Phantom hernia following percutaneous nephrolithotomy

S Rajaian, M Pragatheeswarane, K Krishnamurthy 
 Department of Urology, MIOT International, Chennai, Tamil Nadu, India

Correspondence Address:
S Rajaian
Department of Urology, MIOT International, Chennai, Tamil Nadu
India

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Percutaneous nephrolithotomy (PCNL) is a minimally invasive treatment for renal stones. It is associated with varied complications such as hemorrhage, pyelonephritis, perinephric abscess or urinoma, hemothorax, pneumothorax, colonic injury, and rarely death.[1] The post-PCNL phantom hernia is a rare complication. It occurs due to transient or permanent denervation of the abdominal musculature from injury to the T11 and T12 intercostal nerves.[2]

A 56-year-old man underwent right PCNL for lower pole renal calculus of 2 × 2 cm size. PCNL was performed in a prone position. The infracostal single puncture was done for access into posterior lower calyx, serial metallic fascial dilatation was done up to 22 Fr, and Amplatz sheath was placed. Stone was broken with pneumatic lithotripter and complete stone clearance was achieved. 18 Fr nephrostomy tube was placed at the end of the procedure which was removed on 2nd postoperative day. He was discharged without any complications. At follow-up of 7 days, he complained of right flank bulge [Figure 1]a and [Figure 1]b. He had no history of flank pain, fever, or hematuria. The examination was unremarkable except for a soft non-tender swelling in right flank region. Computerized tomography (CT) was done to rule out perirenal hematoma or urinoma [Figure 2]. CT revealed normal kidneys without perinephric collection or hematoma. A diagnosis of phantom hernia was made and observation was suggested. At follow-up of 6 months, the swelling has reduced in size.{Figure 1}{Figure 2}

A phantom hernia can occur after PCNL due to the damage to intercostal or subcostal nerves. Nerve injury has been reported often following supracostal access.[3] As subcostal nerve innervates rectus and tranversus abdominis muscle, damage to the nerve can cause flank muscle weakness. Flank bulge occurs due to laxity of the anterolateral abdominal musculature caused by damage to the intercostal nerves subsequent to flank incisions of various retroperitoneal surgical procedures.[2] The flank bulge can be minimized by entry into the pelvicalyceal system lateral to the scapular line in appropriate cases and avoiding the lower border of ribs as in thoracentesis.[4] As phantom hernia is common in supracostal puncture, the postulated mechanism is direct injury and crushing of the neurovascular bundle against the upper rib. Damage to the neurovascular bundle usually occurs when a relatively perpendicular access tract is made and the angulated access to the lower calyx and pelviureteric junction is attempted creating pressure on the adjacent neurovascular bundle.[5] In rare instances even lumbar hernia can occur following percutaneous renal surgery. Patients with undernourishment and preexisting muscular atrophy are more prone to lumbar hernia formation.[6] Lumbar hernia with intestinal contents needs surgical correction, which can be safely done with laparoscopic approach.[6] But in most of the cases, the bulge is transient and only reassurance is required. Our case highlights the importance of counseling about nerve injury and occurrence of phantom hernia following PCNL. The following measures are suggested to prevent phantom hernia formation secondary to nerve damage: 1) avoiding perpendicular punctures and excess of torque against the ribs; 2) selecting site of a puncture just lateral to the paraspinal muscle in case of supracostal puncture and staying close to the upper border of 12th rib; 3) avoiding sharp fascial dilators such as lumbotome during tract dilation; 4) use of adequate slender sheaths; and 5) judicious decision about increasing the number of tracts rather than excess of angulation of tract to achieve maximal stone clearance.[4]

Declaration of patient consent

The authors certify that appropriate patient consent was obtained.

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Nil.

Conflicts of interest

There are no conflicts of interest.

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