CASE REPORT OPEN ACCESSInternational Journal of Surgery Case Reports 11 (2015) 57

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International Journal of Surgery Case Reports

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Bilateral prevascular herniae A rare complicatioendovascular abdominal aortic aneurysm repair bypass

Obinna ODepartment of d

a r t i c l

Article history:Received 25 JaReceived in reAccepted 31 MAvailable onlin

Keywords:Emergency EVFemoro-femorPrevascular hePreperitoneal

ilateass foing a .y Els-ND

1. Introdu

Indicatioartery occlusion and following aorto-uniiliac endovascular abdom-inal aortic aneurysm repair (EVAR) [1]. The graft is usually tunnelledsubcutaneously, although, some authors advocate tunnelling viathe retropubic (prevesical) space or cave of Retzius [24]. Prevas-cular hernia is a rare complication postoperatively [5]. We present acase in whicemergency dure were s

2. Present

A 78-yeaand an elevback pain. S(AAA) and sof a 6 cm AA

The aneuendovasculfemoro-femsame generand anasto

CorresponE-mail add

CCanning@rcs

stopd on

yea4.0 cm but the patient developed sudden onset right lower limbclaudication at 100 m. Imaging demonstrated that the femoro-femoral bypass was occluded. It was considered that the graft hadkinked due to the patients body habitus and so a new graft wasinserted and this time tunnelled via the Cave of Retzius. The patient

http://dx.doi.o2210-2612/ (http://creativh bilateral prevascular herniae that developed after anaorto-uniiliac EVAR and femoro-femoral bypass proce-uccessfully repaired using the preperitoneal approach.

ation of case

r old lady with chronic obstructive pulmonary diseaseated body mass index (BMI 32) presented with acutehe had a family history of abdominal aortic aneurysmubsequent CT scan demonstrated a contained ruptureA.rysm was repaired using a Cook Zenith aorto-uniiliac

ar stent graft, a right iliac occluder and a left to rightoral bypass using a 6 mm ringed PTFE graft under theal anaesthetic. The graft was tunnelled subcutaneouslymosed end to side to both common femoral arteries.

ding author. Tel.: +353 1 830 4251; fax: +353 1 802 4252.resses: obinnaobinwa@rcsi.ie (O. Obinwa),i.ie (C. Canning), modonohoe@mater.ie (M. ODonohoe).

made an uneventful recovery and was discharged after six days.Ten months after discharge, the patient developed a reducible

swelling 57 cm in diameter behind her left groin incision. Theswelling had a cough impulse and was diagnosed as a possible inci-sional hernia. Three months later, a similar swelling developed onthe right side. As the left hernia was painful, it was decided that itshould be repaired.

The preperitoneal space was accessed via a 6 cm transversesupra-inguinal incision. The hernia and contents were reduced enmasse, exposing the transversalis fascia on the posterior wall ofthe inguinal canal, inguinal, lacunar and pectineal ligaments. Thedefect was lateral to the lacunar ligament but between the inguinalligament and femoral/external iliac artery, and was therefore, a pre-vascular or Velpeaus hernia. The femoro-femoral bypass was notvisible in this operative eld but could be felt deep to the medial endof the inguinal ligament. The defect was repaired using 15 15 cmpolypropylene mesh, extending 7.5 cm along the iliac artery tothe inguinal ligament and 7.5 cm up the transversalis fascia. Themesh was held in place using four polydioxanone absorbablesutures one in each quadrant and the peritoneum allowed backin place. The supra-inguinal wound was closed in two layers of

rg/10.1016/j.ijscr.2015.03.0602015 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND licenseecommons.org/licenses/by-nc-nd/4.0/).binwa , Caitriona Canning, Martin ODonohoeVascular Surgery, Mater Misericordiae University Hospital, Eccles Street, Dublin, Irelan

e i n f o

nuary 2015vised form 30 March 2015arch 2015e 11 April 2015

ARal bypassrniarepair

a b s t r a c t

A case of a 78-year-old female with buniiliac EVAR and femoro-femoral byprepair of the herniae was achieved usto dealing with this rare complication

2015 The Authors. Published baccess article under the CC BY-NC

ction

ns for femoro-femoral bypass include unilateral iliac

Her pocharge

Twon of aorto-uniiliacand femoro-femoral

ral groin prevascular herniae following an emergency aorto-r a ruptured abdominal aortic aneurysm is presented. Primarypreperitoneal approach. The case emphasises a safe approach

evier Ltd. on behalf of Surgical Associates Ltd. This is an openlicense (http://creativecommons.org/licenses/by-nc-nd/4.0/).

erative course was uneventful, and the patient was dis- the 8th postoperative day.rs postoperatively, the aneurysm sac had shrunk to

CASE REPORT OPEN ACCESS6 O. Obinwa et al. / International Journal of Surgery Case Reports 11 (2015) 57

Fig. 1. Crossover graft tunnelled in the retropubic space.

polydioxanone, with poliglecaprone to the skin. Her postoperativecourse was uneventful, and the patient was discharged on day 3.The right side subsequently became painful and was repaired in asimilar fashion two months later.

The aneurysm sac size continued to shrink, the graft remainedpatent and the herniae had not recurred at the time of her deathsix years later.

