Incisional hernia after laparoscopic nephrectomy with intact specimen removal: caveat emptor

We report 5 cases of postoperative incisional hernia after laparoscopic nephrectomy with intact removal of the specimen.

During the last 5 years 29 patients underwent laparoscopic nephrectomy with intact removal of the resected specimen due to a large kidney and/or malignancy. Of these 29 patients 5 had a postoperative incisional hernia at the site of intact removal, including 3 with renal tumors and 2 with large polycystic kidneys due to adult onset autosomal dominant polycystic kidney disease. The records of these patients were reviewed to determine any specific factors that might relate to the development of this complication.

An incisional hernia developed at the wound site in 5 patients (17%) 41 to 73 years old (mean age 53.4). Average body mass index for the patients was 34.2 (range 26 to 47). Average weight and size were 542 gm. and 20.3 x 10.3 cm., respectively, for the 3 resected malignant specimens and 1,975 gm. and 23.8 x 16.5 cm., respectively, for the 2 benign kidneys. A transverse lower flank muscle cutting incision (average 10.4 cm.) was performed to remove the resected kidney. Incisional hernias appeared after an average of 6.6 weeks postoperatively. Risk factors for a postoperative hernia included obesity in 80% of the patients, chronic renal insufficiency due to autosomal dominant polycystic kidney disease in 40%, postoperative pulmonary complication in 40% and metastatic cancer in 20%.

Our experience has led us to avoid a lower flank port connecting incision for specimen removal. Instead we changed to a midline or subcostal incision in these patients. In addition, we believe that with the availability of the impermeable organ entrapment sacks there is less need for intact specimen removal even for renal tumors. Currently large benign kidneys (autosomal dominant polycystic kidney disease) are morcellated in situ to a suitable size for entrapment, while renal tumors are entrapped and morcellated directly. Presently our only indication for intact removal is in the case of a renal pelvic or caliceal transitional cell cancer.