Large Incisional Hernia Repair Using Bilateral TAR and IFT

Preoperative CT imaging (performed one year prior to surgery) revealed a defect size of 23 × 23 cm and a loss of domain of 28% (EHS-Classification: M2-4W3). After botulinum toxin injections (200 IU/90 ml bilaterally into the lateral abdominal wall muscles at three points per side), the scan demonstrated good lateral abdominal wall relaxation and reduced loss of domain. Additional prehabilitation included smoking cessation, respiratory training, and thrombosis prophylaxis the evening before surgery.

A complete adhesiolysis was performed. Bilateral TAR was carried out prior to traction to allow closure of the posterior rectus sheath. Without tension, defect width in the anterior rectus sheath measured approximately 17 cm. Under tension, this distance was reduced to 8–9 cm.

Traction was performed using the fasciotens®hernia device for 30 minutes after closure of the posterior sheath. The maximum traction force applied intraoperatively was 20 kg. By the end of the traction phase, a fascial closure without tension was achieved.

A 43 × 45 cm mesh was placed in the retromuscular position. The anterior sheath was closed directly, without bridging or the need for peritoneal flaps.

No intraoperative complications occurred.

On postoperative day 1, the patient was mobilized and respiratory training resumed. On day 2, the patient experienced dyspnea with an oxygen saturation of 87%. Laboratory results showed an elevated white blood cell count (12.9) and CRP (159 mg/l). A CT scan indicated subtotal atelectasis of the left lower lobe. Bronchoscopy revealed a mucus plug in the left bronchus, which was successfully removed. Cultures were sterile. Antibiotic therapy was administered from day 2 to day 5.

A localized area of reduced perfusion on the lower left abdominal skin was treated conservatively. The patient was discharged on postoperative day 6. On day 14, sutures were removed. The wound continued to heal well, with most of the initially ischemic area showing recovery.