Patient undergoes robotic epigastric and umbilical hernia repair in August 23, 2024 as a result of a palpable hernia above the umbilicus. A preperitoneal flap was crated at the faciform and carried inferior to at least 5 cm below the lowest hernia defect. this was carried laterally to the contralateral side over 5 cm from the lateral edge of the hernia defects. The hernia contents and sac were reduced and mesh placed. The preperitoneal space was then opened around the umbilicus and surgeon reduced umbilical hernia contents which was preperitoneal fat. The defect was repaired primarily. The findings at surgery were 3 cm epigastric hernia and 1 cm umbilical hernia.
Approximately a month or two later, patient returns complaining of separate bulge that is higher up. A second surgery is performed by the surgeon on March 15, 2025. Again a preperitoneal flap was created at the falciform and carried to at least 5 cm below the lowest hernia. Hernia was found to be episgastric about 5 cm above the umbilicus containing preperitoneal fat. This hernia measured 2cm. It was reduced and mesh placed. A subcentimeter hernia was also identified near xiphoid process and was repaired primarily.
Patient complains that following the surgery he had a lump in the same area. He believes it to be same lump. A CT completed on April 23, 2025 is interpreted by the radiologist as showing "expected post-surgical changes at the anterior abdominal wall. In the area of concern there is subcutaneous fat stranding suspected to be due to mild fat necrosis which is an expected post-surgical finding."
Patient gets second surgical opinion. Second surgeon performs surgery at the end of May 2025. He notes that dissection carried down through the subcutaneous tissues layer, as there was an obvious piece of incarcerated fat which was quite fibrotic and organized corresponding to the patient' area of tenderness, as this was amputated down to the fascia defect versus attenuation. The area was palpated, which is attenuated, as this defect was less than 1 cm. It was reinforced and closed with 2 interrupted 0-Vicryl stitch. Postop dx: incarcerated preperitoneal fat with small recurrent ventral hernia (epigastric region, defect less than 1 cm of attenuated fascia)
No further reports of hard bulge.
Questions: Did the surgeon who performed the first two surgeries fall below the standard of care?
Anything glaring from a technical standpoint as to how he performed the surgeries?
Does this appear to be recurrent hernias as opposed to something missed twice?
Is it a deviation that necrotic fat was incarcerated following the second surgery or did it likely develop as a known risk or complication of the procedure?
Files:
No questions yet!
Do you believe there might have been medical error?
Small hernias with incarcerated fat can occur.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
In the post op period the patient could've coughed and caused a small hernia that could lead to symptoms.
What makes you a good expert for this case?
I do about 800 cases a year of which approximately 200 are hernia cases. I have performed over 1000 robotic procedures.
How often do you encounter cases similar to this one in your practice?
Not uncommon to have symptoms after hernia repair. Also no mention of patient comorbidites as that can factor into this aswell.
Do you believe there might have been medical error?
CT scans are very effective at diagnosing epigastric hernias, but not perfect. It seems in this case the CT scan showed that there was not a hernia, but one was found at the time of exploration. An alternative approach at the very first operation could have been a large mesh covering all defects rather than a piecemeal mesh coverage approach. This may have eliminated the additional surgeries. It can be challenging to find sub centimeter hernias even in the OR with a robotic approach, especially one that is not seen definition CT
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This is a challenging case due to the small but non-zero false negative rate of CT scan. If the patient does not have symptoms in the preop setting, these hernias can be difficult to find in the OR. A different approach can be used to try and mitigate the problem of a missed hernia and that is stripping the peritoneum away from the whole length of the midline and looking for small hernia defects and then covering all of the hernias with one piece of mesh with at least a 5 cm mesh overlap for each hernia
What makes you a good expert for this case?
I am professor of surgery at a large academic medical center with 20 years' experience in hernia surgery. I do open, laparoscopic ad robotic approached to hernia repair.
How often do you encounter cases similar to this one in your practice?
I do several robotic epigastric/ventral hernias per month in my practice, and I have seen small hernias that are missed by imaging, and physical exam that require further surgery
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