Delayed posterior rectus sheath rupture presenting as intestinal obstruction: A case report and review

Extended-view totally extraperitoneal repair (eTEP) is one of the recently introduced, advanced minimal access approaches for the repair of ventral hernias. Posterior sheath rupture (PRSR), though rare, is a lethal complication of eTEP, exposing the polypropylene mesh to the viscera. Few cases of PRSR have been reported following eTEP ventral hernia; however, delayed presentations as acute small bowel obstruction, has not been reported so far. We present the case of acute intestinal obstruction following eTEP ventral hernia repair after 10 months following the primary surgery. A 67-year-old female underwent laparoscopic eTEP repair for an incisional hernia using a polypropylene mesh of 20 cm × 15 cm without mesh fixation, along with anterior and posterior rectus sheath re-approximation 10 months ago. She presented in emergency with abdominal pain and constipation and obstipation for 2 days. Contrast-enhanced computed tomography of the abdomen and pelvis revealed interstitial hernia with dilated small bowel herniating till anterior rectus sheath with adhesions to the mesh through the posterior rectus sheath dehiscence. She was subjected for an emergency laparoscopic surgery. She had an uneventful recovery. Ventral hernia repair with mesh reinforcement in retrorectus plane is considered safer with maintained peritoneal integrity, reducing the risk of bowel obstruction and fistula formation as with an intraperitoneal mesh. There are few documented cases of posterior rectus sheath rupture as an early complication of eTEP, which exposes to similar risks of bowel obstructions. However, PRS rupture as delayed complication with bowel obstructions has not been documented. A high degree of clinical suspicion of PRS rupture must be kept post-ventral hernia repair in patients presenting with obstructive symptoms. We consider that poor muscle tone, strenuous activity and deep bending may cause PRS rupture.