Open Access

Internal inguinal hernia on the transplant side after kidney transplantation: a case report

  • Akihiro Kondo1,
  • Yuji Nishizawa2Email author,
  • Shintaro Akamoto1,
  • Masao Fujiwara1,
  • Keiichi Okano1 and
  • Yasuyuki Suzuki1
Surgical Case Reports20151:108

https://doi.org/10.1186/s40792-015-0094-5

Received: 2 February 2015

Accepted: 1 October 2015

Published: 17 October 2015

Abstract

The patient was a 52-year-old man who presented with right inguinal swelling and pain. He had undergone kidney transplantation in 2005 and bypass surgery using a vascular prosthesis from the left axillary artery to the bilateral femoral arteries in 2008. The vascular prosthesis had invaded the right inguinal canal ventrally. The transplanted ureter had a hazy appearance on a non-enhanced abdominal CT scan. A Lichtenstein operation was performed under a diagnosis of inguinal hernia. A skin incision with pulling of tissue and subcutaneous fat was devised to avoid exposure of the vascular prosthesis. The inguinal canal and spermatic cord were found to have coalesced. The hernia was diagnosed as a supravesical hernia, class II-1. This case shows that a Lichtenstein operation is a suitable procedure for avoidance of damage to the transplanted ureter in treatment of a transplant-side inguinal hernia in a kidney transplant recipient.

Keywords

Kidney transplantation Inguinal hernia Lichtenstein operation

Background

The increased frequency of living-donor or brain-dead kidney transplantation has led to observation of rare post-transplant complications, including kidney transplant-associated inguinal hernia. Here, we describe a case in which internal inguinal hernia developed on the transplant side 7 years after living-donor kidney transplantation. We also provide a literature review of this condition.

This literature had been published in Journal of Japan Surgical Association 2014, volume 75(3), 841–844 pages in Japanese [1].

Case presentation

The patient was a 52-year-old man with a chief complaint of swelling and pain in the right inguinal region, which he had experienced since February 2012. His medical history included a living-donor kidney transplantation in the right iliac fossa for chronic renal failure in 2005. He had also undergone artificial graft bypass surgery from the right axillary artery to the bilateral femoral arteries for treatment of bilateral arteriosclerosis obliterans (ASO) in 2008. He had no particular family medical history.

At the first examination, physical findings were height 179 cm and body weight 60 kg. Hernia in the right inguinal region was noted in a standing position or while defecation. Blood chemistry findings included urea nitrogen, 40.8 mg/dl; creatinine, 2.44; potassium, 5.4 mmol/l; and hemoglobin, 7.6 g/dl; all of which indicated renal dysfunction and anemia. On plain abdominal CT, a subcutaneous vascular prosthesis was present on the ventral side of the right inguinal canal (Fig. 1). The transplanted kidney was observed under the right ilium, but the location of the transplanted ureter was unclear (Fig. 2).
Fig. 1

Non-enhanced abdominal CT scan (axial) showing the vascular prosthesis bilaterally (arrow), one on the right side positioned ventrally in the right inguinal canal

Fig. 2

Non-enhanced abdominal CT scan (coronal) shows that the location of the transplanted ureter is unclear (arrow)

Since the position of the transplanted ureter was uncertain, a right ureteral stent was placed before surgery. A skin incision was made at the lower margin of the vascular prosthesis palpable on the caudal side of the right inguinal canal, and the tissue was pulled with subcutaneous fat while avoiding exposure of the vascular prosthesis (Fig. 3). Mild adhesion of the inguinal canal around the spermatic cord was noted. Since a hernia orifice was palpated on the vesical side of the posterior wall of the inguinal canal, the patient was diagnosed with right internal inguinal hernia (supravesical hernia), class II-1 (Fig. 4). After dissecting the hernia sac, radical surgery for hernia was performed using the Lichtenstein method, which a single polypropylene mesh was fixed on the posterior wall of the inguinal canal. The stent placed in the right ureter was not palpated during surgery. The postoperative course was uneventful, and the patient was discharged 4 days after surgery. No recurrence of hernia or complication has subsequently occurred.
Fig. 3

Preoperative physical findings. A Vascular prosthesis, B skin incision

Fig. 4

Intraoperative findings. A Spermatic cord, B hernia orifice, C hernia sac

Discussion

Inguinal hernia is encountered frequently in routine medical practice. The number of kidney transplantations has increased yearly in Japan, with 1610 procedures performed in 2012 alone, based on data from the Japanese Society for Transplantation. However, it is rare to encounter inguinal hernia developing on the transplant side after kidney transplantation, and this condition has to be treated at institutions certified for kidney transplantation.

