. The athlete is
hospitalized for pain in the left flank, that appeared in 2008 after repeated hits to the area, using the fist and foot.
The sportive /patient had no significant personal and familial pathological history. After the clinical examination
the athlete was diagnosed with antero-lateral wall hernia, uncomplicated. The laboratory examination showed no
important changes. Following the echographic examination of the soft tissues, they could see the defect at the
level of the left Spiegel 7.4 mm, the positive diagnosis being left Spiegel hernia. The complications of hernia
were: incarceration, obstruction, strangulation, loop necrosis, hernia tumors, TBC hernia.
662 Teodor Dan Potecă et al. / Procedia - Social and Behavioral Sciences 117 (2014) 660 – 664

2.1.1. The conceptualisation of the case

The doctor confirms the presence of hernia by performing a clinical examination focused on the area in pain.
The athlete displays serous rhinorrhea and nonproductive cough without rales or pulmonary changes,
ausculatative or percussion, afebrile, normally colored skin and moucus wetted with left flank pain, spontaneous
and deeply inhale installed 4 years ago, exacerbated in the last 6 months. During the examination, the athlete
shows normal breathing, normal thorax expansion, 16 breath / min, pulse: 75 b / min, heart sounds fair,
equipotent, without murmurs, BP 110/60 mm Hg; slim abdomen mobile with breathing spontaneously painful to
touch and inspire deep on the left flank, where we observe, in the lateral position, a reductible pseudo-tumoral
formation, protrusive to maneuvers of increasing abdominal pressure, diameter approximately 0.5 cm, without
signs of peritoneal irritation, transit existent no alterations. Weight curve unchanged for the past two years.
The differential diagnosis consisted in comparing the signs and symptoms of disease presented by the patient,
with the signs and symptoms similar to other diseases and highlighted fibroids, lipomas, lymphadenopathy:
clinical and laboratory excluded, with low anesthetic risk.

2.2. Laparoscopic method

After establishing the diagnosis the only treatment is the surgical cure, the options being the alloplastic
classical technique or the laparoscopic alloplastical cure. The classical intervention involves an 5 to 15 cm
incision centerd on the lesion, the in-depth dissection of the muscular plans and poperitoneal alloplasty, followed
by a recovery period of more than 90 days.
By comparison, the laparoscopic surgery substantially reduces trauma to the abdominal wall and muscles,
decreases operating time (duration of the anesthesia) and hospitalization, while promoting the rapid social and
professional reintegration of the patient.

2.2.1. The treatment/ the intervention plan

After evaluating the case, the medical team opts for the laparoscopic alloplastic cure of the defect,
intraperitoneal method. They create the workroom, Veress needle on the pneumoperitoneum to 12 mmHg
pressure, they install it in the iliac fossa optical trocar in the right side 10 mm diameter, 10 mm trocar 5 mm right
flank and left flank. With the penetration into the peritoneal cavity they highlight the defect parietal left flank
large, post appendectomy adhesive disease. They apply adhesyolisis, they insert the mesh 15/15 cm Parietene
Composite fold through, the 10mm trocar. The 2 pre- existent wires of the mesh are fixed to the skin with a
Reverdin needle inserted through the wall and the net stretches and attaches via a device, with Absorbatckuri
(dissolving staples). Control is performed of the peritoneal cavity, pneumoperitoneum is evacuated and the
breaches are being sutured intradermally.

3. Discussions and conclusions

The diagnosis of Spigelian hernias represents a challenge for the surgeons principally due to their rarity but
also due to their anatomy and the variety of their contents (Demetriou et al., 2012). Laparoscopy, preferably a
totally extraperitoneal procedure, or intraperitoneal when other surgical repairs are planned within the same
procedure, is currently employed as an adjunct to diagnosis and treatment of spigelian hernias. Care must be
taken not to create iatrogenic spigelian hernias when using laparoscopy trocars or classic drains in the spigelian
aponeurosis (Skandalakis et al., 2006).
 Teodor Dan Potecă et al. / Procedia - Social and Behavioral Sciences 117 (2014) 660 – 664 663

Over the last year, our team included a total of 100 cases of parietal defects in a small comparative study,
noting the differences between patients who received alloplastic classical cure and those with laparoscopic
surgery. After the conventional interventions we chose to use three-dimensional structure meshes, auto-fixing,
and in the laparoscopic ones we opted for the composite prosthetic (applied intraperitoneally) and polypropylene
(pro-peritoneal in inguinal and femoral hernias).
In the present case study the laparoscopic approach was elective, allowing both full exploration of the
peritoneal cavity and the rapid and complete integration of the patient in the competition environment. Once you
overcome the learning curve, the only drawback of laparoscopic procedures is the cost of the procedure, but on
the long run it is, though, justified by the rapid socio-professional integration of the patient.
The minimally invasive transperitoneal technique is the best treatment option for active, young people, the
recovery is fast, the lack or minimal perception of postoperative pain syndrome, the reduced complications
recommending this technique.
The case study presented in this paper showed a favorable postoperative evolution and a favorable prognostic,
with hospital discharge in 48 hours, without complications. They recommended rest for 7 days and 14 days
avoiding intense physical effort, while the training sessions at normal rhythm were resumed after a month. The
next international competition in which the athlete participated were the European championships, 6 months after
the surgery.
This study was chosen in order to highlight the postoperative results, both immediate and long term obtained
by laparoscopic surgery on performance athletes operated on in our clinic. Moreover to study their quality of life
and to try to determine the merits of postoperative quality of the results compared to conventional interventions
in Spigelian hernias.
Thus, our research joins recent studies to support laparoscopic repaire surgery in abdominal wall deffects,
studies that prooved the undeniable advantages in recovering patients and also improving their quality of live. We
chose this sportives case report because it is representative for the group of sportives/patients who is part of a
prospective londitudinal study in our clinic.
The results of the study highlight the fact that the laparoscopic surgery does not favour major possibile
postoperative complications, reduces hospitalization and cost control and has great aesthetic effects. Due to the
fact that after surgery the athlete returned to her usual sports activity in 2 weeks proved that laparoscopic surgery
patients have a better quality of life than those operated through the classical procedure, with a positive impact on
future daily activities, because of the low incidence in postoperative pain syndrome which is frequently found
after the open surgery.
In conclusion, we support the laparoscopic technique in performance athlets that are diagnosed with Spiegel
hernia, that can be adjusted to each stage of the disease and additional risk factors (age, fitness, health status, etc)
to obtain maximum benefit.
The present study allows us to support laparoscopic surgery in athletes recovery, whenever necessary, so that
they can resume sports activity as quickly as possible and at optimal parameters of sports training.

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