3. Discussion

Femoro-femoral crossover bypass was rst described by Free-man and Leeds in 1952. The supercial femoral artery was used as aconduit, and was transposed beneath the tissues of the abdominalwall [6]. The TASC II document reports a 75% 5-year patency forfemoro-femoral bypasses, compared to an 8090% 5-year patencyfor aortobifemoral bypasses [7].

The retropubic space (cave of Retzius) is that space betweenthe pubic stive tissue aspace (Bogrthe inguina

In 1972,femoro-fem[4]. In 1983femoral bypthis route tof graft infeMore recenbypasses, t

Fig. 3. S

dence of gretropagesling ihis ckeniith c

casedarth thef a femible pairre wque imilar case has been described in the literature. A 57-year-ntleman who developed bilateral inguinal herniae after a-femoral bypass had his herniae repaired by a laparoscopicch [5].

clusion

teral prevascular herniae are rare complications of aorto-c EVAR and femoro-femoral bypass procedures. Treatment isted both for patients with symptoms and for asymptomaticts who are at risk of developing future complications. In this, an open approach using a preperitoneal technique provedd successful.ymphysis and the bladder. It contains loose connec-nd fat [8]. This space is accessed via the retroinguinalos space), which is the extraperitoneal space deep tol ligament [9]. This is another avascular space.

Tyson and Reichle described retropubic tunnelling oforal crossover bypasses, to reduce the risk of occlusion, Mosley and Marston reported outcomes of 66 femoro-asses that were tunnelled retropubically. They chose

o protect the graft from trauma, and reported no casesction or anastomotic pseudoaneurysm on follow-up [3].tly, Read et al. [2] reported a series of 67 femoro-femoralen of which were tunnelled retropubically. The inci-

with radvanttunnel

In tto weapled win thisiliac enthrougence oto posssical reinterfetechniOne siold gefemoroapproa

4. Con

Bilauniiliaadvocapatienreportsafe anFig. 2. Extra anatomical location of the bypass graft.

Conict of

None.

Funding

No fundubcutaneous versus retropubic tunnelling of the bypass graft.

aft thrombosis and infection was less in those patientsubically-tunnelled grafts [2]. Despite the safety and

of retropubic tunnelling (Figs. 1 and 2), subcutaneouss more commonly practised (Fig. 3) [2,1012].ase, bilateral prevascular hernia probably occurred dueng of the inguinal ligament with repeat dissection cou-hronic cough. A preperitoneal approach was employed. The technique is somewhat similar to that used forerectomy [13]. Bilateral repair by tunnelling the mesh

Cave of Retzius would have been dangerous in the pres-oro-femoral graft and would have exposed the patient

bladder injury or risk of graft infection. The direct clas- was not considered as the presence of the graft wouldith operative manoeuvres. The main advantage of ours avoidance of the graft and subsequent risk of infection.interest

ing was secured for this study.

CASE REPORT OPEN ACCESSO. Obinwa et al. / International Journal of Surgery Case Reports 11 (2015) 57 7

Ethical approval

An ethical approval was not required.

Submission declaration

The authors declare that the work described has not been pub-lished previously, that it is not under consideration for publicationelsewhere, that its publication is approved by all authors and tac-itly or explicitly by the responsible authorities where the work wascarried out, and that if accepted, it will not be published elsewhereincluding electronically in the same form, in English or in any otherlanguage, without the written consent of the copyright-holder.

Authors contribution

Martin ODonohoe conceived the initial idea of the study.Obinna Obinwa, Caitriona Canning and Martin ODohonoe

acquired the data for publication, drafted the article and revisedit critically for important intellectual content.

All authors approved the nal version of the manuscript to besubmitted.

Consent

Patient is deceased. A written informed consent could not there-fore, be obtained. Data presented has been anonymised.

Guarantor

Mr. Martin ODonohoe.

References

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[3] J.G. Mosley, A. Marston, Long term results of 66 femoral-to-femoral by-passgrafts: a 9-year follow-up, Br. J. Surg. 70 (10)(1983) 631634.

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[10] P.J. Whatling, M. Gibson, E.P. Torrie, T.R. Magee, R.B. Galland, Iliac occlusions:stenting or crossover grafting? An examination of patency and cost, Eur. J.Vasc. Endovasc. Surg. 20 (1) (2000) 3640.

[11] R. Pursell, E. Sideso, T.R. Magee, R.B. Galland, Critical appraisal offemorofemoral crossover grafts, Br. J. Surg. 92 (5)(2005) 565569.

[12] Y.W. Kim, J.H. Lee, H.G. Kim, S. Huh, Factors affecting the long-term patency ofcrossover femorofemoral bypass graft, Eur. J. Vasc. Endovasc. Surg. 30 (4)(2005) 376380.

[13] C.L. Donohoe, J.F. Dowdall, C.O. McDonnell, M.K. OMalley, M.K. ODonohoe,Eversion endarterectomy for external iliac artery occlusive disease, Vasc.Endovasc. Surg. 45 (1) (2011) 4650.

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Bilateral prevascular herniae A rare complication of aorto-uniiliac endovascular abdominal aortic aneurysm repair and fe...1 Introduction2 Presentation of case3 Discussion4 ConclusionConflict of interestFundingEthical approvalSubmission declarationAuthors contributionConsentGuarantorReferences