Findings:
Bulging dura through bony defect of the left sacro-iliac joint. The mesorectum appeared to overlay and fill the defect, so bowel entrapment did not seem a reasonable concern. The dura and peritoneum appeared as fused or a single layer, and there was no good point of fixation for mesh, so none was placed.
Procedure:
The patient was placed in the supine position. Adequate anesthesia was initiated. Antibiotics were administered. A urinary catheter was placed. The abdomen was prepped and draped in a sterile fashion. An umbilical incision was made, through which a 5mm Step trocar was placed. Pneumoperitoneum was initiated with carbon dioxide to 15mmHg, which was tolerated well. Exploration was undertaken. A second 5mm trocar was placed in the right upper quadrant for instrumentation. The position was changed to Trendelenburg with rotation to the right or left as needed. The sacral region was examined in particular, retracting the sigmoid colon as needed. On the left in particular, it was felt that there was no narrow cavity in which any bowel could become entrapped and that the mesorectum filled this space. Through the mesorectum, a slowly pulsating cystic structure was seen a few centimeters medial to the left ureter. Intra-operative consultation with neurosurgeon confirmed that this was dura. After careful consideration, it was felt that further dissection and mesh implantation were not feasible or appropriate. This was the case as there was likely no plane of dissection to get behind peritoneum to place a mesh, nor would there be a good location to secure such mesh. Pneumoperitoneum was released. The scope and trocars were withdrawn. The umbilical fascia was closed with a figure-of-eight 2-0 Vicryl suture. Both skin incisions were infiltrated with Marcaine, re-approximated with 4-0 Monocryl subcuticular sutures and covered with Dermabond. The procedure was well tolerated and there were no apparent complications.