Hernia occurred on the kidney transplant side in our patient and additionally, a vascular prosthesis had passed through under the skin on the ventral side of the inguinal canal. A skin incision was made on the caudal side in parallel to the vascular prosthesis, and the surgical field was maintained by pulling the tissue with attached subcutaneous fat to avoid exposure of and damage to the vascular prosthesis. Mild adhesion of the inguinal canal around the spermatic cord was noted and may have been due to the surgery performed for kidney transplantation, but dissection was relatively easy. The transplanted ureter, in which a stent had been placed, was not detected during surgery.

Twelve case reports about inguinal hernia after kidney transplantation has been reported so far in PubMed research (Table 1) [213]. Some literatures reported serious intraoperative accidents or postoperative complications in surgery for inguinal hernia associated with kidney transplantation, including unrecognized ligation of transplanted ureter [2], injury to the urinary bladder [3], transplanted ureter necrosis caused by mesh plug [14, 15], and transplanted ureteral obstruction caused by transabdominal preperitoneal repair (TAPP) [4]. But then, Koizumi et al. [16] were able to avoid complications involving the transplanted ureter by performing radical surgery for hernia using the Lichtenstein operation.
Table 1

Case reports of inguinal hernia after kidney transplantation

Author

Year

Age/gender

Post-kidney transplantation (years)

Hernia content

Operation methods

Morbidity

Selman [2]

1985

58/M

12

Transplanted ureter

McVay

Ureteric stenosis

Kobayashi [3]

2000

39/M

4

N/A

McVay

Urinary bladder injury

Sanchez [5]

2005

70/M

5

Transplanted ureter

Lichtenstein

None

Furtado [6]

2006

44/M

12

Transplanted ureter

N/A

None

Verbeeck [7]

2007

75/M

11

Transplanted ureter

N/A

None

Ingber [8]

2007

72/M

12

Transplanted ureter

Polypropylene mesh use

None

Otani [9]

2008

53/M

9

Transplanted ureter

N/A

None

Azhar [10]

2009

76/M

20

Transplanted ureter

N/A

None

Odisho [11]

2010

58/M

15

Transplanted ureter

Lichtenstein

None

Pourafkari [12]

2012

50/M

12

Transplanted ureter

No operation

Death

Tse [4]

2013

57/M

3

N/A

TAPP

Ureteric stenosis

Vyas [13]

2014

32/M

7

Transplanted ureter and bladder

N/A

None

Our case

 

52/M

7

N/A

Lichtenstein

None

N/A = not available

Lichtenstein et al. [17] first described the Lichtenstein operation for inguinal hernia. In this tension-free surgery, a monofilament polypropylene mesh is inserted into the posterior wall of the inguinal canal. The approaches which insert an underlay mesh into the anterior peritoneal cavity, such as Prolene Hernia System (PHS), direct Kugel methods, and mesh plug methods, may damage a transplanted ureter present in this lesion. In contrast, the Lichtenstein operation does not dissect the anterior peritoneal cavity and, thus, is a most suitable method to prevent complications involving the transplanted organs.

Patients after kidney transplantation take immunosuppressants for a long period, and infectious complications caused by the use of mesh may be a concern. Catena et al. [18] found that the Lichtenstein operation used the porcine small intestine submucosa as a mesh was safe for immunosuppressed patients, but suggested that nonabsorbable polypropylene prostheses is a well-known risk of infection. Since there is a problem of surgical site infection after the mesh repair for the post-transplant patients, it can be considered about optional methods that need no mesh, such as traditional Bassini’s or McVay’s method and Shouldice repair [19] that is recommended as “tissue repair method”.

There have also been 10 case reports (PubMed research) about transplanted ureteral obstruction caused by the inguinal hernia incarceration [513], so we need to attend the incidence of inguinal hernia after kidney transplantation. But we were unable to find studies of the relationship between kidney transplantation and the occurrence of inguinal hernia. There has been the need of amassed research evidence of a number of these cases.

Conclusion

The case reported here illustrates the importance of protection of the transplanted ureter in the treatment of inguinal hernia on the transplant side in a kidney transplant recipient and shows that the Lichtenstein operation is a safe surgical procedure in such cases.

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

This case report is being approved by the institutional ethical review board of Kagawa University Hospital.

Declarations

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Authors’ Affiliations

(1)
Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University
(2)
Department of Colorectal Surgery, National Cancer Center Hospital East

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Copyright

© Kondo et al. 2015